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Evidence-Based Reviews

Adapting dialectical behavior therapy to help suicidal adolescents

Including the family, other changes increase DBT’s efficacy for these patients

Vol. 10, No. 03 / March 2011

Discuss this article at

Dr. Salsman: Teaching suicidal adolescents skills for ‘walking the middle path’

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents, 1-3 although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing. 4 Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged. 5,6 Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once. 7

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al. 8

Evidence of DBT’s effectiveness

A review of DBT research found strong evidence for DBT’s effectiveness for suicidal adults. 9 Recently, DBT has been adapted to treat adolescents with suicidal behavior and nonsuicidal self-injury (NSSI). 10-15

In a nonrandomized trial, Rathus and Miller 10 compared 29 suicidal adolescent outpatients receiving DBT with 82 participants receiving treatment as usual (TAU). Patients were assigned to DBT if they had a suicide attempt in the previous 16 weeks and ≥3 borderline personality disorder (BPD) features or to TAU if they met only 1 of those conditions. Patients in the DBT group had more axis I disorders and pretreatment hospitalizations than the TAU group. Compared with those receiving TAU, patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU vs 38% in DBT). The DBT group experienced significant reductions in suicidal ideation, BPD symptoms, and general psychiatric symptoms. There was 1 suicide attempt in the DBT group vs 7 attempts in the TAU group; however, this difference was not statistically significant.

Woodberry and Popenoe 11 examined the use of DBT for suicidal adolescents and their families in a community outpatient clinic. Adolescents reported reductions in overall symptoms, depression, anger, dissociative symptoms, and urges for intentional self-injury. Parents reported reductions in their children’s problem behaviors and in their own depressive symptoms. In a study of DBT in 16 adolescent females with chronic intentional self-injury, patients reported significant reductions in incidents of intentional self-injury, depression, and hopelessness, and increases in overall functioning. 12

Three studies have examined using DBT for suicidal adolescents in residential facilities. In a pilot study, Katz et al 13 compared DBT with TAU for 62 suicidal adolescent inpatients. At 1-year follow-up, both groups experienced significant reductions in suicidal ideation, NSSI, and depression. However, compared with those who received TAU, DBT patients had fewer behavioral problems during hospitalization. Sunseri 14 used DBT to treat adolescent females in residential treatment. After DBT was implemented, residents were hospitalized because of NSSI and suicidality for fewer days than before DBT. Trupin et al 15 taught DBT to staff who worked with female adolescent offenders at a juvenile rehabilitation facility. After the staff implemented DBT, the rates of problem behaviors and punishment by staff decreased on 1 unit; there were no behavior or punishment changes on another unit.

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation. 8 The biosocial theory postulates that these problems are the result of the transaction, or reciprocal relationship, between biologic predispositions and an invalidating environment. The biosocial theory suggests 3 biologic characteristics often are found among suicidal adolescents:

  • high emotional sensitivity
  • high extremity in reactions
  • a slow return to baseline after experiencing a surge in affect. 8

Although these characteristics indicate higher emotionality, they are not sufficient to account for suicidal adolescents’ difficulties. Problems arise when individuals with these biologic characteristics are raised in an invalidating environment, where the adolescent does not learn how to regulate emotions. Common characteristics of invalidating environments and their effects on adolescents are described in Table 1 . 8

Treatment theory. DBT for suicidal adolescents focuses on a synthesis between 2 seemingly opposite treatment strategies: change and acceptance. The change focus is derived from behavioral science, and treatment incorporates standard behavior therapy practices, including chain analysis (described below), skills training, contingency management, and exposure.

The acceptance focus draws upon principles of Zen and other Eastern spiritual traditions. Therapists teach patients to accept reality as it is in this moment, without judgment. A key extension of this acceptance is the use of validation—radical acceptance and acknowledgement that all behavior has validity and understandability. DBT therapists strive to use 6 levels of validation with their patients ( Table 2 ), 16 which often is a critical strategy for adolescents who reside in an invalidating environment.

DBT attempts to synthesize the acceptance-based Zen tradition with the change-based strategies of behavioral science through a dialectical philosophy. A fundamental postulate of dialectical philosophy is that a tension occurs when an initial truth or thesis is opposed by an apparently contradictory truth or antithesis. 8 DBT therapists work with adolescents to find a synthesis that is the “middle path, “ which includes the truth in both positions as well as what is left out of both. For an example of how this might work for an adolescent patient with NSSI, visit this article at

Table 1

Characteristics of an invalidating environment



Indiscriminately rejects communications of private experiences

Adolescents learn to actively self-invalidate and do not learn to validate themselves, label their emotions, or effectively regulate their emotions

Actively punishes displays of emotions, interspersed with intermittent reinforcement of emotional outbursts

Adolescents develop problematic emotion regulation strategies that oscillate between suppression and extreme outbursts

Oversimplifies problem solving

Adolescents develop high perfectionism and sensitivity to perceived failure, form unrealistic goals, and experience intense negative arousal in response to challenging feedback

Source: Reference 8

Table 2

6 levels of validation employed by DBT therapists


Validation practices

Accurate reflection

Paraphrase what an adolescent says; communicate that you accurately understand what the adolescent has said


Communicate that you understand the adolescent’s private experiences or that which is unsaid. Articulate private experiences of the adolescent based on your knowledge of him or her

Observing and listening

Use nonverbal and paralinguistic cues to indicate interest. Communicate that you wish to know the adolescent’s emotions, thoughts, and behaviors

Validating in terms of causes

Make sense of behavior based on the adolescent’s learning history or biology. Describe how a behavior is effective for short-term but not long-term goals

Validating in terms of the present

Search for and reflect the wisdom and truth in the adolescent’s behavior by saying things such as ‘Of course you feel this way! Anyone would feel the same in your situation’

Radical genuineness

Act natural, like a real person, rather than a ‘therapist. ‘ Communicate belief and confidence in the adolescent

DBT: dialectical behavior therapy

Source: Reference 16

How DBT works

DBT serves 5 functions. It enhances patient capabilities, increases patient motivation, structures the environment to increase the likelihood of success, works to assure generalization from therapy to the natural environment, and enhances therapists’ capabilities and motivation to treat patients effectively. 8 Outpatient DBT for suicidal adolescents uses 4 modes of treatment:

  • weekly individual therapy
  • weekly skills training
  • telephone coaching
  • weekly therapist consultation team meetings. 8

Although Linehan’s original research with adults was based on a 1-year treatment model, 17 treatment lasts 12 to 16 weeks in the adolescent DBT model designed and studied by Miller et al. 8 Treatment for adolescents is shorter because research indicates that suicidal adolescents frequently fail to complete longer courses of therapy. 18

Individual therapy. The rank-ordered targets of individual therapy in the first stage of DBT are to:

  1. eliminate life-threatening behavior, including NSSI
  2. stop therapy-interfering behaviors (eg, not showing up to sessions)
  3. change behaviors that interfere with the adolescent’s quality of life (eg, substance abuse)
  4. enhance the adolescent’s use of skills.8

The individual therapist sets treatment goals in accord with these targets, monitors progress, integrates all modes of therapy, and balances acceptance and validation of the patient with being a catalyst for change. Family members may be included in therapy sessions when family problems emerge as the highest priority.

DBT therapists use chain analysis—which is a process of assessing the series of events, link by link, that lead from a prompting event to a problem behavior (eg, suicide attempt)—to assess problematic behavior and identify methods of change. 8 The therapist and patient use this process to develop alternative behaviors for the patient to use to reach a more effective outcome.

DBT therapists also ask adolescents to fill out a daily diary card that tracks targeted behaviors, including NSSI, suicidal urges, and important emotions. The diary card helps the therapist determine what needs to be targeted in therapy, increases mindfulness and understanding of problem behaviors, and helps change targeted behavior.

Skills training addresses skills deficits believed to be causing the suicidal adolescent’s problems. DBT systematically teaches 5 skill sets:

  • emotional regulation
  • mindfulness
  • interpersonal effectiveness
  • distress tolerance
  • “walking the middle path. “ 8

These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Table 3 provides steps that teach “opposite action, “ which can reduce ineffective emotions and problematic urges associated with these emotions. Table 4 provides mindfulness practices that can help patients address problems such as mindlessness and avoiding the present moment. Although adolescent DBT skills training is similar to that in adults, Table 5 describes key differences.

Table 3

Teaching adolescents ‘opposite action’

Ask, what emotion am I experiencing? (eg, anger)

Ask, is it effective for me to experience this emotion? Does this emotion fit the facts of the situation? (If the answer to either of these questions is no, then proceed)

Ask, what is the action urge associated with this emotion? (eg, to attack)

Do actions that are opposite to the action urge (eg, gently avoid the person with whom you are angry)

Act opposite to the action all the way and completely (eg, have empathy and understanding for the other person, change your body posture by unclenching hands and relaxing facial muscles)

Keep repeating the opposite action until the emotion decreases

Source: Reference 8

Table 4

Mindfulness practices: Teach adolescents to live in the present moment



Mindful eating

Provide patients with a piece of food such as a carrot slice, raisin, saltine, candy, etc. Instruct them to eat the food using all of their senses. Tell them to observe it visually, notice the smells and textures, the taste, etc. Encourage patients to notice all that goes into the process and mechanics of chewing and swallowing. Observe the taste, changes in texture, and even sounds

Observing different body parts

Ask patients to get in a comfortable, relaxed, and still position. Provide verbal instructions to attend to a body part. For example, ‘Focus your attention on your left knee. If you notice your mind wandering, bring your attention back to your left knee. ‘ Spend about 30 seconds attending to the body part and then switch to another body part (eg, upper lip, right ear lobe, third toe on your left foot, etc. )

Mindful blowing bubbles

Provide patients with bubbles and ask them to blow bubbles. Pay attention to the activity and the bubbles themselves. If patients get distracted or have judgments about the activities, instruct them to notice these thoughts and bring themselves back to participating

Source: Reference 8

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