Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks and Intervention Techniques
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Suicide is the second leading cause of death among youth, and as many as one in five youth report having had at least one serious thought of suicide in the past year. Despite the enormous emotional pain and suffering associated with suicidal thoughts and behaviors, up to 40 % of suicidal youth never receive treatment. Given that social workers are employed in multiple settings where suicidal children and adolescents are encountered (e.g. schools, homeless shelters, emergency departments, outpatient mental health agencies, private practice), they play a critical role in the identification and treatment of suicidal youth. In the past decade, evidence has emerged that attachment-based family therapy, integrated cognitive behavioral therapy, and dialectical behavior therapy can reduce suicidal ideation and/or suicide attempt in youth. The purpose of this article is to review the theoretical assumptions, conceptual frameworks and key intervention techniques for these three interventions so that clinicians can integrate these approaches into their practice with suicidal youth and families. Implications for practice are integrated throughout the review.
KeywordsYouth suicide Empirically-supported interventions Attachment-based family therapy Integrated-cognitive behavioral therapy Dialectical behavior therapy
Suicide is the second leading cause of death among youth ages 10–24 years, and 12 % of youth report having serious thoughts of suicide in their lifetime (Centers for Disease Control and Prevention, 2014; Nock et al., 2013). Reducing suicide deaths and improving quality of life has been the focus of federal suicide prevention programs like the Garrett Lee Smith Memorial Act, public–private partnerships like the National Action Alliance for Suicide Prevention, and private initiatives like Zero Suicide. Key components of the 2012 National Strategy for Suicide Prevention include training service providers in assessment and referral and the delivery of high-quality mental health services (U.S. D.H.H.S, 2012). Given that nearly half of all mental health workers in the United States are social workers who work in nearly every service sector (Bureau of Labor Statistics, 2016), social workers are essential in achieving the National Strategy objectives by identifying and assessing suicide risk, and providing high quality ongoing management and treatment (Erbacher, Singer, & Poland, 2015).
Despite the development of several psychosocial interventions for suicidal youth, there is evidence that social workers are not receiving the training and education needed to deliver these potentially life-saving interventions. A 2012 study found that although MSW program administrators and faculty agreed that suicide-related education is important, most social work students receive 4 or fewer hours (Ruth, Gianino, Muroff, McLaughlin, & Feldman, 2012). This is problematic because Over 90 % of social workers will work with a suicidal client in their career (Feldman & Freedenthal, 2006) and mental health professionals consistently rate working with suicidal clients as among the most stressful of all practice situations (Ting, Jacobson, & Sanders, 2008). To our knowledge there are only two MSW programs in the USA that offer a course on suicide and have evaluated pre- to post-course outcomes, which indicated significant increases in knowledge, confidence, and skills as a result of the course (Almeida, O’Brien, Gross, & Gironda, in press; Scott, 2015). If faculty members are not likely to develop and offer stand-alone courses on suicide-related issues, then it is essential to have resources that they can integrate into existing courses. Currently, faculty members have access to several excellent reviews of suicide risk assessment (Barrio, 2007; Joiner & Ribeiro, 2011; Ribeiro, Bodell, Hames, Hagan, & Joiner, 2013; Shea, 2002) and several high quality systematic reviews and meta-analyses of psychosocial interventions for suicidal and self-harming youth (see Brent et al., 2013; Calear et al., 2016; Corcoran, Dattalo, Crowley, Brown, & Grindle, 2011; O’Brien, Singer, LeCloux, Duarté-Vélez, & Spirito, 2014; Robinson et al., 2013). This article builds off that knowledge base by providing a concise review of theoretical assumptions and key intervention techniques for psychosocial interventions for suicidal youth while incorporating a key requirement in social work education: the integration of theory and practice.
The Relationship Between Theory and Empirically-Supported Treatments
Social work students and practitioners are expected to understand, explain and integrate practice and theory (National Association of Social Workers, 1996/2008; Council on Social Work Education, 2015). In social work education, classroom professors emphasize theory while field supervisors focus on practice. A perpetual challenge for students, practitioners, and professors is how to best integrate the two so that theory informs practice, and practice informs theory. Understanding the relationship between theory and practice is particularly important when working with people who are suicidal because of the possibility of lethal outcomes. This is due, in part, to the fact that there are many reasons why adolescents might want to die, and many pathways to help adolescents discover a life worth living. Since theory “attempts to retrospectively explain and to prospectively predict” (Thyer, 2001, p. 16), theoretically-informed treatments provide a roadmap for where to go and how to get there. The manualized treatments discussed in this article provide insight into whether you should spend time addressing affect, behavior, or cognition; whether you should focus on the past, present, or future; and whether you should focus on the individual, family, or group. Few social workers, however, are trained in such treatments. Unless a practitioner has been trained to fidelity in a treatment, it can be difficult to understand how the theoretical assumptions and constructs inform the intervention techniques.
According to Singer and Greeno (2013), frequently noted barriers to implementing manualized treatments include: provider concern that the treatment was not developed with or for low-income, ethnically diverse populations; concern that the treatment will not have better outcomes than treatment-as-usual; the time and expense required to get trained in manualized treatment; lack of training opportunities and organizational support for implementation; and a disconnect between the theoretical orientation of the treatments and that of the provider. Knowing which theories are associated with which interventions will help social workers decide which model best fits their practice approach and make it easier to identify whether they would like to pursue advanced training in ABFT, I-CBT, or DBT-A.
Identification and Inclusion of Studies
The three treatments discussed in this article were identified based on a search of the empirical literature using PsycINFO, PubMed and Google Scholar. Initial search terms included: (psychotherapy OR psychosocial OR clinical OR intervention) AND (suicid$) AND (youth OR adolescen$). The search was limited to peer-reviewed journal articles in English published between 1996 and 2016. This result yielded 2282 articles. Studies were excluded if reduction of suicidal ideation, suicide attempt, suicide or self-harm was not the primary focus of the intervention; if they combined self-harm and suicidal ideation/suicide attempt; if they focused only on caregivers and not youth; if the program leader was not a clinician (e.g. teacher implementing a school-based screening or researcher showing video psychoeducation or mailing a postcard); if the treatment manual was in a language other than English; or if there was no control condition. After applying exclusion criteria and eliminating duplicates, we were left with 33 articles. We compared these results to SAMHSA’s National Registry of Evidence-based Programs and Practices (http://nrepp.samhsa.gov/); the Suicide Prevention Resource Center’s Best Practice Registry (http://www.sprc.org/strategic-planning/finding-programs-practices) and recent meta-analyses, systematic reviews, and narrative reviews of psychosocial interventions for suicidal youth (Brent et al., 2013; Calear et al., 2016; Corcoran, Dattalo, Crowley, Brown, & Grindle, 2011; O’Brien et al., 2014; Robinson et al., 2013).
Nine treatments met criteria for inclusion (Asarnow et al., 2011; Diamond et al., 2010; Donaldson, Spirito, & Esposito-Smythers, 2005; Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011; Harrington et al., 1998; Huey et al., 2004; Mehlum et al., 2014, 2016; Rossouw & Fonagy, 2012; Stanley et al., 2009). Of these, three were excluded because they reported no significant difference in outcomes between the control and experimental condition (Asarnow et al., 2011; Donaldson et al., 2005; Harrington et al., 1998). Among the five studies that reported significant differences, we eliminated two (Huey et al., 2004; Rossouw & Fonagy, 2012) from the review for the following reasons: Multi-systemic therapy (MST; Huey et al., 2004) is not a theoretically-based treatment with specific interventions. Rather, it is a framework for providing interventions across multiple systems. Mentalization-based therapy for adolescents (MBT-A; Rossouw & Fonagy; 2012) is an adolescent modification of a psychodynamic therapy developed in Great Britain for adults with borderline personality disorder. It is unclear whether MBT-A is effective at reducing suicidal ideation and/or attempt because the outcome measure is a broad category of self-harm that includes suicidal ideation and attempt as well as non-suicidal self-injury. Additionally there are currently no MBT-A training opportunities in the USA.
The three remaining treatments, attachment-based family therapy (ABFT; Diamond et al., 2010; G. S. Diamond, G. M. Diamond, & Levy, 2013), integrated-cognitive behavioral therapy (I-CBT; Spirito, Esposito-Smythers, Wolff, & Uhl, 2011), and dialectical-behavior therapy for adolescents (DBT-A; Fleischhaker et al., 2011; Mehlum et al., 2014, 2016; Miller, Rathus, & Linehan, 2007) demonstrated better suicide-related outcomes than control conditions, were theoretically-based, had specific interventions, and addressed domains and problem areas common to social work that also increase risk for suicide: depressed mood, a rupture in the parent–child relationship (Donath, Graessel, Baier, Bleich, & Hillemacher, 2014), substance use (Wong, Zhou, Goebert, & Hishinuman, 2013), emotion dysregulation (Pisani et al., 2013), and non-suicidal self-injury (Klonsky, May & Glenn, 2013). Empirical support, theoretical assumptions, and specific interventions for each of the three treatments are presented.
Attachment-Based Family Therapy (ABFT)
Attachment-Based Family Therapy (ABFT; Diamond et al., 2013) is the only family-based therapy designed to reduce depression and suicide risk in adolescents. ABFT is a 12–16 week family therapy model that integrates concepts from family systems theory and attachment theory. ABFT has demonstrated efficacy in reducing suicidal ideation in 5 clinical trials (G. M. Diamond et al., 2012; Diamond et al., 2010; Diamond, Creed, Gillham, Gallop, & Hamilton, 2012; G. S. Diamond, Reis, G. M. Diamond, Siqueland, & Isaacs, 2002).
A core assumption of family systems theory is that interactions between family members follow predictable patterns. Interrupting and altering these patterns results in long-lasting changes for individuals and the family as a unit. ABFT assumes interaction patterns can either exacerbate or reduce suicide risk. ABFT integrates a family systems approach with attachment theory through the parent-adolescent relationship. ABFT subscribes to the notion that attachment is a biological instinct, with roots in infant development, which is shaped by interpersonal interactions throughout the lifespan (Ainsworth & Bowlby, 1991). There are two basic attachment styles—secure and insecure. Secure attachments develop when a primary caregiver consistently addresses an infant’s basic needs (hunger, boredom, soothing, love, affection, etc.). Insecure attachments develop when a primary caregiver is inconsistent or does not meet these basic needs. Research has found that attachment styles are fairly stable across cultures and across the lifespan (McConnell & Moss, 2011). However, because they are shaped by the interpersonal environment, attachment styles can change. A child with a secure attachment whose sense of safety and security is repeatedly violated (e.g. through abuse or neglect) might develop an insecure attachment style. Conversely, a child with an insecure attachment who experiences a primary caregiver meeting basic needs can “earn” security (Main, Hesse, & Kaplan, 2005). The capacity to earn security is central to the effectiveness of ABFT. ABFT assumes that one of the best ways to reduce suicide risk is to strengthen the adolescent-parent attachment. During a course of ABFT, which includes five treatment tasks, the therapist is constantly listening and looking for ways for adolescents to earn security or strengthen an already secure attachment. Two of the techniques used to achieve this goal are called “Relational Reframe,” and “Attachment” (Diamond, 2014).
The first intervention used in ABFT is a relational reframe (Diamond, 2014; G. S. Diamond, G. M. Diamond, & Levy, 2014). Consistent with ABFT’s family systems perspective, the purpose of the relational reframe is for family members to reframe adolescent suicide risk as a relational rather than individual issue. The family might come to therapy seeing the adolescent as the problem (e.g., “can you help him with his depression?”), but the reframe ensures that they leave understanding that the family is the solution. During the first session, the therapist elicits information from the suicidal adolescent and their parent(s) about what has contributed to the current suicidal crisis, and then works with the family to see how the interaction between the parent and the child can be a solution to the crisis. For example, the adolescent might say, “When I’m feeling bad I just want to go to my room. I don’t want to talk to anyone, especially my parents. It would be embarrassing. Dad wouldn’t know what to say and mom would just blame herself.” The therapist reflects back that it seems like he’d rather kill himself than feel embarrassed, or make his parents uncomfortable. The therapist notes the affect in the room (typically sad or anxious), and draws out the parents’ longing and desire for their adolescent to see them as safe people to turn to. Drawing out emotion, rather than tapping into cognitions, is consistent with the attachment-focus of the treatment. The therapist assumes that the parents’ attachment instincts will be triggered upon hearing their child’s pain and sadness. The therapist makes the connection that both the adolescent and parents are in pain and long for a different kind of relationship. The therapist assures the family that there are things they can do differently that would make it more likely that their son would talk with them when he is depressed or suicidal. By the end of the session, an ideal outcome for the relational reframe is for the adolescent and parent(s) to acknowledge a desire to be closer to each other. The therapist then contracts with the family to work on that goal. If the adolescent or the parent(s) is unable or unwilling to agree to that goal, the therapist “steps down” to a relational goal that might be less threatening, such as improving parent–child communication.
The attachment task typically occurs halfway through treatment. This intervention is a core ABFT technique which involves a conversation between the adolescent and his or her parent. After the relational reframe in the first session and the attachment task, the adolescent and parent(s) have been prepared to address the question, “what makes it so difficult for the adolescent to go to the parent(s) when feeling depressed and suicidal?” Part of the preparation for the attachment task is providing the adolescent with a narrative that frames their current struggles as attachment issues. For example, if the adolescent does not feel safe sharing intense emotions with a parent because of the parent’s emotional instability, then the attachment reframe is that the parent cannot meet a basic need for protection and comfort. During the attachment task the adolescent will tell the parent why it has been difficult to come to them when depressed or suicidal. The adolescent might say, “I don’t go to you because I’m afraid you will freak out and start crying, which will make me feel worse.” ABFT recognizes that parents might react with statements that could be invalidating (e.g. “No, I wouldn’t”), critical (e.g. “How would you know if you never do it?”), dismissive (e.g. “You don’t understand”) or self-involved (e.g. “I’m a terrible parent, of course you wouldn’t want to talk to me”). These are not attachment repairing statements. In order to prepare the parents to respond in ways that will demonstrate that they are capable of providing validation, affirmation, love and support, the parent has received emotion coaching (e.g. asking for more details, labeling emotions, providing validating statements such as “it makes sense why you would be worried to come to me”). The therapist’s role is to redirect the conversation when necessary and provide affirmation when the parent and adolescent are having the conversation. After the adolescent feels heard and validated, and the parent feels successful in meeting their adolescent’s needs, there is a shift in the attachment pattern. If the adolescent was preoccupied, i.e., always worried about the parent being available, the attachment task would provide a small but profound experience of the parent being there. The assumption is that this shift in the mental model of the parent–child relationship will reduce suicide risk by increasing the adolescent’s sense of security, safety, and protection; and the parent’s sense of competence and connection (Diamond 2014). The gains from this intervention are solidified over the second half of therapy (i.e., Task 5), as the adolescent repeatedly experiences the parent as a safe and secure base with whom they can work through a variety of psychosocial issues, ranging from the least to most distressing.
Integrated Cognitive Behavioral Therapy (I-CBT)
Suicide-related thoughts and behaviors and substance use are interrelated in adolescents (Bagge & Sher, 2008; Goldston, 2004) and increase markedly during this developmental period, demonstrating the importance of intervention during this time (Daniel & Goldston, 2009; Galaif, Sussman, Newcomb, & Locke, 2007). Despite the strong link between suicide-related thoughts and behaviors and substance use, the standard of care is to treat these two problems separately (Esposito-Smythers et al., 2012). However, integrated services have demonstrated greater promise than serial or parallel treatment for comorbid substance abuse and psychiatric disorders (Esposito-Smythers & Goldston, 2008; Hawkins, 2009; Sher & Zalsman, 2005). Integrated Cognitive Behavioral Therapy (I-CBT; Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011) is one such intervention for adolescents with comorbid suicide-related thoughts and behaviors and substance abuse.
I-CBT uses a social cognitive learning theory perspective (Bandura, 1986) to promote change in adolescents by helping them to relearn adaptive ways of relating to themselves and others and develop self-efficacy in their ability to utilize these skills. The I-CBT protocol targets the maladaptive behaviors and beliefs that are common to the two problems of substance use and suicide-related thoughts and behaviors, in order reduce the amount and severity of problems in both areas simultaneously (Esposito-Smythers et al., 2011). When treating substance use and suicide-related thoughts and behaviors in an integrated manner, it is important to understand how each can exacerbate the other. For instance, alcohol and other drug use may serve as a means of self-medication (Kuntsche, Knibbe, Gmel, & Engels, 2005), as a coping mechanism for depression (Galaif et al. 2007; Sher & Zalsman, 2005), or as a way to reduce or relieve negative affect. There is also evidence that alcohol and other drug use facilitates suicide-related thoughts and behaviors. Alcohol use causes disinhibition which can increase the likelihood of acting impulsively on suicidal thoughts (Sher, 2006), especially in the context of heavy episodic drinking, which has been found to be associated with increased risk of suicide attempts among suicidal adolescents (Schilling, Aseltine, Glanovsky, James, & Jacobs, 2009). With respect to maladaptive cognitions and behaviors, alcohol may inhibit the cognitive ability to use effective coping skills to deal with suicidal thoughts, which contributes to an elevated risk for a suicide attempt in the context of suicidal thoughts (Sher, 2006). Therefore, when addressing alcohol and other drug use in treatment with suicidal youth, it is critical to draw attention to the relationship between the two problems, and by doing so in a collaborative and informative way that does not come across as a lecture or as telling adolescents what they should be doing with respect to their drug and alcohol use.
To enhance collaboration and commitment to treatment, I-CBT uses many Motivational Interviewing (MI) techniques. MI is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2013). MI has been used effectively with adolescents with comorbid substance use and psychiatric symptoms (Brown et al., 2009) because of its ability to create a therapeutic atmosphere that acknowledges the choice and ambivalence of the adolescent and supports personal change goals rather than institutional or counselor-based goals. Because MI uses a nonjudgmental and nonconfrontational style, it may be particularly useful for engaging adolescents who have not yet considered change, or may have an apparent lack of motivation to change, their substance use or other problem behaviors related to their suicide-related thoughts or behaviors. Even a brief motivational interviewing intervention can serve to increase negative expectancies (i.e., the belief that using substances will have negative effects and consequences), increase situational confidence (i.e., confidence in the ability to resist the urge to use substance in certain situations), and increase mental health and substance use treatment engagement. In doing so, brief substance use interventions have the ability to decrease likelihood of substance use, which in turn will decrease the frequency of substance-related suicidal thoughts and behaviors.
I-CBT works under the premise that reduction of suicide and substance abuse risk requires coordinated efforts with adolescents and their parents. Individually with the adolescent, I-CBT addresses issues with cognitive distortions, coping, and communication, by working with the adolescent on cognitive restructuring, problem solving, affect regulation, and communication skills (Esposito-Smythers et al., 2011). For instance, one common cognitive distortion among suicidal adolescents is the belief that “I am worthless.” This self-deprecation can increase the likelihood of adolescents engaging in risky behaviors such as substance use because they want to use the substance to align themselves with these negative views of self, distract themselves from their distressing thoughts, or to numb themselves from their accompanying emotions. Substance use in this context exacerbates suicide risk by inhibiting their ability to use coping skills and facilitating the transition from suicidal thoughts to action.
Parental involvement has been show to enhance the effectiveness of treatment with suicidal adolescents (Brent et al., 2013). Strategies for inclusion of parents in the I-CBT protocol typically involve a parent training session about psychoeducation about emotion regulation, as well as the importance of parental monitoring and communication (Esposito-Smythers et al., 2011). Teaching parents about what their adolescent is experiencing, as well as how they can effectively communicate with their adolescent during times of heightened emotional distress, increases the likelihood that parents can be a buffer, rather than a trigger, to adolescents future suicidal crises. Additionally, teaching parents about the importance of monitoring their adolescents’ whereabouts, including the peers with whom they are spending their time, influences the likelihood that their adolescents will be spending time with peers who don’t use substances which will in turn decrease the likelihood of their own adolescents using substances. Family sessions in I-CBT typically focus on improving communication and behavioral contracting (Esposito-Smythers et al., 2011). Addressing the suicide- and substance-related treatment goals of the adolescent together with the parent serves to align the parent with the adolescent, building up the parents as a support in achieving their treatment goals.
Through the simultaneous improvement in overall adolescent and parent skills, adolescents can then demonstrate reductions in substance use and suicide-related thoughts and behaviors. For instance, in their randomized trial, Esposito-Smythers et al. (2011) found I-CBT, relative to enhanced treatment as usual (E-TAU), to be associated with significantly fewer heavy drinking days and days of marijuana use. Less global impairment as well as fewer suicide attempts, inpatient psychiatric hospitalizations, and emergency department visits were reported by adolescents receiving I-CBT as compared to those receiving E-TAU.
In their meta-analysis of the effectiveness of brief alcohol interventions for adolescents, Tanner-Smith and Lipsey (2015) found the specific components of decisional balance and goal-setting exercises to be associated with larger reductions in alcohol consumption and alcohol-related problems. Therefore, suggested adaptations of these modalities for adolescents with comorbid suicide-related thoughts and behaviors will be presented here. These techniques are currently being utilized in a clinical trial of a brief alcohol intervention with adolescent inpatients following a suicidal event (O’Brien & Spirito, 2014).
The decisional balance is a MI technique used to consider options and systematically evoke the advantages and disadvantages of each (Miller & Rollnick, 2013). The decisional balance typically uses four quadrants to ask about the pros and cons regarding a decision (e.g., “what do you like about alcohol,” “what don’t you like about alcohol,” “what would be the bad things about changing your drinking,” and “what would be the good things about changing your drinking”). The diagonal boxes are complementary and may contain similar entries. Some adolescents may find it confusing to distinguish between the two, in which case, a simple pros and cons list may be more effective. When completing the decisional balance with adolescents, it is important to first elicit what it is they like about their substance of choice (or other problem behavior) before asking them about what they don’t like. It is critical that while they are telling you what they like, you maintain a nonjudgmental and nonconfrontational stance. Some common reasons suicidal adolescents cite for why they like drinking or other drug use include “helps me feel more comfortable to talk to people at a party,” “makes me forget about all the bad things going on,” or “like the way it feels.” Reasons they don’t like drinking or other drug use frequently include “get sick,” “feel sad or down the next day,” or “feel bad the next day about something I did when I was drunk.” Knowing these reasons can help you in the therapeutic process to understand the functions the alcohol or other drugs are serving for the adolescent, especially with respect to their suicide-related thoughts and behaviors. Clinicians must remember that this relationship is not always unidirectional; in fact, many adolescents endorse a bidirectional relationship between their substance use and suicide-related thoughts and behaviors. Once this relationship is understood, then the clinician can work with the adolescent to identify alternate ways to replace the function that the alcohol is serving for the adolescent, especially in cases where it is contributing to the exacerbation of suicide-related thoughts and behaviors. In the I-CBT protocol, the decisional balance is typically used in session 3 (of 13 or more sessions), but because of its flexibility, it can be adapted for a wide range of uses in both brief and long term treatment modalities.
In MI, goal setting exercises, such as making a change plan, are conducted only when the client demonstrates sufficient readiness (Miller & Rollnick, 2013). Change plans can take many forms, but they typically include a list of goals and steps to take to achieve those goals. It is important that adolescents develop their own goals to emphasize their autonomy and therefore increase motivation to adhere to the change plan. Goals often relate to substance use or other problem behaviors that affect their suicide-related thoughts and behaviors, but are not limited to these areas. For example, suicidal adolescents may decide to make a plan to reduce their alcohol use at a party, rather than stop use altogether. They may choose to do reduce use because they want to be able to drink a little so they can feel comfortable at a party, but not so much that they get drunk and do something they regret the next day. It is recommended that the change plan identifies adults who can help the adolescent achieve their goals, as well as barriers that could get in the way of the adolescent’s goal attainment. It can be helpful for the clinician to talk with the adolescent about how the parent can be of assistance in the change plan process. Adolescents often come up with unique ideas that you, as the clinician, could not think up on your own. With respect to barriers, it can be useful to have the adolescent take you step-by-step through a situation where they typically use substances in order to identify what the specific barriers are for that adolescent. Once a barrier has been identified, the clinician can then brainstorm with the adolescent what they can do they next time the situation comes up. In the I-CBT protocol, the change plan is typically completed at the end of session 3, but can be revisited throughout the remainder of treatment when appropriate.
Dialectical Behavior Therapy for Adolescents (DBT-A)
DBT-A was adapted from Dialectical Behavior Therapy (DBT; Linehan, 1993), a treatment modality that combines principles of behavioral science, dialectical philosophy, and Zen practice (Miller et al., 2007). DBT was initially developed in the 1980’s to address self-harming behaviors in women, many of whom met criteria for borderline personality disorders. DBT-A is a version of DBT that was adapted for use with adolescents who struggle with suicidality, self-harm, and chronic emotion dysregulation. These adolescents are often struggling with one or more additional comorbid disorders, such as substance use, disordered eating, mood and anxiety disorders, and disruptive behavior disorders (Miller et al., 2007).
DBT-A is a versatile treatment that can be used in both inpatient and outpatient treatment centers and has also recently been adapted to a school-based curriculum (Mazza, Dexter-Mazza, Miller, Rathus, & Murphy, 2016). Clinical trials of DBT-A have found it is associated with improvements in overall psychiatric functioning, and significant decreases in suicidal ideation and behaviors as well as comorbid symptoms, such as non-suicidal self-injury (NSSI) and depression (MacPherson, Cheavens, & Fristad, 2013). Additionally, a recent review and meta-analysis of suicide-related treatments for adolescents found that, along with CBT, DBT-related treatments had the largest effect sizes in relation to clinical improvements (Ougrin, Tranah, Stahl, Moran, & Asarnow, 2015).
One of the core assumptions of DBT-A is that successful treatment involves helping the client recognize, synthesize, and integrate ideas that seem to be in opposition to each other;his is the main idea behind the word “dialectic.” In DBT-A, the adolescent is coached to be able to tolerate painful feelings and simultaneously contemplate the possibility for change. For example, a teen who reports feeling suicidal due to poor peer and parental relationships might work on the following dialectic: “I might not be responsible for all the things that are bad about my relationships, but I am responsible for working on them to make them better.” A teen whose suicidal ideation is triggered by not meeting academic expectations (either internally or externally conceived) might work on the following dialectic: “I am doing the best I can, but I can do better.” The therapist uses a variety of cognitive strategies in therapy throughout treatment that allow adolescents to explore and synthesize these sorts of dialects as they are relevant to their treatment targets.
A second core assumption of DBT-A is that adolescents express emotions through self-harming behaviors because they have a systemic problem with emotion dysregulation. Systemic emotion dysregulation, according to Linehan (1993), develops as the result of a combination of biological pre-disposition and exposure to an “invalidating environment.” The “invalidating environment” involves having primary caregivers early in life who react to a child’s emotions and behaviors with either erratic, inappropriate, or invalidating responses (Linehan, 1993), which makes it difficult for children to develop the ability to appropriately identify and modulate emotions and self-soothe in response to distress. These individuals also have difficulty appropriately identifying the emotions of others, selecting appropriate responses, and/or modulating their affect, which results in the inability to maintain a stable sense of self (Linehan, 1993). Adolescents with a pre-disposition to emotional dysregulation and who are exposed to an “invalidating environment,” typically develop extreme difficultly tolerating conflict, may engage in “all or nothing” thinking, and/or will have irrational fears of abandonment. As a result, they can develop behaviors that alienate others and/or sustain dysfunctional social relationships (Miller et al., 2007).
In DBT-A, it is assumed that suicide-related affect, thoughts, and behaviors are ways of directing anger towards the self and/or escaping from extreme hopelessness or despair (Miller et al., 2007). Suicide-related thoughts and behaviors and non-suicidal self-injury (NSSI) are categorized as “life threatening behaviors” which are targeted with similar interventions, and are considered one of the first targets of treatment (Miller et al., 2007). They are prioritized and addressed with a multi-modal approach, which is described further below.
“Life threatening behaviors” are addressed in DBT-A through a multi-modal approach that includes individual treatment, psychopharmacology, skills training, phone-consultation, family work, and consultation with other significant providers in the adolescent’s life (such as school personnel) (Miller et al., 2007). The following section gives a brief overview of some of the DBT-A techniques formulated by Miller et al. (2007) that can be applied to work with suicidal adolescents in either inpatient or outpatient settings. While all of the techniques described below can be integrated into individual therapy, DBT-A skills are typically taught through skills-based training groups on either inpatient or outpatient settings, or with a DBT-A skills coach, so that individual therapy can focus on assessing safety and monitoring the use of these skills to manage distressing situations (Miller et al., 2007).
One of the major assumptions of DBT is that self-harming behaviors and suicidal thoughts stem from core problems with emotion regulation and many of the strategies and skills employed in DBT-A attempt to improve adolescents’ abilities to tolerate and regulate difficult emotions. One key emotion regulation skill that is taught in DBT-A is the concept of mindfulness. Mindfulness refers to experiencing thoughts and feelings without attaching judgment or negativity to them. The assumption is that if one is unable to fully experience one’s feelings, one cannot ever learn to regulate them (Linehan, 1993). An adolescent, for example, who experiences conflicting feelings of “love” and “hate” for an abusive parent might be encouraged to feel each of these feelings fully, without attaching judgment or blame to either one. The general concept of mindfulness is found in many of the DBT-A skills, but can be integrated into the individual therapy regularly as well by using techniques similar to the example described above.
There are several DBT-A skills-based exercises that teach mindfulness. In the Describe, Express, Assert, Reinforce, (stay) Mindfully, Appear confident, Negotiate (DEAR MAN) exercise, for example, youth are asked to describe a situation without judgment, express their feelings or emotions about it, discuss ways they could have appropriately asserted their wishes, and to reward or reinforce people who do respond positively to them. Being “mindful” refers to the ability to keep focus by repeating their requests and ignoring attacks or threats from the other party. This is often done with the aid of a Diary Card, in which adolescents are asked to keep track of target behaviors (including self-harm) and the skills they have used each week to manage them.
The DBT concept of radical acceptance refers to the idea that in order to move forward from pain, one must accept it and experience it in its entirety. Distressful feelings are reframed as a way the psyche informs an individual of the need for action (Linehan, 1993). In conjunction with radical acceptance, DBT-A focuses on helping adolescents develop core skills that help them make pain more tolerable. The distress tolerance techniques in DBT-A target the adolescent’s ability to tolerate painful or difficult situations. One way this can be accomplished is by teaching the adolescent ways to self-soothe when faced with difficult or distressing feelings. The Vision, Hearing, Smell, Taste, Touch exercise, for example, encourages adolescents to find ways to engage and soothe each of the five senses. By engaging in behaviors that “soothe the body,” adolescents are taught that they can learn to tolerate difficult feelings without becoming overwhelmed by them. Other examples of this sort of technique include using positive imagery, prayer, and relaxation to replace negative experiences with positive ones. An adolescent who is feeling overwhelmed and anxious by a distressing conversation with a significant other, for example, might be encouraged to imagine an “alternate experience,” where the conversation progressed to what is considered a positive (and safe) end. Another example might be encouraging an adolescent to use a progressive muscle relaxation technique when feeling distressed. In this way, the adolescent can create a more positive physical feeling in his or her body, making it easier to tolerate difficult feelings.
Behavioral or Chain Analysis
Another core tenet of DBT is that problematic behaviors often result from a deficiency in coping and problem solving skills (Rizvi & Ritschel, 2014). Adolescents may engage in self-harm, for example, when feeling overwhelmed by emotion and unable to cope. Alternatively, they may use self-harming behaviors as a way to communicate distress when feeling unable to assert their needs effectively. One well-known cognitive-behavioral technique that has been adapted to DBT-A that attempts to address these issues is called behavioral or chain analysis (Miller et al., 2007).
A chain analysis can be completed at any time in treatment, but is intended to be the first step in identifying problematic situations that trigger a self-harming or suicidal event in order to generate solutions. The chain analysis documents what happened internally and externally leading up to a suicidal or self-injurious event (this can include thoughts and/or behaviors), and is sometimes referred to as a video which is stopped at every frame to identify what is going on. Although the chain analysis technique is primarily done with the adolescent, a chain analysis can be done with the parents as well in order to gather the fullest picture possible of what happened and what lessons can be learned to prevent future events. The chain analysis is a time-intensive process and typically takes a minimum of 30 min. The clinician very methodically goes through the events with the adolescent, writes down what happened when, and asks clarifying questions such as, “and after he said that, how did you feel? What did you do then?” The chain analysis is complete once a thorough picture is obtained of what happened leading up to the suicide-related event.
One goal of this technique is to identify vulnerabilities as well as draw out strengths, resources, and solutions that the adolescent might not have previously recognized. A chain analysis can also be useful because it helps the therapist and adolescent identify “solution” or “change” procedures that address the suicide-related behavior. The particular focus of the change procedures often differs depending upon the findings in the chain analysis. For example, for an adolescent who reports engaging in self-harming behavior after becoming enraged during a fight with a parent, the therapist might work on helping the adolescent identify some distress tolerance techniques to manage emotions in the moment as well as some interpersonal effectiveness skills that could have been used to make the interaction with the parents more productive.
The chain analysis also allows the adolescent to re-experience situations involving difficult or painful feelings in a safe and removed way. During the chain analysis, the therapist can help adolescents tolerate difficult feelings without engaging in self-harming behaviors and help the teen learn to manage his or her affect (Rizvi & Ritschel, 2014). In this way, the chain analysis technique is also very much consistent with the DBT concepts of radical acceptance and distress tolerance. In the example above, in addition to identifying antecedents and alternative strategies to the situation, the therapist might help the youth modulate feelings of anger, frustration or sadness triggered by the argument with the parent. Additionally, the therapist could encourage the use of mindfulness and distress tolerance techniques that could be used to fully experience these feelings while still learning to manage them.
Despite the value placed on understanding the intersection between theory and practice, there are very few resources that provide students and practitioners with insight into this intersection with specific treatments (for a comparable article on substance use disorders see Wells, Kristman-Valente, Peavy, & Jackson, 2013; see also the Springer and Rubin book series “Clinician’s Guide to Evidence-Based Practice”). This review provides the theoretical assumptions, conceptual frameworks, and key intervention techniques for three probably efficacious psychotherapies for suicidal youth: attachment-based family therapy (ABFT), integrated-cognitive behavioral therapy (I-CBT) and dialectical behavior therapy (DBT). The selection of these three treatments was based on several criteria, including: empirical support for reduction of suicidal ideation or attempt; an explicit relationship between the interventions and the theories; theoretical diversity (ABFT is an emotion-focused, attachment-oriented family-based intervention; I-CBT and DBT are grounded in cognitive-behavioral theory with humanistic and mindfulness components); evaluation with low-income people of color; and availability of a treatment manual for further study. In addition they address clinical issues that are regularly addressed by social workers including mood disorders, parent–child conflict, substance use, emotion dysregulation, and non-suicidal self-injury.
Considerations and Limitations
One important consideration related to these treatments is the feasibility of implementing them with fidelity in day-to-day social work practice (Singer & Greeno, 2013). Becoming certified in each of these treatments, for example, can take several years and thousands of dollars. Practitioners cannot say they are providing “DBT, ABFT, or I-CBT” unless they have received the requisite formal training. Attending online or in-person non-certification continuing education workshops allows practitioners to learn and integrate approach-specific techniques and to say that their practice is “informed” by these manualized treatments.
Secondly, there are several limitations to the existing research-base and the conceptual frameworks for each of these treatments. For ABFT, research participants in the United States have primarily been low-income African American families living in Philadelphia which might limit generalizability to more affluent or racially diverse samples. The primary outcome of ABFT research has been reduction in suicidal ideation and depression which means it has never been evaluated for preventing suicide attempts or deaths. As with all manualized treatments, ABFT has a specific theoretical orientation (attachment and systems theory). ABFT therapists enter the treatment relationship with the intention of helping families see the current suicidal crisis through an attachment lens. Clinicians who practice from a solution-focused or narrative perspective might find this a priori assumption to be counter to their client-centered treatment approach. Indeed, ABFT is described as “client-respectful,” rather than “client-centered” (Diamond et al., 2010). With I-CBT, the role of medication management is not explicitly addressed in the protocol (Esposito-Smythers et al., 2012), which is important because of the possibility of abusing prescription medication, and the ongoing controversy about the role of medication and increased suicide risk (Sharma, Guski, Freund, & Gøtzsche, 2016). Another possible limitation of I-CBT is that the focus on substance use and suicide may lead other risky behaviors to be ignored if not observed or asked about in the context of treatment. In addition, replication of I-CBT in randomized trials with other samples (e.g., juvenile justice) is warranted. Criticisms of DBT have included concerns that change mechanisms may be related more to the structure of DBT (e.g., high levels of supervision, consistency and stability of treatment, and the high level of motivation of providers) as opposed to the techniques themselves (Scheel, 2000), as well as the need for a high level of organizational support in order for the treatment to be effective (Swales, Taylor, & Hibbs, 2012). Additionally, while there is initial empirical support for the effectiveness of DBT-A, more randomized clinical trials are needed (MacPherson et al., 2013).
We hope that by addressing theory in detail, this review addresses some of the concerns about fit between the treatment’s and the provider’s theoretical orientation. Although there is great utility in understanding how and why these psychotherapies address suicide risk, individual and family therapies are not the only modalities that have seen support in reducing suicide risk. For example, two recent studies analyzed outcomes from community-based youth suicide prevention programs across the USA and found that these programs reduced youth suicide attempts and deaths (Garraza, Walrath, Goldston, Reid, & McKeon, 2015; Walrath, Garraza, Reid, Goldston, & McKeon, 2015).
Although all three therapies have the goal of reducing suicide risk in youth, the differences in theoretical assumptions have important implications for how and when to intervene. Whereas ABFT and I-CBT provide guidance for when and how to work with families, DBT provides guidance for when and how to work in groups. ABFT is an affective-based therapy, whereas I-CBT and DBT are cognitive-based interventions. Although all three include skill-building, ABFT teaches skills to parents, and I-CBT and DBT teach skills to youth. While all treatments have been evaluated in outpatient settings, only DBT-A has been evaluated in an inpatient setting. Each therapy was developed to address suicide risk within different psychiatric disorders, including depression (ABFT), substance abuse (I-CBT) and borderline personality disorders (DBT). These differences are not the eccentric whims of the developers, but are based on differing theoretical assumptions about what leads to change. When social workers understand the theoretical differences, they can make decisions about which interventions are theoretically consistent and which are not.
In sum, working with suicidal youth is complex and fraught with anxiety for both the client and the clinician. Potentially efficacious treatments reduce some of that burden by providing a theoretically-informed pathway to navigating this complex and potentially life-threatening situation. Social work education programs can accelerate the speed with which providers are able to deliver treatments for suicidal adolescents by offering semester-long electives in any of the interventions listed in this article, post-graduate certificate programs in partnership with the model developers, and technology mediated learning such as webinars or podcast series.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
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