Dialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial

doi:10.1016/j.jaac.2014.07.003

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 53, Issue 10, October 2014, Pages 1082-1091

https://doi.org/10.1016/j.jaac.2014.07.003 Get rights and content

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.

Section snippets

Method

This was a single-blind randomized trial comparing DBT-A with enhanced usual care (EUC). Participants were randomly allocated (Figure 1) to receive either treatment at 1 of the participating child and adolescent psychiatric outpatient clinics in a 1:1 ratio stratified according to gender, presence of major depression, and presence of suicide intent during the most serious episode of self-harm behavior within the 16 weeks before enrollment. Treatment allocation of participants after baseline

Sample Characteristics

Screening, assessment, and randomization procedures leading to allocation of 77 adolescents to either DBT-A (n = 39) or EUC (n = 38) are summarized in Figure 1. Although some patients dropped out of treatment, all patients were followed from baseline to trial completion with no dropouts from the research. Baseline demographic characteristics, diagnostic variables, and pretreatment suicidal and nonsuicidal self-harm behaviors are displayed in Table 1. No significant differences between the

Discussion

This was the first randomized trial of the efficacy of a short version of DBT adapted for the treatment of multi-problem self-harming adolescents with BPD features. Treatment retention in this study was generally good, with no differences between the 2 treatment conditions. DBT was superior to EUC in reducing frequency of self-harm, severity of suicidal ideation, and depressive symptoms, with generally large effect sizes for outcomes in the DBT-A condition, but weak or moderate outcomes in the

References (43)

M. Ystgaard et al.
Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not
J Adolesc
(2009)
A.L. Miller et al.
Fact or fiction: diagnosing borderline personality disorder in adolescents
Clin Psychol Rev
(2008)
A. Wood et al.
Randomized trial of group therapy for repeated deliberate self-harm in adolescents
J Am Acad Child Adolesc Psychiatry
(2001)
P.L. Hazell et al.
Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial
J Am Acad Child Adolesc Psychiatry
(2009)
D.A. Brent et al.
Protecting adolescents from self-harm: a critical review of intervention studies
J Am Acad Child Adolesc Psychiatry
(2013)
C.R. Koons et al.
Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder
Behav Ther
(2001)
L.Y. Katz et al.
Feasibility of dialectical behavior therapy for suicidal adolescent inpatients
J Am Acad Child Adolesc Psychiatry
(2004)
J. Kaufman et al.
Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL): initial reliability and validity data
J Am Acad Child Adolesc Psychiatry
(1997)
A.D. Neacsiu et al.
Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder
Behav Res Ther
(2010)
K. Hawton et al.
Deliberate self harm in adolescents: self report survey in schools in England
BMJ
(2002)

N. Madge et al.

Deliberate self-harm within an international community sample of young people: comparative findings from the Child and Adolescent Self-harm in Europe (CASE) Study

J Child Psychol Psychiatry

(2008)

C.M. Jacobson et al.

The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature

Arch Suicide Res

(2007)

D. Owens et al.

Fatal and non-fatal repetition of self-harm. Systematic review

Br J Psychiatry

(2002)

M.M. Linehan

Cognitive-Behavioral Treatment of Borderline Personality Disorder

(1993)

P.H. Soloff et al.

Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study

Am J Psychiatry

(2000)

G. Winograd et al.

Adolescent borderline symptoms in the community: prognosis for functioning over 20 years

J Child Psychol Psychiatry

(2008)

J.M. Green et al.

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation

BMJ

(2011)

T.I. Rossouw et al.

Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial

J Am Acad Child Adolesc Psychiatry

(2012)

G.L. Carter et al.

Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder

Aust NZ J Psychiatry

(2010)

J.F. Clarkin et al.

Evaluating three treatments for borderline personality disorder: a multiwave study

Am J Psychiatry

(2007)

M.M. Linehan et al.

Cognitive-behavioral treatment of chronically parasuicidal borderline patients

Arch Gen Psychiatry

(1991)

Cited by (364)

Benchmarks for dialectical behavioural therapy intervention in adults and adolescents with borderline personality symptoms
2024, International Journal of Clinical and Health Psychology
Dialectical Behaviour Therapy (DBT) is a multi-component cognitive behavioural intervention with proven efficacy in treating people with borderline personality disorder symptoms. Establishing benchmarks for DBT intervention with both adults and adolescents is essential for bridging the gap between research and clinical practice, improving teams' performance and procedures.
This study aimed to establish benchmarks for DBT using the EQ-5D, Borderline Symptoms List (BSL) and Difficulties in Emotion Regulation Scale (DERS) for adults and adolescents.
After searching four databases for randomised controlled trials and effectiveness studies that applied standard DBT to people with borderline symptoms, a total of 589 studies were included (after duplicates' removal), of which 16 met our inclusion criteria. A meta-analysis and respective effect-size pooling calculations (Hedges-g) were undertaken, and heterogeneity between studies was assessed with I² and Q tests. Benchmarks were calculated using pre–post treatment means of the studies through aggregation of adjusted effect sizes and critical values.
DBT aggregated effect sizes per subsample derived from RCTs and effectiveness studies are presented, along with critical values, categorised by age group (adults vs adolescents), mode of DBT treatment (full-programme vs skills-training) and per outcome measure (EQ-5D, BSL and DERS).
Practitioners from routine clinical practice delivering DBT and researchers can now use these benchmarks to evaluate their teams' performance according to their clients' outcomes, using the EQ-5D, BSL and DERS. Through benchmarking, teams can reflect on their teams' efficiency and determine if their delivery needs adjustment or if it is up to the standards of current empirical studies.
Changing the emotion process: The role of emotion regulation
2024, Change in Emotion and Mental Health
Emotion regulation refers to efforts to change the emotion process in ourselves or others. In this chapter, we first review foundational concepts and define key terms, considering an integrative conceptual framework for understanding emotion regulation—the process model of emotion regulation. The process model identifies five families of regulatory strategies, defined by when they change the emotion generation process. These strategies are embedded in stages in which a need for regulation is identified, a strategy is selected and implemented, and the success of the implementation is monitored. Second, we describe key points at which emotion regulation difficulties can lead to undesired states of affect, followed by strategies that may alleviate these difficulties. Third, we consider adaptive and maladaptive profiles of emotion regulation. Fourth, we describe how interventions might improve how well and how often people use emotion regulation, illustrated by recent studies on therapist-supported internet-delivered therapy for maladaptive anger and nonsuicidal self-injury. Finally, we consider several important growth points for the field.
Promoting Validation and Acceptance: Clinical Applications of Dialectical Behavior Therapy With Pediatric Populations and Systems
2024, Cognitive and Behavioral Practice
Youth living with chronic medical conditions and their families face several challenges (e.g., adjustment to a new diagnosis, ongoing daily condition management, coping with potential long-term consequences of illness). Traditional CBT approaches emphasize collaborative problem-solving with a core focus on change. At times, these approaches may feel inaccessible or unhelpful for pediatric patients and their families who are facing illness-related challenges that they cannot change or control. Dialectical behavior therapy integrates CBT-based change interventions with acceptance-based strategies to normalize challenging thoughts and emotions and help individuals feel validated. Medical providers working with pediatric patients and families can also benefit from a DBT-based conceptualization and approach to improve patient/family-provider relationships. This article summarizes the current evidence base for and justifies the use of adaptations of DBT for patients with medical illness. Further, through clinical case examples, it illustrates the use of DBT skills and concepts in improving outcomes for pediatric patients and their families.
Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy
2024, Journal of the American Academy of Child and Adolescent Psychiatry
To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).
Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ² was used for between-group contrasts.
Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.
Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.
We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.
Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.clinicaltrials.gov/; NCT01528020.
Systematic Review: The Measurement Properties of the Suicidal Ideation Questionnaire and Suicidal Ideation Questionnaire—Jr
2024, Journal of the American Academy of Child and Adolescent Psychiatry
The Suicidal Ideation Questionnaire (SIQ) and the Suicidal Ideation Questionnaire—Junior (SIQ-Jr) were designed to capture suicidal ideation in adolescents and are often used in clinical trials. Our aim was to identify and appraise the published literature with respect to the validity, reliability, responsiveness, and interpretability of the SIQ and SIQ-Jr.
We conducted a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines to identify, appraise, and synthesize published literature on measurement properties and interpretability of the SIQ and SIQ-Jr. We searched MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, and Scopus from inception to May 16, 2023, to identify sources relevant to our aim.
We identified 15 sources meeting our eligibility criteria. The body of literature did not meet COSMIN standards to make recommendations for use with regard to these measurement instruments.
Further research is needed, with a focus on content validity and structural validity, prior to recommending the SIQ and SIQ-Jr for use in clinical practice and in clinical trials. No specific grant funding was used for this review.
Frequency and predictors of individual treatment outcomes (response, remission, exacerbation, and relapse) in clinical adolescents with nonsuicidal self-injury
2023, Psychological Medicine

View all citing articles on Scopus

: This article is discussed in an editorial by Dr. Alan Apter on page 1048.

: This article can be used to obtain continuing medical education (CME) at www.jaacap.org.

: Clinical guidance is available at the end of this article.

: The study was funded by grants from the Norwegian Directorate of Health, the South Eastern Regional Health Authority, the ExtraFoundation for Health and Rehabilitation, and the University of Oslo.

: Lien M. Diep, MSc, served as the statistical expert for this research.

: Disclosure: Drs. Mehlum, Ramberg, Haga, Larsson, Stanley, Miller, Sund, Grøholt, and Mss. Tørmoen, Diep, and Laberg report no biomedical financial interests or potential conflicts of interest.

View full text

New researchDialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial

Objective

Method

Results

Conclusion

Section snippets

Method

Sample Characteristics

Discussion

J Adolesc

Clin Psychol Rev

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Ther

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Behav Res Ther

Deliberate self harm in adolescents: self report survey in schools in England

BMJ

Deliberate self-harm within an international community sample of young people: comparative findings from the Child and Adolescent Self-harm in Europe (CASE) Study

J Child Psychol Psychiatry

The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature

Arch Suicide Res

Fatal and non-fatal repetition of self-harm. Systematic review

Br J Psychiatry

Cognitive-Behavioral Treatment of Borderline Personality Disorder

Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study

Am J Psychiatry

Adolescent borderline symptoms in the community: prognosis for functioning over 20 years

J Child Psychol Psychiatry

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation

BMJ

Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial

J Am Acad Child Adolesc Psychiatry

Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder

Aust NZ J Psychiatry

Evaluating three treatments for borderline personality disorder: a multiwave study

Am J Psychiatry

Cognitive-behavioral treatment of chronically parasuicidal borderline patients

Arch Gen Psychiatry

New research
Dialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial