The most promising outcomes are for intensive outpatient psychotherapies with a strong family focus such as dialectical behavior therapy (DBT), a “third wave” cognitive behavioral therapy (CBT). DBT begins with CBT strategies and adds a focus on acceptance and validation, dialectical processes such as the need to achieve a balance between acceptance and change strategies, addresses behavior that interferes with therapy, and emphasizes the therapeutic relationship as key for healing. Originally developed/tested for treating suicidal adults with borderline personality disorder, DBT for adolescents includes individual psychotherapy with some family sessions, multifamily group skills training with adolescents and parents, therapist availability for phone coaching 24 hours daily for youths and parents, and weekly therapist consultation teams to support therapists in doing the best they can to provide effective treatment and stay within the treatment model.9-11 In contrast to DBT with adults, which was developed as a 1-year treatment, DBT for adolescents is briefer (16 weeks,10 or 6 months) and includes parents.9,11 There are two RCTs demonstrating benefits of DBT relative to comparator conditions (supportive therapy, treatment as usual [TAU]) for reducing SH, with one trial indicating an advantage of DBT for reducing SAs.10,11 Replication of a DBT advantage across two independent RCTs makes DBT the first well-established treatment for SH in adolescents. Further, results from both RCTs indicate an advantage of DBT for reducing SH over a 1-year follow-up period, and one trial supports cost-effectiveness of DBT relative to TAU.10-12
Other treatments have shown efficacy in reducing SAs in single trials, although replication is needed. These include: SAFETY, a DBT-informed child- and family-centered treatment found to lead to reduced SA risk relative to TAU after an SA or recurrent SH; integrated-CBT for youths presenting with substance abuse and SAs or SI that resulted in fewer SAs compared to TAU; and mentalization-based therapy for reducing SH.13-15 Meta-analyses evaluating existing trials of therapies for SH demonstrate the importance of family interventions in reducing SH.7 DBT, SAFETY, and Integrated-CBT have strong family components and use a two-therapist model with one therapist working primarily with the teen and the other primarily with the parent(s)/caregivers. Although assignment of two therapists to a case can be challenging in practice, this model allows more intensive work with parents and family within a short time frame, which may be needed with youths at high risk for suicide and SH. Enhancing the family’s ability to keep the youth safe, and the youth’s ability to accept this protection, allows parents to function like “protective seatbelts” when a youth is experiencing intense pain and distress.13
Dr Asarnow is Professor; Dr Fogelson is Clinical Professor; Ms Fitzpatrick is Clinical Research Coordinator; Psychiatry and Biobehavioral Sciences, University of California, Los Angeles; Dr Hughes is Assistant Professor, Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX. Dr Asarnow reports that she is a consultant/receives funding from the NIMH, the Substance Abuse and Mental Health Services Administration, the American Psychological Association, the American Foundation for Suicide Prevention, and the Klingenstein Third Generation Foundation. Drs Fogelson and Hughes and Ms Fitzpatrick report no conflicts of interest concerning the subject matter of this article.
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