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DBT the Gold Standard for Treating Adolescent Self-Harm and Suicidal Ideation

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT

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How to Help Teens Who Self-Harm and Think About Suicide

If you read the news at all these days, there’s a good chance you know about the troubling increase in suicide among teens in the U.S. Once you get past the stories about the pandemic, politics, and entertainment, you find stories about mental health. Most focus on the negative effect of the pandemic on mental health disorders such as depression and anxiety. Which makes sense: the pandemic needs our attention.

Earlier this month, the Centers for Disease Control (CDC) published a report charting the rise and fall of anxiety and depressive disorders against the rise and fall of daily COVID-19 positive tests. You may not be surprised to learn that the two trends mirrored one another almost exactly. As positive tests for COVID-19 rose between August 2020 and February 2021, symptoms of anxiety and depression increased as well. Then, as positive tests for COVID-19 decreased between February 2021 and June 2021, symptoms of anxiety decreased.

Another CDC report described the increase in suicidal ideation during the pandemic. That report was important because, with the nation’s attention on anxiety and depression related to the cumulative stress of 2020 and 2021, it reminded us of the increase in teen self-harm, suicidal ideation, and suicide that occurred between 2014 and 2019.

If you weren’t aware of those increases, we’ll bring you up to date on where we stood before the pandemic, with regards to adolescent mental health, with a specific focus on teen suicide and teen self-harm. Then we’ll share the results of a new study that presents evidence about one of the most effective treatments for reducing teen self-harm and suicidal ideation: Dialectical Behavior Therapy (DBT).

Self-Harm and Suicidal Ideation Among U.S. Teens

First, we should clarify the language we use, here. Unfortunately, most of us can easily define suicide. It’s when an individual intentionally ends their own life. Most of us also know suicidal ideation refers to the phenomenon of an individual thinking or talking about taking their own life. However, many people don’t know exactly what we mean by self-harm beyond the surface meaning implied by the basic definitions of the two words in the phrase.

The  American Psychological Association (APA) defines self-harming behavior – also known by the clinical name non-suicidal self-injury (NSSI) – as follows:

“The condition…is characterized by 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 myriad other behaviors that are intended to cause themselves pain but not end their lives.”

Another common term for NSSI or self-harm is cutting, since using sharp objects to harm oneself – typically on the arms, wrists, or thighs – is one of the most common forms of NSSI among teens.

But how common is teen self-harm, a.k.a. cutting?

Two studies – one conducted in 2018 and the other conducted in 2019  give us the most up-to-date data on teen self-harm.

Here’s the data:

Self-Harm in Teens: Facts and Figures

  • In the U.S.:
    • 17% of teens engage in self-injury in their lives
      • 11% of males
      • 24% of females
    • Worldwide:
      • 9% of teens engage in self-injury in their lives (gender data not available)
      • 6% reported engaging in self-injury in the past year
    • The average age of a first self-harm incident is 14 years old
    • Around 74% of teens self-harm to escape of process negative emotions
    • Around 46% of teens self-harm to communicate emotional distress or pain to parents, friends, or others.

Those studies reveal something it’s critical to understand, which we haven’t mentioned yet. Teens who engage in self-harm typically do not want to die. As the last two bullet points indicate, the two most common reasons teens self-harm are to handle – in a maladaptive manner – negative emotions, or to communicate – again, in a maladaptive manner – the presence of emotional pain or difficulty. While self-harm is associated with suicidal ideation and suicide attempts, not all teens who engage in self-harm want to die: they do it because they what they seek is a way to make their emotions bearable, and communicate the fact they’re having problems because they don’t have the words to explain what they’re going through.

Now let’s look at the latest information and the second topic we address in this article, suicidal ideation. We retrieved these statistics from the American Foundation for Suicide Prevention (AFSP), the Centers for Disease Control (CDC), and the 2019 National Youth Risk Behavior Survey (2019 YRBS).

Suicidal Ideation Among Teens in 9th – 12th Grade: 2019

  • 18.8% reported seriously considering suicide in the past 12 months
    • 24.1% of females
    • 13.3%of males
  • 47% of LGBTQI+ high school students reported seriously considering suicide
  • 14.4% of non-LGBTQI+ students reported seriously considering suicide
  • 30.4% of students who were not sure of their sexual orientation reported seriously considering suicide

Those statistics tell us two things. First, almost one-fifth of high school students in the U.S. engaged in suicidal ideation in 2019. Second, teens at highest risk of suicidal ideation are those who identify as members of the LGBTQ+ community.

That’s the scope of the problem – and it’s bigger than most people think. We can now move on to our discussion of the evidence-based treatment that’s widely known as the most effective approach to reducing self-harm and suicidal ideation in teens: a from Dialectical Behavior Therapy (DBT) designed specifically for teens – Dialectical Behavior Therapy for Adolescents (DBT-A).

What is DBT and How Does it Help Teens Who Self-Harm?

Dialectical Behavior Therapy (DBT) is a data-driven treatment developed by Dr. Masha Linehan in the 1980s. Originally formulated to help women with borderline personality disorder manage NSSI and suicidal ideation, Dr. Linehan modified DBT to help support teens with mental health disorders characterized by high emotional reactivity, overwhelming or out-of-control patterns of thought and behavior, and risk of NSSI, suicidal ideation, and suicidal attempts.

The first iteration of DBT included the following four core modules:

  1. Mindfulness: Awareness of the present moment
  2. Emotion Regulation: Processing unpredictable feelings
  3. Interpersonal Effectiveness: Navigating family and peer relationships
  4. Distress tolerance: Managing painful or difficult emotions safely

To tailor DBT for teens who self-harm and engage in suicidal ideation, Dr. Linehan added the fifth core skill:

  1. The Middle Path: Finding the balance between two extremes

Therapists trained in DBT-A teach teens actionable, practical skills to improve their lives. For teens who need significant support to learn to process out-of-control emotions, reduce impulsivity, improve self-awareness, and manage safe relationships, decades of research show DBT-A programs work. You can take a deep dive into the scientific literature on DBT-Aby reading these articles here and here. For a read with less scientific/psychology jargon than those two articles, you can read this helpful article published by the Child Mind Institute and this powerpoint published by the National Alliance on Mental Illness (NAMI).

DBT-A for Teens: The Latest Research

The study we want to introduce now, however, is a more recent meta-analysis – meaning a review of all the studies to date on a particular topic – that specifically addresses the efficacy of DBT for adolescent self-harm and suicidal ideation.

In fact, that’s the name of the article: Efficacy of Dialectical Behavior Therapy for Adolescent Self-Harm and Suicidal Ideation: A Systematic Review and Meta-Analysis. Here’s how the study authors describe the goal of their research:

“Given the widespread nature and clinical consequences of adolescent self-injury, establishing developmentally appropriate treatments that reduce both self-harm and suicidal ideation in the context of broader adolescent psychopathology is critical.”

We agree one hundred percent. That’s why we publish articles on these topics. That’s also why we often focus on DBT, because of its documented record of helping teens who self-harm and engage in NSSI. To date, the data on DBT – and what we see with our own eyes in a clinical setting every day – convinces us that DBT is an effective treatment for teen self-harm, cutting, and teen suicidal ideation. We read each new study with an open mind, ready to make data-driven, evidence-based conclusions on the best way to support our teens.

Here’s what the data and evidence from this latest study shows:

Self-harm:

  • In the studies with control groups, teens who received treatment with DBT-A showed moderate reductions in self-harming behavior, as compared to control groups.
  • In the studies that assessed teens before and after treatment – called pre/post studies – teens who received treatment with DBT-A showed large reductions in self-harming behavior, as compared to control groups.

Suicidal Ideation:

  • In the studies with control groups, teens who received treatment with DBT-A showed reductions in suicidal ideation, as compared to control groups.
  • In the studies that assessed teens before and after treatment – called pre/post studies – teens who received treatment with DBT-A showed large reductions in suicidal ideation, as compared to control groups.

Using a different metric – treatment duration, a.k.a. length of treatment – researchers found that DBT-A had a significant positive effect on suicidal ideation but did not change the effect of DBT-A on self-harming behavior. That tells us something we did not expect. While the data in the study show DBT-A is effective in reducing both suicidal ideation and self-harm, the length of treatment – as compared to controls – neither increased nor decreased the efficacy of DBT-A for self-harm.

A New Wrinkle in the New Data on DBT for Teen Suicidal Ideation and Self-Harm

The information on treatment duration gives us something to think about. Typically, a longer course of treatment improves outcomes. That’s true for almost all mental health, behavioral, or addiction disorders across all age groups, including teens. In this case, though, the data shows that DBT-A can effectively help teens reduce self-harming behaviors in a relatively short amount of time. This is a positive result. It’s something we see firsthand in clinical practice but have yet to see in a peer-reviewed journal article.

Now that we have, we know what we see in our teens is supported by data collected on teens in other places. DBT-A gives teens practical tools they can use right away to help transform extreme, negative, life-interrupting thoughts, feelings, and behaviors into effective, positive, life-affirming ones. That’s positive news for teens, offers hope for parents of teens who engage in NSSI or suicidal ideation, and both validates and confirms our use of DBT in daily practice for our most vulnerable and at-risk teens.

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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