Dialectical behavior therapy (DBT) is one of the acceptance-based therapies, which characterize the third generation of behavior therapy. Other acceptance-based therapies are acceptance and commitment therapy (ACT) and mindfulness. Dialectical behavioral therapy is an evidence-based therapy. Originally, Linehan (1993a, 1993b) developed DBT for adults with suicidal-related behavior, extreme emotional and behavioral dysregulation, and borderline personality disorder (BPD). Further research has also shown that DBT can be applied effectively to adolescents with suicide ideation and behavior (Fleischhaker et al., 2011; James et al., 2008; Miller et al., 2000; Woodberry & Popenoe, 2008). The purpose of this study is to examine the effectiveness of DBT application to adolescents with suicide ideation and behavior.

The Theoretical Foundation of Dialectical Behavioral Therapy

Primarily, DBT assumes that emotions precede the development of thoughts, and so are the primary causes of psychopathology (Seligman & Reichenberg, 2014). Thus, helping clients regulate their emotions will resolve several psychological. Secondly, DBT is founded on behavioral therapy and its principles. Historically, the first generation of behavior therapy involves classical (S-R) behaviorism and neobehaviorism, whereas the second generation (e. g., cognitive behavioral therapy) involves the rise of the cognitive revolution while retaining some behavioral principles (Guercio, 2020). The third wave behavioral therapy involves incorporating acceptance-based therapies into cognitive behavioral therapy (e. g., DBT). Hence, DBT clinicians incorporate behavioral techniques and principles (e. g., problem-solving, exposure, and cognitive reconstruction) to assess clients’ needs, help them define their goals, and acquire the essential skills for effective behavior (Budak et al., 2020).

Thirdly, DBT is founded on dialectical philosophy, which involves looking at reality and integrating the opposites. There is an alternative story or a dialectical pole in every person’s story. Similarly, DBT holds the assumption that clients are experiencing a dialectical conflict between themselves and their environment. Thus, DBT clinicians work to understand clients’ worlds and help them consider alternative possibilities (dialectic poles). Fourthly, as an acceptance-based therapy, DBT is founded on mindfulness meditation, acceptance, and other Zen practices. In mindfulness, thoughts are observed without judgment. Through acceptance, DBT clients learn to remain available to the present experience without attempting to end the painful experience or prolong the pleasant experience (Budak et al., 2020; Kramer et al., 2013). Based on acceptance and mindfulness principles, DBT assumes that trying to deny, avoid, and escape strong emotions paradoxically makes those emotions more intense.

Major Dialectical Behavioral Therapy Techniques

The major DBT strategies include: (a) dialectical techniques, (b) validation techniques, (c) problem-solving strategies, (d) stylistic communication strategies, and (d) case management techniques.

Dialectical Techniques

Dialectical strategies define DBT. In addition to functioning as a specific set of procedures, they organize therapy sessions and integrate other treatment strategies. In this way, dialectics attends to the entire therapy context and the oppositions naturally ensuing in the therapeutic relationship. Dialectical techniques include entering the paradox, playing the devil’s advocate, extending, using metaphor, making lemonade out of lemons. Entering the paradox requires the therapists to highlight the conflicting nature of the client’s behaviors, the therapeutic relationship, and reality in general. The therapist might enter the paradox with a client who refuses to admit her problems thus: no one comes to therapy to change good behavior. Other examples of paradoxes include unwillingness to experience anxiety perpetuate anxiety, one must accept people’s inability to accept, and treatment for insomnia is staying awake.

Metaphors, storytelling, analogies, or anecdotes help to teach the paradoxical nature of clients’ behavior and open up the possibilities for new behavior. For instance, using the metaphor of the sun, the therapists can tell the client who has agoraphobia, “it’s like living a life where you’re trying to hide from the sun because you might get burned.” Playing the devil’s advocate, another dialectical technique, is a form of reversal role in which the clinician holds the client’s distorted belief so that the client argues against the belief. For instance, the therapist holds a client’s belief that disagreement means hatred, while the client argues against it. Extending is another dialectical strategy, and it involves the therapist taking clients more seriously than they expect. For instance, a therapist might offer to give a client threatening to leave therapy referrals. Making lemonade out of lemons involves seeing something positive in the negative event. For instance, accepting suffering enhances sympathy.

Validation Techniques

Validating the client’s subjective experience requires accepting the client’s emotional, cognitive, or behavioral response to a situation. According to Linehan (1993a), validation occurs when the therapist communicates to clients that their responses make sense and are understandable within their current life context or situation. Heard and Linehan (1994) noted various levels in which validation can occur: active listening, reflecting the client’s experience back to the client, and noting the client’s unstated experience. Other levels are validating the response or experience in terms of past learning experience or present circumstances.

Problem Solving Techniques

These strategies focus on change. The first part of problem-solving involves behavioral analysis of the client’s dysfunctional behavior. To complete behavioral analysis, the client must accept that the problem occurred, describe the detailed behavior without judgment, and explain the effect of the behavior analysis (Heard and Linehan, 1994). The second part of problem-solving involves solution analysis. Behavioral skills used for solution analysis include cognitive modification/reconstruction, contingency management, exposure, and desensitization. Another important behavioral skill for solution analysis is skills training modules. The skills modules include mindfulness skills, distress tolerance skills, emotion regulation, and interpersonal effectiveness. The skills modules target confusion about oneself, impulsivity, emotional dysregulation, and interpersonal problem. These four behavior problems are the common features of suicide ideation and behavior (Miller et al., 2000).

Specifically, mindfulness skills include wise mind, observing, describing, participating, nonjudging, staying focused, doing what works. These skills treat confusion about oneself. Distress tolerance skills target impulsivity, and they include ACCEPTS (i. e., Activities, Contributing, Comparison, Emotions, Pushing away, Thoughts, Sensation), distract, self-soothe, pros and cons, radical acceptance. Emotion regulation skills target treating emotional dysregulation, and they include PLEASE (i. e., treat Physical iLlness, balance Eating, Avoid mood-altering drugs, balance Sleep, Exercise) building mastery, building positive experience, and acting opposite. The fourth skills module, interpersonal effectiveness skills, targets interpersonal problems. The modules include GIVE (i. e., be Gentle, act Interested, Validate, use an Easy manner), DEARMAN (i. e., Describe, Express, Assert, Reinforce, take hold of your Mind, Appear confident, Negotiate), and FAST (i. e., be Fair, no Apologies, Stick to values, be Truthful).

Stylistic communication Techniques

These strategies involve how the therapist interacts with the client. In DBT, stylistic strategies are grouped into reciprocal and irrelevant communication. According to Linehan (1993a), reciprocal communication styles include responsiveness, compassion, caring, self-disclosure, warmth, genuineness, attending to the clients mindfully without any prejudgment or noticing subtle responses. In contrast, irrelevant communication styles include confronting the client’s crazy behavior and unorthodox, unhallowed, impertinent, and incongruous responses to clients. However, therapists must apply irrelevant communication styles upon a foundation of relevant communication styles.

Case Management Techniques

These strategies involve helping clients manage their physical and social environment to facilitate their overall life functioning and wellness. In other words, the strategies help therapists respond to clients’ environment beyond the therapeutic relationship. Case management strategies comprise environmental intervention (therapists interacting with the client’s environment), consultation to the clients (helping clients interact with their environment), and supervision/consultation (According to Heard and Linehan, 1994).

Dialectical Behavioral Therapy Stages of Intervention

Dialectical behavioral therapy is a four-stage based intervention that incorporates many behavioral principles. The first stage is the pretreatment stage. Here the primary target is to familiarize clients with the treatment process, secure commitment to treatment, and facilitate attainment and basic competencies, such as keeping themselves safe, reducing self-harm (e. g., drug use, self-injury, unwise and sexual activity). Activities in this stage include: discussing DBT concepts; discussing clients’ responsibility, expectations, assessment, planning; overview of treatment stages; and teaching client relevant skills, such as self-care, emotional regulations, and interpersonal effectiveness. There four targets in this stage. The first and highest priority is to decrease life threatening behaviors, such as suicidal or parasuicidal behavior. It is possible that such behavioral problems do not occur. The second priority is to decrease therapy-interfering behavior (e. g., tardiness, not showing up for session, or not completing home assignments). The third priority is decreasing quality-of-life interfering behaviors, such as school problems, depression, anxiety, relationship problems, impulsivity, acting out problems, and substance abuse. The fourth priority is to increase behavioral skills.

The second stage is the decrease of traumatic experiences and associative symptoms of distress and anxiety. Desensitization and other strategies can be helpful here. However, many clients do not experience this type of response. In this case, they can move on to the third stage, which involves enhancing self-respect, resolving problems of living, and accomplishing individual goals. In stage four, the focus is to address deeper existential issues, including cultivating greater sense of freedom, creating joy, and finding happiness in life. To achieve these gains, there is the need to synthesize and generalize gains, integrate the past, present and future, develop spirituality, acceptance of self and reality, increase self-respect and achievement of individual goals, increase coping skills.

Applying Dialectical Behavior Therapy on Adolescents with Suicide-Related Behavior

Miller et al. (1997) proposed adaptations of DBT for adolescents (DBT-A) in their work Dialectical Behavior Therapy Adapted for Suicidal Adolescents. In this work, Miller et al. (1997) noted that the modifications of DBT for adolescents targeted adolescents with suicide ideation, suicide behavior, and non-suicidal self-harm. The adaptations include shortening the length of the treatment from I year to 12 weeks, reducing the total number of skills modules, and incorporating family members into treatments. Other modifications include simplifying the language used in handouts and skills training lectures and adding an optional 12-week follow-up patient consultation group.

Later, Miller et al. expanded on their research on DBT modifications for adolescents with emotional and behavioral dysregulation, including suicide ideation and behavior. They provided seven main adaptations of standard DBT. The first adaptation is to incorporate family members, usually parents, into treatment to serve as models and coaches for their adolescents in utilizing implementation skills, facilitate skill generalization for their adolescents, and provide skill reinforcement, support, and validation for them (Miller et al., 2007b). Incorporating family members provides the opportunity for role-playing skills, fosters interfamily support, reduces adolescents’ disruptive behaviors in the group, and enhances treatment compliance.

The second adaptation is conducting 3 to 4 family therapy sessions when the contingencies at home reinforce the dysfunctional behavior. Under these circumstances, the therapist initiates family therapy to enhance treatment by educating the family members about particular skills or aspects of treatment. In addition to modifying contingencies in the home, family therapy sessions improve family communication, and address parents’ emotional dysregulation, and help family members understand the adolescent’s emotional vulnerability (MacPherson et al., 2012). The third adaptation is developing and teaching the three adolescent-family dialectical dilemmas (MacPherson et al., 2012; Rathus & Miller, 2000). These dialectical dilemmas are excessive leniency versus authoritarian control, viewing the normal adolescent behavior as deviant versus the inability to perceive or address the adolescent deviant behavior, and forcing autonomy (e. g., through severing ties with the adolescent) versus fostering dependence (e. g., through excessive caretaking and overreliance on parents. The fourth adaptation is the reduction of treatment length from I year to 16 weeks. The therapy content (e. g., skills training modules) is increased to compensate for this reduction (Miller et al., 2007b).

The fifth adaptation is the second phase of the therapy, which involves a 16-week optional graduate group for clients who continue to show difficulties after completing the first phase of the treatment. The purpose of this graduate group is to reinforce and generalize skills taught in the first phase. Adolescents may repeat the graduate group as often as possible to attain their identified goals. The sixth adaptation involves slightly reducing the number of skills taught within each of the four skills modules (i. e., mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance) and adding a fifth adolescent-specific skills module, namely, walking the middle path for the adolescents and their family. This additional skills module teaches validation for self and others, behavioral principles (e. g., reinforcement, punishment, extinction, and shaping), and three adolescent-family dialectical dilemmas (MacPherson et al., 2012). The seventh and last adaptation involves modifying skills hands to improve their appeal and applicability to adolescents. Modifications include streamlined language, simplifying terminology and visual layouts, adapting examples of each skill, utilizing experiential and in vivo than didactic methods (MacPherson et al., 2012).

Research Supporting the Efficacy of Dialectical Behavioral Therapy on Adolescents with Suicide Behavior

Several empirical studies have evaluated DBT for adolescents with suicide ideation and suicidal behavior. For instance, Miller et al. (2000) treated adolescents (n = 33) with BPD using the four DBT skill modules: mindfulness, distress tolerance, emotion regulation skills, and interpersonal effectiveness skills. They found a statistically significant reduction in confusion about oneself, impulsivity, emotional instability, interpersonal problems and overall BPD symptom reduction. Similarly, James et al. (2008) examined the use of DBT in treating a community sample of female adolescents (n = 16) with persistent suicide ideation or severe, deliberate self-harm using DBT. Pre- and posttreatment assessments revealed a significant reduction of depression, hopelessness, episodes of deliberate self-harm, as well as increased general functioning. The authors also reported that the intervention was well accepted in a notoriously difficult group whenever it comes to psychotherapy.

Fleischhaker et al. (2011) used Rathus and Miller’s modified version of DBT for Adolescents to treat adolescents (n = 12) with suicidal behavior, non-suicidal self-injurious behavior, and BPD. Using pre/post comparison and a one-year follow-up, the authors measured the treatment efficacy. The study results indicated that suicidal behavior and non-suicidal injurious behavior reduced significantly over the year. Also, nine completed the therapy regularly out of ten patients diagnosed with BPD at the beginning of the therapy. Among these nine patients, BPD features persisted only in one participant one year after therapy. Thus, the intervention was well accepted by the patients and their family members, who also played a role in the treatment.

Additionally, Woodberry and Popenoe (2008) examined the DBT program for adolescents (n=28) with suicidal and self-injuring behavior in a community outpatient treatment settings. The study involved an uncontrolled pre- to posttreatment design. The authors also reported including parents (n = 19) who collected reports for adolescents and parental change. The study results showed a large and significant reduction of suicide behavior among the adolescents (n = 27, d= .73, p = .001). Similarly, there was a significant decrease in the frequency of self-harming behavior (n = 27, d= .62, p = .004). The percentage of adolescents wanting to kill themselves reduced from 32% to 5 %, and those not wanting to kill themselves increased from 32% to 63%. However, the authors reported that confounding variables (e. g., medication, maturation, placebo, selection bias, and clinical instability) might have contributed to the reported changes in the absence of a control group.

Conclusion

Dialectical behavior therapy, one of the acceptance-based therapies, can be applied effectively to adolescents with suicidal-related behavior. Family therapy sessions are an important requirement for DBT with adolescents to address contingencies at home reinforcing dysfunctional behavior. Major DBT techniques for effective treatment include dialectical techniques, validation techniques, problem-solving strategies, skill training modules, and stylistic communication strategies. However, the skills training modules (mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness) are highly effective in treating confusion about oneself, impulsivity, emotional dysregulation, and interpersonal problem, which are common features of suicidal behavior.

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