Are Outpatient Treatment Programs for Suicidal Teens Safe and Effective?

Suicide has become a serious problem among adolescents and young adults in the United States. Suicide is one of a cluster of behaviors that have increased over the past twenty years. When mental health professionals talk about suicide as a teen health crisis, they include things directly associated with a completed suicide such as suicide attempts, self-harming behaviors, and suicidal ideation.

Before we discuss this subject further, let’s define these terms.

• Suicide is self-inflicted death caused by deliberate self-injury with the intent to die.
• Suicide attempts are instances of deliberate self-injury performed with the intent to die that do not result in death.
• Suicidal ideation is thinking and talking about suicide. Mental health experts discuss suicidal ideation on a scale of severity. A teen at most risk for suicide has a suicide plan, the means to carry out the plan, and the intent to carry out the plan. A teen who thinks and talks about suicide but does not have a plan, the means to carry out the plan, or the intent to carry out the plan is also at risk of suicide but may not be in crisis. In both cases, teens need immediate support from a qualified mental health professional.
• Self-harm, also called non-suicidal self-injury (NSSI), is intentional injury inflicted by an individual on themselves. Mental health experts differentiate self-harm and NSSI from suicide attempts because self-harm/NSSI is not performed with the intent to die.

Evidence shows that suicide attempts, suicidal ideation, and self-harming behavior increase risk for suicide. When a teen attempts suicide or is at severe risk of attempting suicide, the most common intervention is a short period of inpatient hospitalization. However, recent studies show that outpatient treatment for suicidal adolescents – if a teen is not in immediate crisis – may be an effective alternative.

Suicide Prevention in Teens: Why is it Important Now?

The reason suicide prevention among teens appears as a recurring topic in the news media, among adolescent development experts, and in the treatment community is because the data over the past twenty years – and the past five years in particular – virtually overflows with bright red flashing warning signs that indicate our teens are in the midst of a mental health crisis.

The following suicide data is a clear indicator of the crisis. This is the most recent, reliable, vetted, and reviewed data on teen and young adult suicide, published in the 2019 Youth Risk Behavior Survey:

• Suicide is the second leading cause of death for teens and young adults age 15-24
• 19% of high school students seriously considered suicide
• 16% of high school students made a suicide plan
• 9% of high school students attempted suicide
• 3% of high school students required medical attention after a suicide attempt

Suicide attempts, suicidal ideation, and self-harm occur more often than fatal suicide among teens in the U.S. These phenomena, while not fatal, are associated with significant negative consequences, including:

• Co-occurring mental health disorders
• Impaired academic achievement
• Impaired vocational achievement
• Suicide attempts during adulthood
• Mental health disorder diagnosis during adulthood

The increasing prevalence of suicidal behavior – which include suicidal ideation and suicide attempts – raises another real problem among teens that increases overall suicide risk in the adolescent population: the suicide contagion effect.

Suicide is not contagious in the way an infectious disease is contagious. Here’s how the Department of Health and Human Services (HHS) defines suicide contagion:

“Suicide contagion is the exposure to suicide or suicidal behaviors within one’s family, one’s peer group, or through media reports of suicide and can result in an increase in suicide and suicidal behaviors. Direct and indirect exposure to suicidal behavior has been shown to precede an increase in suicidal behavior in persons at risk for suicide, especially in adolescents and young adults.”

That’s the current situation in the U.S. with regards to adolescents and suicide. Prevalence rates have increased dramatically over the past twenty years, new evidence on the negative effect of the pandemic on teen mental health appears almost every day, and we know the suicide contagion effect is real. We’ll now look at evidence-based approaches for the outpatient treatment for suicidal adolescents. The source we’ll use for the information that follows is this Evidence-Based Resource Guide published in 2020 by the Substance Abuse and Health Services Administration, called “Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth.”

To read the complete guide, we encourage you to follow the link and learn as much as you can. Or you can read our summary of the key points, below.

Suicide Prevention in Teens: Can Outpatient Treatment Work?

In a word, yes.

But not just any type of treatment.

As we mention above, the safest course of action for a teen in crisis – which means they’re at imminent risk of harming themselves or others – is to call 911, go to the emergency room in a typical hospital, or utilize emergency services at a specialized psychiatric hospital for adolescents. In some cases, teens stay in inpatient hospitalization until a medical team determines they’re safe and stable. When a teen is discharged, they may receive a referral of residential treatment, partial hospitalization treatment, or outpatient treatment.

Until recently, the common approach for teens in the period following a suicide attempt was some form of residential or inpatient treatment. However, the SAMHSA publication above indicates there are several forms of outpatient treatment that work for suicidal teens. By work, what we mean is that evidence shows teens who engage in one of these types of treatment have a decreased risk of suicide attempts, suicidal ideation, and self-harming behavior.

The SAMHSA publication is valuable because it divides the types of treatment by the strength of the evidence supporting it. The report reviews the following types of treatment, and classifies the supporting evidence as Strong, Moderate, or Emerging.

Here are the approaches they reviewed, along with their respective classifications:

1. Dialectical Behavior Therapy (DBT)

• Strong evidence supports the effectiveness of DBT for adolescent suicidality

2. Attachment-Based Family Therapy (ABFT)

• Moderate evidence supports the effectiveness of ABFT for adolescent suicidality

3. Multisystemic Therapy-Psychiatric (MST-Psych)

• Moderate evidence supports the effectiveness of DBT for adolescent suicidality

4. Safe Alternatives for Teens and Youth (SAFETY)

• Moderate evidence supports the effectiveness of MST-Psych for adolescent suicidality

5. Integrated Cognitive Behavioral Therapy (I-CBT)

• Moderate evidence supports the effectiveness of I-CBT for adolescent suicidality

6. Youth-Nominated Support Team-Version II (YST-II)

• Moderate evidence supports the effectiveness of YST-II for adolescent suicidality

We’ll examine the approach SAMHSA determined had the strongest evidence base in its outpatient application: dialectical behavior therapy (DBT). We prioritize DBT because, among other things, a real DBT program – meaning therapists who provide treatment have official DBT training – incorporates elements of family therapy, cognitive behavioral therapy, and patient directed treatment in support of adolescents who engage in or display suicidal behavior.

Dialectical Behavior Therapy: Effective Outpatient Treatment for Suicidal Adolescents

DBT is a type of cognitive behavioral therapy that includes the following elements:

• Individual therapy
• Family therapy
• Multifamily therapy
• Telephone/virtual coaching

DBT was developed in the 1990s to support adults with borderline personality disorder (BPD) with chronic, severe suicidal ideation. Its effectiveness in the adult population led therapists to adapt DBT for the adolescent population. Therapists trained in adolescent DBT focus on five core skills:

1. Mindfulness helps teens develop a non-judgmental, objective experience of the present moment.
2. Interpersonal Effectiveness helps teens recognize, respect, and create boundaries, while helping them find productive ways to negotiate relationships and find solutions when interpersonal problems appear.
3. Emotion Regulation helps teens recognize feelings and teaches them techniques to manage and process emotions that are painful, overwhelming, and disruptive.
4. Distress Tolerance teaches teens practical skills and techniques to cope with stressful or challenging events and situations.
5. The Middle Path helps teens avoid the black-and-white, all-or-nothing thinking common to both mental health disorders and adolescence. This module helps teens find balance between extreme ideas and thoughts, and teaches them that in most cases, there’s more than one valid solution or approach to a problem or set of circumstances.

The studies on DBT included in the SAMHSA publication involved two outpatient programs. One lasted four months, and the other lasted six months. Teens participate in:

• One weekly individual therapy session
• Weekly multi-family group sessions
• Less frequent one-family sessions
• 24/7 on call telephone access for teens and parents

The results of the studies on DBT showed reductions in:

• Suicidal ideation
• Self-harm
• Suicide attempts
• Depressive symptoms
• Psychiatric hospitalizations

Those results address the question we pose at the beginning of this article:

Are Outpatient Treatment Programs for Suicidal Teens Safe and Effective?

The answer – and we repeat – is yes.

And DBT is the approach with the strongest evidence base.

Outpatient Treatment for Suicidal Teens: DBT is Effective Across Treatment Settings and Populations

Researchers also found that DBT is effective across a wide range of treatment settings and for a variety of demographic and socioeconomic groups. When adapted as an approach for suicide prevention in teens, data support the use of DBT in intensive outpatient settings, residential treatment settings, and inpatient settings – as well as the typical outpatient settings. Data also shows that DBT is effective in community clinic settings that serve youth from low-income, ethnic minority families, including “non-white and youth and Latino youth.”

The information in this article – and the SAMHSA resource we link to above – is important for any parent of a teen who engages in suicidal behavior. What it shows is that while a suicidal teen may need inpatient hospitalization for a short time during a period of crisis, the treatment that follows does not necessarily have to be inpatient treatment or residential treatment: evidence indicates outpatient DBT is effective in reducing suicidal behavior in adolescents.

However, we must conclude this with the following statement: this article does not constitute medical advice. Parents of teens who engage in suicidal behavior should have their teen evaluated by a mental health professional. The evaluating professional can determine a diagnosis, recommend course of treatment, and collaborate on a treatment plan with the parents and the teen. The information in this article can help parents make an informed decision about treatment. We’ll conclude with one last thing every parent should know: treatment works – and the sooner a teen who needs treatment gets the treatment they need, the better the outcome.