Long term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior.

BACKGROUND: Knowledge is lacking on the long-term outcomes of treatment for adolescents with repetitive suicidal and self-harming behavior. Furthermore, the pathways through which treatment effects may operate are poorly understood. Our aims were to investigate enduring treatment effects of dialectical behavior therapy adapted for adolescents (DBT-A) compared to enhanced usual care (EUC) through a prospective 3-year follow-up and to analyze possible mediators of treatment effects. METHODS: Interview and self-report data covering the follow-up interval were collected from 92% of the adolescents who participated in the original randomized trial. TRIAL REGISTRATION NUMBER: NCT01593202 (www.ClinicalTrials.gov). RESULTS: At the 3-year follow-up DBT-A remained superior to EUC in reducing the frequency of self-harm, whereas for suicidal ideation, hopelessness and depressive and borderline symptoms and global level of functioning there were no inter-group differences, with no sign of symptom relapse in either of the participant groups. A substantial proportion (70.8%) of the effect of DBT-A on self-harm frequency over the long-term was mediated through a reduction in participants' experience of hopelessness during the trial treatment phase. Receiving more than 3 months follow-up treatment after completion of the trial treatment was associated with further enhanced outcomes in patients who had received DBT-A. CONCLUSIONS: There were on average no between-group differences at the 3-year follow-up in clinical outcomes such as suicidal ideation, hopelessness, depressive and borderline symptoms. The significantly and consistently larger long-term reduction in self-harm behavior for adolescents having received DBT-A compared with enhanced usual care, however, suggests that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior.

Introduction to a Special Issue Dialectical Behavior Therapy: Evolution and Adaptations in the 21(st) Century.

Born from the randomized controlled trial by Linehan and colleagues in 1991, dialectical behavior therapy (DBT) has become the gold standard for treatment of individuals who are suicidal and have borderline personality disorder. In this special issue, we begin with a historical review of DBT provided by the treatment developer herself. We then introduce readers to new, 21(st) century adaptations developed of this treatment modality. In this issue we explore the use of DBT for suicidal adolescents with one paper focusing on Latina teens and their parents, and one focused on the more recently developed walking the middle path skills module. Other papers in this issue include unique adaptations of DBT for eating disorders, and disorders of over-control, as well as trauma in incarcerated male adolescents. We also look at transdiagnostic applications of DBT and finally a comparison of DBT with mentalization-based treatment.

Towards the Development of an Effective Working Alliance: The Application of DBT Validation and Stylistic Strategies in the Adaptation of a Manualized Complex Trauma Group Treatment Program for Adolescents in Long-Term Detention.

The current paper details a case of adapting a manualized group therapy treatment for youths experiencing chronic stress. It was used for use with a highly traumatized and behaviorally disordered group of adolescents (ages 14 to 17 years) in long-term juvenile detention. The authors argue for a phasic approach to treatment for this population, with the goal of the essential, initial phase being the development of an authentic therapeutic alliance before other treatment goals are pursued. The authors provide clinical examples of liberally and patiently utilizing dialectical behavior therapy-framed acceptance-based strategies to achieve this therapeutic alliance, and only then naturally weaving in more traditional cognitive behavioral, change-oriented psychoeducational approaches successfully. Clinical and research implications for effective treatment of traumatized, detained youths are also discussed.

Dialectical Behavior Therapy for Suicidal Latina Adolescents: Supplemental Dialectical Corollaries and Treatment Targets.

The primary aim of this paper is to describe extreme behavioral patterns that the authors have observed in treating Latina adolescents who are suicidal and their parents within the framework of dialectical behavior therapy (DBT). These extreme patterns, called dialectical corollaries, serve to supplement the adolescent/family dialectical dilemmas described by Rathus and Miller (2002) as part of dialectical behavior therapy for suicidal adolescents with borderline personality features. The dialectical corollaries proposed are "old school versus new school" and "overprotecting" versus "underprotecting," and they are described in-depth. We also identify specific treatment targets for each corollary and discuss therapeutic techniques aimed at achieving a synthesis between the polarities that characterize each corollary. Lastly, we suggest clinical strategies to use when therapists reach a therapeutic impasse with the parent-adolescent dyad (i.e., dialectical failures).

Coping with Transitions: A Promising Intensive Outpatient DBT Program for Emerging Adults and Their Families.

Emerging adulthood is a period of significant exploration, transformation, variability, and growth. Simultaneously, this developmental period presents unique challenges as emerging adults work to achieve developmental milestones including self-identity formation, the establishment of long-term intimate relationships, career advancement, and independence from parents. For those who are vulnerable, this period is also marked by the development of significant mental health problems and associated impairment, which prevents individuals from successfully reaching these developmental milestones. To address the various challenges unique to this developmental period, we created and implemented a multifaceted DBT treatment protocol to specifically address emotional dysregulation within emerging adults. The current study presents an evaluation of a novel, intensive, outpatient DBT program called System for Adult Growth and Emergence-Foundations (SAGE-F). We aim to first introduce the SAGE-F treatment protocol, and then to assess both its short and long-term therapeutic value. Participants enrolled in SAGE-F were administered a testing battery assessing symptom severity, functioning capacities, and coping strategies at intake, upon completion of the program 6-weeks later, and at 3-month follow-up. It was found participants who completed SAGE-F reported significant reductions in depression and anxiety symptoms, as well as non-suicidal self-injurious behaviors. Simultaneously, participants also reported improvements in their daily functioning and coping capacities. Follow-up assessments indicated therapeutic progress remained.

Borderline personality symptoms differentiate non-suicidal and suicidal self-injury in ethnically diverse adolescent outpatients.

BACKGROUND: There is little research on how specific borderline personality disorder (BPD) symptoms relate to suicide attempts or suicide and non-suicidal self-injury (NSSI) within adolescent populations, which is important to know given the recent proposal of an NSSI disorder. Even less well known is whether specific BPD symptoms distinguish NSSI from suicide attempts or differentiate single from repeated acts of either suicide or NSSI. METHOD: Archival, de-identified outpatient clinical charts from 441 ethnically diverse (4.3% Caucasian; 70.9% female) adolescents (mean age = 14.9, SD = 1.61) were reviewed. Data pertaining to NSSI, suicide attempt history, BPD symptoms, and psychiatric diagnoses were obtained from self-report measures and semi-structured interviews administered at intake. RESULTS: MANOVA and logistic regression analyses revealed significant differences across groups, with the BPD symptoms of 'confusion about self' and 'unstable interpersonal relationships' significantly predicting NSSI and NSSI+Suicide group status. The number of BPD criteria met plus high levels of confusion about self significantly predicted single vs. repeat self-harm group membership. CONCLUSIONS: Two BPD symptoms exhibit distinct relationships to NSSI and suicide attempts, but there is not strong variation in their relationship to BPD. Treatment addressing BPD symptoms may be useful to reducing both NSSI and suicide in ethnically diverse adolescents.

Adapting Dialectical Behaviour Therapy for Children: Towards a New Research Agenda for Paediatric Suicidal and Non-Suicidal Self-Injurious Behaviours.

BACKGROUND: Dialectical Behaviour Therapy (DBT) has been used to treat adults and adolescents with suicidal and non-suicidal self-injury. This article describes initial progress in modifying DBT for affected pre-adolescent children. METHOD: Eleven children from regular education classes participated in a 6-week pilot DBT skills training program for children. Self-report measures of children's emotional and behavioural difficulties, social skills and coping strategies were administered at pre- and post-intervention, and indicated that the children had mild to moderate symptoms of depression, anxiety and suicidal ideation at baseline. RESULTS: Subjects were able to understand and utilise DBT skills for children and believed that the skills were important and engaging. Parents also regarded skills as important, child friendly, comprehensible and beneficial. At post-treatment, children reported a significant increase in adaptive coping skills and significant decreases in depressive symptoms, suicidal ideation and problematic internalising behaviours. CONCLUSIONS: These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted. Progress on adapting child individual DBT and developing a caregiver training component in behavioural modification and validation techniques is discussed.

Psychiatric impairment among adolescents engaging in different types of deliberate self-harm.

This retrospective chart review study of 227 participants examined the psychiatric profiles of outpatient adolescents ages 12 to 19 years (M = 15.08 years, SD = 1.72 years) engaging in different types of deliberate self-harm (DSH) behaviors. Participants were divided into four groups: no deliberate self-harm (NoDSH; n = 119), nonsuicidal self-injury only (NSSI only; n = 30), suicide attempt only (n = 38), and suicide attempt plus NSSI (n = 40). Those who attempted suicide were more likely to have major depressive disorder and/or posttraumatic stress disorder than those who engaged in NSSI only. Those who engaged in any type of DSH were more likely to have features of borderline personality disorder than those who did not engage in DSH. The suicidal ideation levels of those in the NSSI group were similar to those in the NoDSH group. Findings offer empirical support for the importance of distinguishing between suicidal and nonsuicidal self-harm behaviors.

An Ecological Investigation of the Emotional Context Surrounding Nonsuicidal Self-Injurious Thoughts and Behaviors in Adolescents and Young Adults.

Ecological momentary assessment (EMA) methodology was used to examine the emotional context of nonsuicidal self-injury (NSSI). Forty-seven adolescents and young adults used a novel smartphone app to monitor their emotional experiences, NSSI thoughts, and NSSI behaviors for 2 weeks. Momentary changes in both negative and positive emotions predicted greater intensity of NSSI thoughts at the subsequent assessment, while only increases in negative emotion predicted NSSI behaviors. Immediately following NSSI behaviors participants reported reduced high-arousal negative emotions and increased low-arousal positive emotions, suggesting that NSSI may be an efficient and effective method of regulating emotion. Findings highlight the importance of addressing emotion regulation in NSSI interventions.

The Role of Sleep Disturbance in Suicidal and Nonsuicidal Self-Injurious Behavior among Adolescents.

The relationship between different sleep disturbances and self-harm thoughts and behaviors was examined among 223 adolescents presenting to a community clinic for mood disorders and suicidal and nonsuicidal self-injurious behaviors. Two-thirds of the adolescents reported nightly, severe sleep complaints. Relative to adolescents without significant sleep complaints, patients with severe sleep complaints at the time of clinic entry endorsed significantly more engagement in nonsuicidal self-injury. Middle insomnia and circadian reversal were both significant predictors of suicide attempts. Terminal insomnia was significantly associated with suicidal ideation. Results support the importance of assessing sleep difficulties among adolescents at risk for suicide.

Dialectical Behavior Therapy Compared With Enhanced Usual Care for Adolescents With Repeated Suicidal and Self-Harming Behavior: Outcomes Over a One-Year Follow-Up.

OBJECTIVE: We conducted a 1-year prospective follow-up study of posttreatment clinical outcomes in adolescents with recent and repetitive self-harm who had been randomly allocated to receive 19 weeks of either dialectical behavior therapy adapted for adolescents (DBT-A) or enhanced usual care (EUC) at community child and adolescent psychiatric outpatient clinics. METHOD: Assessments of self-harm, suicidal ideation, depression, hopelessness, borderline symptoms, and global level of functioning were made at the end of the 19-week treatment period and at follow-up 1 year later. Altogether 75 of the 77 (97%) adolescents participated at both time points. Frequencies of hospitalizations, emergency department visits and other use of mental health care during the 1-year follow-up period were recorded. Change analyses were performed using mixed effects linear spline regression and mixed effect Poisson regression with robust variance. RESULTS: Over the 52-week follow-up period, DBT-A remained superior to EUC in reducing the frequency of self-harm. For other outcomes such as suicidal ideation, hopelessness, and depressive or borderline symptoms and for the global level of functioning, inter-group differences apparent at the 19-week assessment were no longer observed, mainly due to participants in the EUC group having significantly improved on these dimensions over the follow-up year, whereas DBT-A participants remained unchanged. CONCLUSION: A stronger long-term reduction in self-harm and a more rapid recovery in suicidal ideation, depression, and borderline symptoms suggest that DBT-A may be a favorable treatment alternative for adolescents with repetitive self-harming behavior. CLINICAL TRIAL REGISTRATION INFORMATION: Treatment for Adolescents With Deliberate Self Harm; http://clinicaltrials.gov/; NCT00675129.

Feasibility of dialectical behavior therapy for suicidal adolescent inpatients.

OBJECTIVE: To evaluate the feasibility of dialectical behavior therapy (DBT) implementation in a general child and adolescent psychiatric inpatient unit and to provide preliminary effectiveness data on DBT versus treatment as usual (TAU). METHOD: Sixty-two adolescents with suicide attempts or suicidal ideation were admitted to one of two psychiatric inpatient units. One unit used a DBT protocol and the other unit relied on TAU. Assessments of depressive symptoms, suicidal ideation, hopelessness, parasuicidal behavior, hospitalizations, emergency room visits, and adherence to follow-up recommendations were conducted before and after treatment and at 1-year follow-up for both groups. In addition, behavioral incidents on the units were evaluated. RESULTS: DBT significantly reduced behavioral incidents during admission when compared with TAU. Both groups demonstrated highly significant reductions in parasuicidal behavior, depressive symptoms, and suicidal ideation at 1 year. CONCLUSIONS: DBT can be effectively implemented in acute-care child and adolescent psychiatric inpatient units. The promising results from this pilot study suggest that further evaluation of DBT for adolescent inpatients appears warranted.

Psychiatric and social barriers to HIV medication adherence in a triply diagnosed methadone population.

Although antiretrovirals can prolong life, medication adherence also poses a constant challenge for HIV-infected individuals because the success of antiretroviral regimens demands nearly perfect adherence to medications. This paper describes the psychiatric and social barriers to adherence in a convenience sample of HIV-positive clients in methadone treatment in the Bronx, New York. The study sample was part of a national study of HIV treatment adherence and health care utilization among triply diagnosed populations, the HIV/AIDS Treatment Adherence Health Outcomes and Cost Study. The triply diagnosed study sample is defined here as HIV-infected individuals who screened into the study with at least one psychiatric diagnosis in addition to opioid dependence on agonist therapy (methadone treatment) and at least one substance use diagnosis. Interviewers utilized modified versions of the Structured Clinical Interview for DSM-IV Disorders (SCID-I), the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II), and the Addiction Severity Index (ASI-Lite), among a battery of Cost Study instruments. Results showed that within this sample, borderline personality disorder was significantly associated with nonadherence to HIV medications. A related finding showed a significant relationship between serious social/family problems and nonadherence. These findings build on previous research on the impact of psychiatric illness on HIV medication adherence and suggest that psychiatric assessment and treatment options be linked to adherence interventions.

Dialectical behavior therapy adapted for suicidal adolescents.

We report a quasi-experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT) with a group of suicidal adolescents with borderline personality features. The DBT group (n = 29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n = 82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pre-treatment symptomatology in the DBT group, at post-treatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.

Family therapy and dialectical behavior therapy with adolescents: Part I: Proposing a clinical synthesis.

Although the practice of family therapy in dialectical behavior therapy (DBT) with multiproblem suicidal adolescents is common and generally indicated, a particular model has yet to be delineated with this age group. The purpose of this article is to propose a coherent clinical synthesis of the more individually oriented DBT strategies with a broader family-systems orientation that maintains the integrity of both theoretical approaches while addressing the treatment needs of adolescents and their families. First, the authors briefly review the literature. Second, they describe the core dialectic of DBT, balancing acceptance and change, and its relevance to family therapy. Finally, the authors propose several specific acceptance and change strategies useful when implementing DBT family therapy with multi-problem adolescents.

Family therapy and dialectical behavior therapy with adolescents: Part II: A theoretical review.

Dialectical Behavior Therapy (DBT) is based on a transactional model of the etiology of borderline personality disorder (BPD). It assumes that the associated emotional dysregulation is not simply biological or family induced but the result of a dynamic interaction between the biology and characteristics of an individual with the individual's social environment. This paper discusses the theoretical issues and empirical research relating to a synthesis of family therapy and DBT with adolescents. A review of the literature identifies support for a greater understanding and inclusion of families in treatment, attention to relational aspects of affect, and a dialectical framework for synthesizing individual-oriented and systemic-oriented theories and practice. Some implications for the development of a DBT family therapy model are discussed.

Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial.

OBJECTIVE: We examined whether a shortened form of dialectical behavior therapy, dialectical behavior therapy for adolescents (DBT-A) is more effective than enhanced usual care (EUC) to reduce self-harm in adolescents. METHOD: This was a randomized study of 77 adolescents with recent and repetitive self-harm treated at community child and adolescent psychiatric outpatient clinics who were randomly allocated to either DBT-A or EUC. Assessments of self-harm, suicidal ideation, depression, hopelessness, and symptoms of borderline personality disorder were made at baseline and after 9, 15, and 19 weeks (end of trial period), and frequency of hospitalizations and emergency department visits over the trial period were recorded. RESULTS: Treatment retention was generally good in both treatment conditions, and the use of emergency services was low. DBT-A was superior to EUC in reducing self-harm, suicidal ideation, and depressive symptoms. Effect sizes were large for treatment outcomes in patients who received DBT-A, whereas effect sizes were small for outcomes in patients receiving EUC. Total number of treatment contacts was found to be a partial mediator of the association between treatment and changes in the severity of suicidal ideation, whereas no mediation effects were found on the other outcomes or for total treatment time. CONCLUSION: DBT-A may be an effective intervention to reduce self-harm, suicidal ideation, and depression in adolescents with repetitive self-harming behavior. Clinical trial registration information-Treatment for Adolescents With Deliberate Self Harm; http://ClinicalTrials.gov/; NCT00675129.

Dialectical behavior therapy for suicidal adolescents with borderline personality disorder.

Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and nonsuicidal self-injury. This article introduces dialectical behavior therapy's theoretical underpinnings, describes its adaptation for suicidal adolescents, and provides a brief review of the empirical literature evaluating DBT with adolescents.

Engaging suicidal youth in outpatient treatment: theoretical and empirical underpinnings.

Suicidal and non-suicidal self-injurious behaviors are pernicious and highly prevalent among youth worldwide. Studies confirm that engaging suicidal youth in outpatient treatment is a challenge for most therapists and that a substantial number of suicidal youth never follow through with treatment referrals received in emergency departments and eventually re-attempt suicide. The treatment engagement literature for suicidal youth has largely focused on identifying empirical correlates of attendance and testing interventions to increase compliance. In an effort to promote the use of theory in this field, this article employs Staudt's (2007) conceptual model of the treatment engagement process to both organize the empirical literature and to explain specific treatment engagement and retention strategies used in dialectical behavior therapy for suicidal adolescents. Recommendations for future research are offered.

Fact or fiction: diagnosing borderline personality disorder in adolescents.

Borderline Personality Disorder (BPD) has long been considered a mental health problem that results in considerable costs in terms of human suffering and psychiatric expenses among adult patients. Although the diagnosis of BPD for adolescents is frequently used in clinical settings, the field of mental health has questioned whether one should diagnose BPD among adolescents. This paper reviews the recent empirical literature (identified through PsycINFO 1980 to present) to evaluate prevalence, reliability, and validity of a BPD diagnosis in adolescents. It is concluded that the features BPD diagnoses in adolescents are comparable to those in adults. Furthermore, there appears to be a legitimate subgroup of adolescents for whom the diagnosis remains stable over time as well as a less severe subgroup that moves in and out of the diagnosis. While caution is warranted, formal assessment of BPD in adolescents may yield more accurate and effective treatment for adolescents experiencing BPD symptomatology. More longitudinal research is necessary to further explicate the issues of diagnosing BPD in adolescents.