Improved Emotion Regulation in Dialectical Behavior Therapy Reduces Suicide Risk in Youth
Suicide is the second leading cause of death among adolescents and young adults in the U.S. To address the need to reduce suicide deaths, researchers have focused their efforts on identifying treatments for those at high risk and learning more about the mechanisms that make treatments work best.
A type of psychotherapy called dialectical behavior therapy (DBT) has shown promise as a treatment for individuals with histories of suicide attempts and non-suicidal self-injury (NSSI). In 2018, findings from an NIMH-supported clinical trial of adolescents at high risk for suicide and self-harm showed that rates of suicide attempt and NSSI were lower for those who received DBT than they were for those who received individual and group supportive therapy (IGST) during the trial.
Investigators from that trial recently expanded on their initial findings by analyzing whether the lower rates of suicide attempt and NSSI in the youth receiving DBT could be due to changes in emotion regulation induced by the therapy. In DBT, emotion regulation refers to managing sensitivity to emotional stimuli and intensity of emotional reactions. Because difficulties in emotion regulation are believed to be drivers of suicidal and self-harm behaviors, a goal of DBT is to strengthen skills that lead to improved emotion regulation, or managing painful emotions in healthy, safe ways. DBT also aims to teach skills to parents so they can support their children in the treatment.
The trial enrolled 173 adolescents age 12 to 18 who had prior suicide attempts, self-harm, and suicidal ideation. Participants were randomly selected to receive either DBT or IGST for 6 months with up to 12 months of follow-up. DBT included individual psychotherapy, multi-family group skills training, youth and parent telephone coaching, and therapist team coaching. IGST included individual therapy, adolescent supportive group therapy, as-needed parent sessions, and weekly therapist team consultation.
The new analysis, by Joan Asarnow, Ph.D., of the University of California, Los Angeles, and colleagues, showed that even though both groups showed improved emotion regulation, youth who received DBT showed bigger improvements through the treatment period and at the 12-month follow-up than those who received IGST. Furthermore, improvements in emotion regulation in the DBT group at 6 months predicted greater self-harm remission at 12 months. These findings suggest that it was the improved emotion regulation from DBT that in turn reduced self-harm behaviors.
In addition, parents of adolescents who received DBT reported using more DBT skills during and after treatment, indicating that DBT may have enhanced their abilities to support skill use in their children when they struggled with painful emotions and self-harm urges. Adolescents who received DBT also reported lower substance misuse, externalizing behavior, and total problems at 6 months than those who received IGST.
The analysis showed that the relatively greater improvements in emotion regulation seen in the DBT group lessened during the follow-up period when study treatments were withdrawn, though self-harm remission remained higher in the DBT group at 12 months. Overall, the results suggest that the DBT-induced changes in emotion regulation drove the improvements seen in the clinical trial. The study also shows how research focused on mechanisms that contribute to recovery in youth at very high risk for suicide can inform the development and optimization of more effective treatments.
Asarnow, J.R., Berk, M.S., Bedics, J., Adrian, M., Gallop, R., Cohen, J., Korslund, K., Hughes, J., Avina, C., Linehan, M.M., & McCauley, E. (2021) Dialectical Behavior Therapy for Suicidal Self-Harming Youth: Emotion Regulation, Mechanisms, and Mediators. Journal of the American Academy of Child and Adolescent Psychiatry. doi:10.1016/j.jaac.2021.01.016