Dialectical behavior therapy Dialectic behavior therapy (DBT; Linehan, 1993) is one of the most commonly used psychotherapeutic techniques for recurrent suicidal behavior. DBT is based on concepts from cognitive behavioral therapy, and it has been used mostly in patients with borderline personality disorder, but increasing evidence suggests it may be useful to people with a variety of different diagnoses (DeCou, Comtois, & Landes, 2019). Furthermore, DBT is one of the few treatments for suicidal individuals with solid data supporting its use in both adults and adolescents (DeCou et al., 2019; McCauley et al., 2018; Rathus, Berk, Miller, & Halpert, 2020). The roots of dialectical behavior therapy (DBT) lie in Marsha Linehan’s work with chronically suicidal adult patients. She originally attempted to use cognitive behavioral strategies with these individuals, only to discover that those approaches simply did not work well. The population with which she was working felt misunderstood and invalidated. Cognitive behavioral therapy’s exclusive focus on change often pushed individuals into feeling emotionally overwhelmed, and they would frequently shut down. Conversely, focusing on acceptance also had its limitations. Individuals would feel extreme hopelessness or even rage at the clinician for failing to appreciate their emotional suffering and for treating it as inconsequential. As a result, Linehan (1993) developed DBT as a model that would balance and synthesize the opposing tensions between acceptance and change, good and bad, positive and negative. An important dialectical idea is that each position contains within it its own opposition. As Miller, Rathus, and Linehan (2007) describe it, “dialectic refers to change by persuasion and by making use of the oppositions inherent in the therapeutic relationship, rather than by formal impersonal logic” (p. 39). The therapy involves balancing problem solving and validation. Dialectic behavior therapy promotes the belief in one's own ability to succeed, the ability to emotionally self-regulate, and interpersonal effectiveness. It has repeatedly been shown to reduce the recurrence of suicidal behaviors in affected patients when compared to standard treatment for both adults (DeCou et al., 2019) and adolescents (McCauley,
Berk, Asarnow, Adrian, Cohen, et al., 2018). The DBT perspective emphasizes the role of emotional dysregulation and impulsivity in suicide. DBT therapists would respond to the patient by first assessing the patient’s suicide intent. As in other therapies, if intent was high, the therapist would engage the patient in revisiting her commitment to refrain from life-threatening behaviors and review plans for safety. If the patient is safe to proceed with therapy, the DBT therapist might explore whether and how her suicidal ideation is an expression of her distress. The DBT therapist might use an intervention method called “extending,” wherein they 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 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.
CLINICAL DECISION-MAKING CONCERNS AND DOCUMENTATION
When mental health providers are dealing with individuals who are suicidal, it is imperative that they be aware of the legal implications related to the seriousness of suicidal thoughts. There are times when clients will need to be protected from themselves through hospitalization. At times, hospitalization even may be involuntary. It is critical Commitment criteria and imminent risk Experiencing elevated intent to act on a suicide plan is perhaps the primary cause for concern in suicide crisis evaluations of high-risk individuals (Jordan & Samuelson, 2016). An important clinician concern is deciding when to hospitalize a suicidal patient. This is especially the case when a patient reports elevated “intent” to act on suicidal thoughts or plans (Jordan et al., 2019). In this situation, the clinician has an ethical responsibility to ensure the patient’s safety (Obergi, 2017). Therefore, it is good practice to know and understand the applicable state statutes where one practices regarding options and obligations concerning involuntary treatment. Most states offer an option of pursuing involuntary commitment if a patient is endangering him- or herself or a third party as a result of psychiatric illness. See the Resources section for a link where practitioners may access their state’s statutes. Once clinicians have a good working knowledge of the state laws that govern involuntary commitment, they still
that clinicians be aware of the need for professional documentation of their decision-making process when dealing with clients who are at risk for suicide. The following section reviews various issues related to commitment and documentation issues.
are faced with the difficult decision of when to recommend this step for patients who are seriously at risk for engaging in self-harm. Unfortunately, there is no concrete, universally accepted definition of “imminent risk” for suicide. Suicide risk likely varies from minute to minute, hour to hour, day to day (Kleiman et al., 2017). This makes any prediction about imminent suicide, in Simon’s words, “illusory.” Moreover, time attenuates the accuracy of suicide assessments that are “here-and-now” judgments. Therefore, according to Simon, suicide assessment must be a process, not an event (Sommers-Flanagan & Shaw, 2017). Outpatient settings are not an appropriate level of care for patients who express a clear imminent intent and acknowledge possession of means to kill themselves. If such patients are unwilling to voluntarily admit themselves to an inpatient setting, they do meet the criteria for commitment to a secure inpatient hospital setting.
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