take the patient extremely seriously, possibly more seriously than the patient, and might wonder aloud about hospitalization with the expectation that the patient would back away from expressing suicidality in order to get a more desirable response, such as the therapist understanding her distress. This would allow the therapist to take the dialectic stance of validating the patient’s experience while engaging her in problem solving and developing a plan for using previously-taught skills. DBT involves a pretreatment stage and four additional stages, each with its own intervention targets. The pre-treatment phase aims to forge a mutual commitment to eliminate suicidal behavior and entails an intensive approach with weekly individual therapy and skills-training groups. Stage one focuses Mentalization-based therapy Mentalization-based therapy focuses on teaching patients how to think about how their underlying thoughts and emotions are secondary to their own and other people’s actions. This enables their ability to understand their own and other people’s perceptions and thus proves effective in reducing suicidal behaviors. Children and adolescents with early-onset bipolar disorder (BD) are at high risk for intentionally hurting themselves. Although therapies exist for youths with BD, they do not address suicide prevention specifically. Mentalization-based therapy for adolescents (MBT-A) has been shown to be helpful in reducing self-harm in the adolescent and adult population with borderline personality disorder (Bo, Sharp, Beck, Pedersen, Gondan, & Simonsen, 2017). Adolescents vulnerable to emotion dysregulation and self-harm often have deficits in the ability to mentalize: that is, to understand, acknowledge, and predict thoughts and feelings in themselves and others. MBT-A has been shown to be more effective than “usual care” in reducing self-harm for adolescents and adults with borderline personality disorder. MBT-A includes psychoeducational and coping strategies that may prove quite effective for bipolar adolescents who are at elevated risk for self-harm. Transference focused psychotherapy (TFP) TFP employs a psychodynamic object relations model that includes structure, a clear frame, and limit setting (Calati, 2016). TFP focuses on internal representations of self and other, and the affects that link them, as a way to understand the patient’s subjective and interpersonal experience. Suicide in BPD is understood to be related to distorted images of self and others. TFP explores these internal representations and affect states as they relate to suicide, with a focus on gaining awareness of the experience of self in relation to other that could motivate suicidal urges, ultimately creating the capacity for a stable, realistic and integrated experience of self and other in place of partial and Caring letters and postcard interventions This intervention addresses questions about the wellbeing of individuals who drop out of treatment, a situation that can be particularly concerning when the individual has previously expressed thoughts of suicide or engaged in suicidal behavior. One intervention for both youth and adults who have either dropped out of treatment or were seen in triage settings is the use of caring letters, postcards, or even emails (Luxton et al., 2020; Reger et al., 2017). Either personalized or form letters may be used and simply state: “We hope you are well, and we are here if you need us. Here is how you contact us.” Caring letter interventions are thought to increase feelings of connectedness between the patient and clinical care providers (Whitlock, Wyman, & Moore, 2014), as even a small interaction can have a meaningful impact. For adolescents, parental consent for post-treatment outreach should be established at the start of treatment. In one of the first studies researching caring letter intervention, Motto (1976) suggested that the mechanism of change in such
on: (a) decreasing behaviors that are life-threatening, interfere with therapy, and diminish quality of life, and (b) increasing behavioral skills. Stage two addresses decreasing post- traumatic stress. Stage three aims at increasing respect for self and achieving individual goals. Finally, Stage four focuses on resolving a sense of incompleteness and finding freedom and joy. DBT skills are divided into several modules, including core mindfulness, emotion regulation, interpersonal effectiveness, distress tolerance, and walking the middle path. DBT therapists meet weekly with other DBT providers in consultative groups to help one another maintain a validating and “dialectic” stance toward their patients. The dialectic stance involves balancing validation strategies with change interventions. With an attachment perspective, MBT works toward improving the patient’s capacity to “mentalize,” that is, to keep in mind the patient’s own mind and the mind of the other (Vogt & Norman, 2019). Although a dynamic therapy, MBT avoids focusing on transference, free association, and fantasy, which are assumed to move the patient away from the capacity to mentalize, and does not pursue insight per se. MBT therapists view the patient as operating in a “psychic equivalence mode” based on rigid convictions, and use tactful self-disclosure to provide the patient a new perspective. MBT therapists focus on what the patient believes about a relationship rather than on the patterns behind it and provides the patient with a written formulation of mentalization deficits to refer to throughout treatment and revise as necessary. MBT, as with most interventions, is intensive and usually carried out as once-weekly individual sessions combined with group therapy. The MBT therapist would explore what might have occurred that led to the impulse to engage in suicidal behaviors, and how that related to distress intolerance and the emergence of impulsive behavior instead of a fuller capacity to mentalize and bear the feelings without action. The therapist might refer to a written formulation to show the patient how the emergence of suicide in this moment represents a familiar vulnerability. extreme experiences of self and others. TFP sessions are twice weekly. A TFP therapist would review the initial agreement about the management of emergencies and explore with the patient the different perceptions of self and others that relate to the emergence of suicide, with their associated negative effects. The articulation and reflection on the patient’s extreme negative representations of self and other, and resolving the obstacles to linking these with positive representations experienced at other moments, would help the patient develop realistic, nuanced, and flexible views associated with moderate affects. interventions is increased connection through a sign of caring with no demand for reciprocation. Building on this mechanism, the World Health Organization published results from five diverse countries suggesting that nine follow-up contacts (phone or visit) over a period of 18 months significantly reduced suicide and other deaths in suicide attempters when compared with usual care that involved little or no follow-up. In the original Motto study (1976), 843 depressed and suicidal patients discharged from psychiatric hospitals who refused follow-up treatment were randomly selected to receive 24 letters or no contact (usual care) over a period of five years. Those who received the letters were significantly less likely to die by suicide than those who did not receive the letters. The same finding applied in comparing the letter-receiving group to patients who actively engaged in treatment post-discharge. However, Motto and Bostrom (2001) found that the positive impact of letters declined once these letters were discontinued five years after hospital discharge. In fact, the difference in
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