During the initial stages, the therapist helps the patient and his family to understand the nature of the illness by assigning a limited sick role that emphasizes the disease model of depression and removes any blame (by self or by a parent). The therapist also uses a closeness circle to help the adolescent map the current connectedness of the significant relationships in his life and to identify those that he would like to deepen, distance, or change (Table 2).
IPT-A is a principle-driven approach with an active patient role. Thus, providers are offered a variety of helpful intervention techniques, but a particular intervention is not prescribed for each week. The selection of the specific techniques to use is driven by the early identification of the interpersonal problem area of focus.
The efficacy of IPT for depressive disorders has been well studied; there have been 38 randomized controlled trials. Five of these specifically examined an adolescent (versus adult) population. Studies that compared adolescents who received IPT-A with a control group (wait list control, clinical monitoring, TAU, CBT) yielded an estimated average effect size of 0.63 in meta-analysis.14 Adolescents who received IPT-A rather than clinical monitoring or TAU reported greater reduction in depressive symptoms posttreatment and greater increase in problem-solving skills and interpersonal functioning at 16-week follow-up.
Several international studies examined the efficacy of IPT-A with Ugandan, Taiwanese, and Puerto Rican adolescents.15-17 These studies yielded similar results, suggesting that IPT-A is as effective as CBT in reducing depressogenic symptoms, including decreases in depressed mood, suicidal ideation, hopelessness, and anxiety. Both IPT-A and CBT were found to be more effective than the wait list control at posttreatment and 3-month follow-up assessments.14-16 However, IPT-A appears to have a supplementary effect on adolescents in that it also increased overall social functioning, self-esteem, and problem-solving skills, which may act as protective factors against relapse.17,18
Although these studies shed light on the efficacy of IPT-A, the treatment has yet to be compared with pharmacotherapy in an adolescent population. The NIMH did, however, conduct a study in which IPT was found to be as effective as imipramine in the treatment of MDD in adults.19
Dialectical behavior therapy
DBT was developed by Linehan20 in the early 1990s. It is based on her extensive clinical and research experience in treating chronically suicidal women. The approach was originally aimed at treating borderline personality disorder (BPD), of which chronic suicidality is a major feature. Adaptations to adolescent populations (DBT-A) were made in 2002 by Rathus and Miller,21 eventually culminating in a manual for adolescents in 2007.22
Although experts have suggested that BPD can be meaningfully diagnosed in adolescents, historically, personality disorders were not diagnosed in persons younger than 18. Thus, DBT for adolescents (DBT-A) was targeted specifically at suicidality, as opposed to BPD. However, in defining their criteria for admittance, specific DBT-A programs may seek to identify adolescents with multiple problem behaviors (mood symptoms, self-harm, substance abuse, eating disorder, risky sexual behavior, high-risk activities, and problem behaviors such as stealing and lying) of which suicidality or parasuicidal and self-injurious behavior are prominent. Some programs require the adolescent to meet at least 3 or 4 of the BPD criteria for inclusion.22
The DBT model is predominantly a behavioral one; however, this underlying theoretical approach is melded with Zen mindfulness principles to create a dialectic that simultaneously emphasizes acceptance of the patient in his current state and a willingness to continually work to change and improve. The treatment approach targets 5 functions: enhancing patient capabilities, increasing motivation, structuring the environment to increase the likelihood of success, promoting generalization from therapy to the natural environment, and enhancing therapists’ capabilities and motivation to treat patients effectively (Table 3).
These functions are addressed through 4 modes of treatment: multifamily group skills training, individual psychotherapy, coaching calls, and a consultation team for the therapist. The approach is a “life enhancement” as opposed to suicide prevention program. Thus, if an adolescent can be helped to envision and work toward an obtainable, truly exciting life, then suicide no longer becomes a logical “solution” to the adolescent’s problems. The adolescent’s presenting problems (target behaviors) are behaviorally defined and logically identified as barriers to his self-defined “life worth living.”
Skills training is founded on evidence that patients who present with chronic suicidality lack certain coping skills for soothing and regulating themselves during times of high stress and emotion. The skills taught encompass 5 areas, 4 original to DBT and the fifth added for the adolescent adaptation: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and walking the middle path (adolescent-specific).20,22
Although the structure of skills training is specific, individual DBT sessions are principle- rather than protocol-driven—the clinician is given a toolbox of techniques and a road map based on DBT principles and the patient’s treatment goals and target behaviors. This allows treatment to stay cohesive in the face of a patient population that typically is under a great deal of stress and distress, with multiple problems otherwise resulting in the challenge to treatment of an ever-moving target with “crises du jour” threatening to derail treatment gains. By keeping a principle-driven approach, the therapist and adolescent are able to incorporate the important events of the week into overarching treatment goals without losing momentum or focus.
Goals in DBT follow a hierarchy, with life-interfering behaviors taking precedent, followed by behaviors that interfere with or threaten treatment, quality-of-life–interfering behaviors, and finally skills enhancement. A full description of DBT techniques is beyond the scope of this article, but additional information can be found in primary texts and summary articles.20,22-24
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