Dialectical Behavior Therapy (DBT): Lasting Effect, Less Time to Symptom Reduction

A random controlled trial (RCT) called “Dialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial” examined the effect of a short-term DBT treatment program designed for adolescents (DBT-A) on self-harming behavior, suicidal ideation, and depressive symptoms. Researchers compared the effect of DBT-A with the effect of an enhanced usual care protocol based on cognitive behavioral therapy (CBT).

This study is relevant to us, the parents of the teens we work with, and any parents seeking information on treatment approaches for teens who engage in self-harm or suicidal ideation for several reasons:

1. It adds to the substantial evidence-base for supporting the use of DBT to treat teens with mental health disorders such as depression, anxiety, bipolar disorder, and borderline personality disorder.
2. It shows reductions in the types of symptoms and behaviors – i.e. self-harm, suicidal ideation, feelings of hopelessness – associated with the development or mental health disorders in adulthood.
3. It shows DBT works quickly and with long-lasting effect.

We’ll add another thing. Because self-harming behavior and suicidal ideation are associated with suicide attempts and completed suicides in adolescents, it’s important for parents of teens who engage in self-harming behavior and/or suicidal ideation to understand that there’s an evidence-based treatment available that’s proven effective in reducing symptoms associated with suicide attempts and completed suicide among adolescents.

Before we get to the results of the study, let’s talk about the current prevalence of self-harm, suicidal ideation, and suicide among adolescents in the U.S.

Trends in Adolescent Self-Harm, Suicidal Ideation, and Suicide

First, let’s define the clinical terms in the title of the study: self-harm and suicidal ideation.

Self-Harm (NSSI):

American Psychological Association (APA) defines self-harm or NSSI as:

“Deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm may carve or cut their skin, burn themselves, bang or punch objects or themselves, embed objects under their skin, or engage in in myriad other behaviors that are intended to cause themselves pain but not end their lives.”

Suicidal Ideation (SI):

The American Psychological Association (APA) defines suicidal ideation (SI) as:

“Having thoughts of serving as the agent of one’s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent.”

Now let’s look at the rates of self-harm, suicidal ideation, and suicide among adolescents.

Self-Harm, Suicidal Ideation, and Suicide Among U.S. Teens: Facts and Figures

Here are the latest statistics on self-harm:

• Overall, about 17% of teens in the engage in self-harm:
  • 11% of males
  • 24% of females
• The average age of onset for self-harming behavior is 14

Parents of teens who engage in self-harm should understand that in most cases, self-injury is not done with intent to die. In most cases, teens self-harm in order to:

• Escape or process negative emotions (74%)
• Signal their emotions to loved ones, friends, or family (46%)

Here are the latest statistics on suicide and suicidal ideation:

• Around 3,703 high school age teens attempt suicide every day
• Between 2009-2018, the suicide rate among adolescents age 14-18 increased by 61.7%
• 80% of adolescents who attempt suicide give clear warning signs beforehand
• 8% reported seriously considering suicide in the past 12 months
• 54% of teens with a psychiatric disorder reported suicidal ideation
• 29% of pre-teens age 10-12 reported suicidal ideation

Please keep in mind that the most recent reliable statistics on these behaviors are from studies performed before the coronavirus pandemic. All available initial evidence from 2020-present indicates that mental health disorder prevalence among teens increased during the pandemic – and there’s a direct relationship between mental health disorder prevalence and suicide risk.

That’s why it’s important for parents to know about dialectical behavioral therapy (DBT): it’s associated with decreased suicidal behavior among teens.

DBT For Teens: A Quick Primer

Dialectical Behavior Therapy (DBT) was developed Dr. Masha Linehan in the 1980s for adults who engaged in severe and repeated self-harm and suicidal ideation. It soon became apparent that DBT was an effective treatment for people with conditions involving high emotional reactivity, unmanageable thoughts and patterns of behavior, and risk of NSSI, suicidal ideation, and suicidal attempts. Over the past thirty years, Dr. Linehan and others adapted DBT for adolescents. Collectively, these adaptations are known as DBT-A.

DBT-A includes the following five core modules:

1. Mindfulness
2. Emotion Regulation
3. Interpersonal Effectiveness
4. Distress tolerance
5. The Middle Path

These modules help teens improve their awareness of the present moment, process unwanted thoughts, navigate family and peer relationships, manage painful or difficult emotions, and finding the balance between two extremes. As a whole, DBT programs give teens actionable skills that help them manage the symptoms of their mental health disorder in real-world situations.

The specific DBT-A program in the study we discuss below is based on the five core principle we list above. Teens engaged in three outpatient sessions per week over a 9-week period.

Program components included:

• Individual psychotherapy
• Multifamily skills training groups
• Family meetings
• Telephone coaching for patients and family members
• Supervision for therapists

Let’s take a look at that study.

DBT-A: Effective, Fast-Acting, Long Lasting

We know – that heading sounds like a marketing pitch.

We wouldn’t write it, though, without evidence to support the claim.

Remember, the study in question compares a cognitive behavioral therapy (CBT) program – called EUC below – with a DBT-A program, and examines the effect on self-harming behavior, suicidal ideation, and depressive symptoms. Researchers examined data from 77 teens diagnosed with recent and repetitive self-harm. The teens in the study were treated at community psychiatric outpatient clinics community serving children and adolescents. The baseline program lasted 9 weeks. Researchers collect data at the beginning of the program, the end of the program and followed up with interviews at 15 weeks, 19 weeks, and 52 weeks.

Here’s what the researchers found.

Overall, DBT-A was superior to EUC in reducing:

Self-harm

• At 9 weeks:
• • DBT-A: large effect
  • EUC: small effect
• At 15 weeks
• • DBT-A: large effect
  • EUC: small effect

Suicidal ideation

• At 9 weeks
• • DBT-A: large effect
  • EUC: small effect
• At 15 weeks
• • DBT-A: large effect
  • EUC: small effect

Depressive Symptoms:

• At 9 weeks
• • DBT-A: large effect
  • EUC: small effect
• At 15 weeks
• • DBT-A: large effect
  • EUC: small effect

What this data shows us is that DBT-A reduces symptoms of self-harm, suicidal ideation, and depression in a short period of time, compared to most outpatient treatment programs. Whereas most programs last at least six months, this program last three months – and DBT had a large therapeutic effect. And here’s where it gets interesting: at 19 weeks and 52 weeks, the difference between the DBT-A group and the EUC group levelled off, and became statistically insignificant.

That confirms for us something we see every day: DBT programs give teens skills they can use right away. And once they master the skills, they’re last. They’re what we call durable skills, because they’re effective over time in a variety of situations.

Self-Harm, Suicidal Ideation, and Suicide: How Parents Can Help Their Teens

First, parents need to take these topics seriously.

If a teen is at imminent risk of harming themselves or others, call 911 or get them to an emergency room in a hospital or a psychiatric hospital immediately. Do not wait.

Next, for parents with teens who are not in immediate crisis, the most important thing to do is arrange a full psychiatric evaluation with a qualified mental health professional. A mental health professional can diagnose a mental health disorder and offer a referral for treatment. A teen might receive a referral for outpatient treatment, intensive outpatient treatment (IOP), a partial hospitalization program (PHP), or a residential treatment program (RTC).

The program in the study above was an outpatient program in DBT-A, or DBT for adolescents. Parents can find treatment providers through the American Academy of Child and Adolescent Psychiatry (AACAP).

In addition, parents can navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

Finally, teens in need of support can use the following self-harm and suicide resources, which are available right now:

• The Trevor Project Phone (24/7/365): 1-866-488-7386
• Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
• The Trevor Project Chat: CLICK HERE
• The Crisis Text Line (24/7/365): Text CONNECT to 741741
• The Youth Yellow Pages TEEN LINE (6pm-10pm PT) 310-855-4673
• The Youth Yellow Pages TEXT: Text TEEN to 839863