The Handbook of Dialectical Behavior Therapy

Theory, Research, and Evaluation

Jamie Bedics, Jamie Bedics

• Publisher: Academic Press
• Year: 2020
• ISBN:
  9780128166086
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Dialectical behavior therapy (DBT) has become a useful treatment for a range of clinical problems and is no longer limited to the treatment of suicidal behaviors or borderline personality disorder. The Handbook of Dialectical Behavior Therapy: Theory, Research, and Evaluation reviews the evidence-based literature on use of DBT in a wide range of populations and settings. The book begins with the foundations of DBT: its history, development, core principles, mechanisms of change, and the importance of the therapeutic relationship. It also reviews the efficacy of DBT for treatment of suicidal behavior, eating disorders, and substance abuse disorders, as well as its use for children, adolescents, and families. A section on clinical settings reviews implementation in schools, college counseling centers, and hospitals.

• Provides an overview of DBT including its development, core principles, and training
• Discusses the importance of the therapeutic relationship and alliance in DBT
• Outlines DBT treatment for suicidal behavior, eating disorders, and substance use disorders
• Includes DBT as treatment for adolescents and children
• Covers DBT implementation in schools, counseling centers, and hospitals

II

Clinical populations

Outline

• Chapter 5 Efficacy of dialectical behavior therapy in the treatment of suicidal behavior
• Chapter 6 Eating disorders
• Chapter 7 Dialectical behavior therapy for individuals with substance use problems: theoretical adaptations and empirical evidence
• Chapter 8 Dialectical behavior therapy for adolescents: a review of the research
• Chapter 9 Clinical illustration of the dialectical behavior therapy for preadolescent children: addressing primary targets

Chapter 5

Efficacy of dialectical behavior therapy in the treatment of suicidal behavior

Christopher R. DeCou and Adam Carmel, Department of Psychiatry and Behavioral Sciences, University of Washington at Harborview Medical Center, Seattle, WA, United States

Abstract

Dialectical behavior therapy (DBT) is an evidence-based treatment that conceptualizes suicidal behavior as a dysfunctional method of coping with life’s problems. The goal of this chapter is to first define several subcategories of suicidal behavior as part of targeting suicidality in DBT, including suicide crisis behaviors, suicide attempts and nonsuicidal self-injury, suicidal ideation and communications, and suicide-related expectancies and beliefs. The approach to conceptualizing and treating each domain of suicidality is discussed drawing from the theoretical underpinnings and interventions in DBT. This chapter outlines the current efficacy of DBT for reducing suicide-specific outcomes and other self-directed violence. Although evidence remains limited with regard to the efficacy of DBT to reduce suicidal ideation, there is clear evidence that DBT is efficacious for reducing the frequency and severity of self-directed violence among patients with borderline personality disorder, as well as reducing the utilization of psychiatric crisis services.

Keywords

Dialectical behavior therapy; borderline personality disorder; suicide; self-directed violence; treatment efficacy

Borderline personality disorder (BPD) is a psychiatric disorder with a prevalence of approximately 1%–2% in the general population. (Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004; Trull, Jahng, Tomko, Wood, & Sher, 2010). Patients with BPD are associated with high utilization of psychiatric services, accounting for approximately 15%−20% of psychiatric hospital and clinic admissions (Korzekwa, Dell, Links, Thabane, & Webb, 2008; Zimmerman, Chelminski, & Young, 2008), 10%−15% of emergency room visits (Chaput & Lebel, 2007; Tomko, Trull, Wood, & Sher, 2014), 6% of primary care visits (Gross et al., 2002), 10%–22% of psychiatric outpatients, and 20% of psychiatric inpatients (Korzekwa et al., 2008; Torgersen, Kringlen, & Cramer, 2001). Thus BPD represents a disproportionate burden on psychiatric crisis services relative to the prevalence of BPD in the population.

BPD is marked by durable patterns of impulsivity and behavioral dyscontrol, including suicidal and self-injurious behaviors. Patients with BPD demonstrate high rates of chronic nonsuicidal self-injury (NSSI) and suicide attempts, consistent with these behaviors as a defined criterion of the disorder within DSM-5 (American Psychiatric Association, American Psychiatric Association, & DSM-5 Task Force, 2013; Pompili, Girardi, Ruberto, & Tatarelli, 2005). Rates of NSSI among individuals with BPD range from 69% to 80% (Clarkin, Widiger, Frances, Hurt, & Gilmore, 1983; Cowdry, Pickar, & Davies, 1985; Frances, Fyer, & Clarkin, 1986). The rate of death by suicide is 5%–10% among people with BPD, and twice that among people with BPD and a previous history of self-directed violence (Frances et al., 1986; Linehan, Rizvi, Welch, & Page, 2000; Stone, 1993). These high rates of fatal and nonfatal suicidal behavior among people with BPD contributes to disparate long-term outcomes for people with BPD and large burdens on healthcare systems. For example, within one large urban public health system in the United States, patients with BPD accounted for 29% of all patient death by suicide and 50% of all suicide attempts (Carmel, 2010).

Indeed, several studies have found that suicide risk in patients with personality disorders (PDs) is higher than those with other psychiatric disorders, suggesting the need for interventions that are responsive to the nature of PD symptoms as distinct from other patterns of mood and anxiety symptomatology. Among individuals who die by suicide, an estimate of 57% met criteria for a PD (McMain, 2007). Thus it is important for clinicians to incorporate evidence-based technologies of change and acceptance that promote effective resolution of suicidality in high risk clinical populations, such as those diagnosed with BPD.

Dialectical behavior therapy (DBT; described in the introductory chapter) conceptualizes suicidal behavior as a dysfunctional method of coping with life’s problems. Suicidal behavior is both considered a faulty method of attempting to solve a problem and, therefore, is a problem in itself. The DBT therapist will implement the treatment by continuously seeking to help patients replace dysfunctional problem-solving strategies with functional and more adept problem-solving abilities in an effort to achieve their goals. Rather than emphasizing the treatment of suicidal behaviors, DBT places overall emphasis on the patient’s ability to build a life worth living.

The goal of this chapter is to first define several subcategories of suicidal behavior and the DBT approach to conceptualization and treatment of suicidality in each domain. The chapter will then discuss the efficacy of DBT for reducing suicide-specific outcomes and other self-directed violence among patients with BPD.

Treating suicidal behaviors in dialectical behavior therapy

DBT is considered a standard of care in the treatment of chronically suicidal individuals with BPD. Chapter 15, A review of the empirical evidence for DBT skills training as a stand-alone intervention, of the DBT treatment manual includes principles and guidelines for responding to suicide risk (Linehan, 1993). Drawing from this content in its development, the Linehan Risk Assessment and Management Protocol (LRAMP; formerly the University of Washington Risk Assessment and Management Protocol or the UWRAMP) is a suicide risk assessment and management protocol for therapists to utilize following clinical contact with a suicidal patient to guide in their clinical decision making [(Linehan, Comtois, & Ward-Ciesielski, 2012); available at http://depts.washington.edu/uwbrtc/wp-content/uploads/LSSN-LRAMP-v1.0.pdf]. The LRAMP serves as a crisis protocol that can assist the therapist in providing comprehensive clinical care of suicidal patients and provide a template for documentation of this care.

A critical pretreatment step in DBT is for the therapist to obtain a credible commitment from the patient to remain alive and discontinue suicidal means of coping. Obtaining this commitment (and strengthening the commitment over time) is the highest priority in treatment, given that if the ...