Dialectical behavior therapy: a new treatment approach for suicidal adolescents.

Suicide accounts for more adolescent deaths in the United States than all natural causes combined and ranks as the third leading cause of death among 15- to 19-year-olds (1). It is estimated that in 1990, almost 300,000 high school students in the United States made suicide attempts that required medical attention (2). Follow-up studies find that about 10-50% of adolescents who attempt suicide make future attempts (3), and up to 11 % of adolescent attempters eventually die by suicide (4). Nearly all adolescents who engage in suicidal behavior have a diagnosable psychiatric disorder (5), such as affective disorder, substance use disorder, conduct disorder (6, 7) or borderline personality disorder (BPD) (8, 9), with high rates of comorbid Axis I and Axis II disorders being the rule rather than the exception (10). Many of these teens are at high risk for dropping out of school, substance abuse, violence, and high-risk sexual behaviors, which contribute to teenage pregnancy and HIV transmission (11-14). Unfortunately, up to 77% of adolescent suicide attempters will not attend or will drop out of outpatient treatment (15) before learning how to better tolerate distress and regulate their emotions with skills that would serve to reduce suicidal and other extreme behaviors. These alarming statistics beg the question: what is being done to effectively treat these suicidal multi-problem adolescents? Many different therapeutic interventions (e.g., psychodynamic, cognitive-behavioral, group, family, pharmacologic) have been applied to this difficult-to-treat population; yet, to date, there is not a single empirically supported psychotherapy developed specifically for suicidal multi-problem adolescents (16). DIALECTICAL BEHAVIOR THERAPY Dialectical behavior therapy (DBT) (17, 18) was developed by Linehan for chronically parasuicidal women who were diagnosed with borderline personality disorder (BPD). Parasuicide is defined as any acute, intentionally self-injurious behavior resulting in physical harm, with or without intent to die (17). DBT is currently the only empirically supported treatment for suicidal multi-problem patients who commonly exhibit severe behavioral dyscontrol. In a one-year randomized clinical trial compared to Treatment-As-Usual, DBT not only significantly reduced suicidal behavior (including frequency and medical severity of parasuicidal acts), the number of inpatient psychiatric days, drop-out rate, and anger, it also improved social adjustment and treatment compliance (19, 20). Miller and colleagues (16) adapted DBT for suicidal adolescents with borderline personality traits because of its specific focus on reducing suicidal and quality-of-life-interfering behaviors, as well as keeping adolescents engaged in treatment. DBT is based on Linehan's (17) biosocial theory in which BPD is thought to be caused by pervasive emotional dysregulation. Emotional dysregulation is viewed as the result of the transaction between an individual who is biologically predisposed to have difficulty regulating emotion and an environment that intensifies this vulnerability. The theory suggests that BPD behavior results when a child who has difficulty regulating emotion is placed in an invalidating environment, i.e., one that pervasively and chronically communicates that the child's responses are inappropriate, faulty, inaccurate, or otherwise invalid (17, 21). Thus, DBT conceptualizes parasuicidal behaviors as having several potential functions, including affect-regulating and help-eliciting behavior from an otherwise invalidating environment. From this perspective, parasuicidal behaviors are considered maladaptive solutions to overwhelming, intensely painful negative emotions. DBT with adolescents consists of 12 concomitant weekly individual and group therapy sessions. A primary focus and dialectic of the treatment is the emphasis on balancing change and acceptance. Hence, the therapist selectively applies problem-oriented change strategies (i. …