Dialectical behavior therapy for inpatient and outpatient parasuicidal adolescents

Adolescent Psychiatry, 2002 by Katz, Laurence Y, Gunasekara, Shiny, Miller, Alec L

Dialectical behavior therapy (DBT) is a principle-based psychotherapy developed by Linehan (1993a, b) for chronically parasuicidal women with borderline personality disorder (BPD). It is the first empirically supported treatment for this population. DBT blends standard cognitive-- behavioral therapy with Eastern philosophy and meditation practices and shares elements with psychodynamic, client-centered, gestalt, paradoxical, and strategic approaches (Koerner, Miller, and Wagner, 1998). In a one-year, randomized, controlled trial comparing DBT with "treatment as usual" for outpatient, parasuicidal adult women with BPD, Linehan et al. (1991) found that DBT significantly reduced inpatient psychiatric days and parasuicidal behavior and increased treatment compliance. More recently, Koons and colleagues (1998) found that DBT was more effective than treatment as usual in reducing suicidal ideation, depression, hopelessness, and anger.

DBT has been modified for use in various settings, including inpatient programs (Barley et al., 1993; Bohus et al., 2000), day treatment programs, and residential programs. Adaptations have been developed for use with different forms of psychopathology, including substance abuse (Linehan et al., 1998; Dimeff et al., 2000), eating disorders (Safer, Telch, and Agras, 2001), domestic violence (Fruzetti and Levensky, 2000), antisocial personality disorder (McCann, Ball, and Ivanoff, 2000), and triply diagnosed persons (substance-abusing HIV-positive adults diagnosed with BPD; Wagner et al., in press). Most recently, DBT has been applied to different age groups, including adolescent inpatients (Katz et al., 2000), adolescent outpatients (Rathus and Miller, in press), and geriatric populations (Lynch, 2000).

In this chapter, we briefly review standard DBT as developed by Linehan and then discuss modification of DBT for use with adolescents. We review DBT for suicidal adolescent outpatients and then provide a detailed description of the modification for suicidal adolescent inpatients.

STANDARD DIALECTICAL BEHAVIOR THERAPY

Biosocial Theory of Borderline Personality Disorder

Linehan purports that BPD develops when a child who is biologically vulnerable to difficulties regulating emotions is placed in environments perceived as pervasively socially toxic or "invalidating." Biologically vulnerable children are more sensitive to emotional stimuli, have more intense emotional reactions, and return slowly to baseline. An invalidating environment pervasively trivializes, blames, rejects, and attributes socially unacceptable characteristics to an individual's cognitive, behavioral, and emotional responses despite the fact that the responses make sense in terms of facts, inferences, accepted norms, or long-term goals (Koerner et al., 1998). For example, a person may be accused of overreacting when she complains of being yelled at constantly.

Some environments, such as those that are physically or sexually abusive, are universally invalidating, whereas others are invalidating only when there is a poor fit between the family's and child's temperaments. Still others do not start out as invalidating but become so as a result of stresses arising out of interactions between the individual and others-a situation termed reciprocal determinism (Koerner et al., 1998). Linehan's biosocial theory helps us to understand not only the etiology of BPD and its problem areas but also the maintenance of the disorder, as illustrated in the following case.

Sixteen-year-old Julia had her first admission to the inpatient DBT program after taking an overdose. She completed the program and was discharged to her parent's home. Four months after discharge, she presented to the emergency room with intense suicidal ideation but without suicidal behavior. She was readmitted. She told the inpatient staff that she could no longer live with her parents because of the intense emotionality in the home. During a ward meeting of the patient, her parents, the treatment team, and children's protective services, the patient frequently attempted to discuss the constant yelling, occasional physical violence, and other intolerable aspects of her home environment. The patient's mother listened but repeatedly deflected the blame onto the patient's boyfriend and the problems that he was causing, thus invalidating the patient's complaints. Julia's history of intense emotionality-together with her invalidating environment and the high level of affective dyscontrol and impulsive behavior within the home-- dysregulated her emotional state and led to her suicidal ideation and increased risk of self-harm.

Dimensions of Dysfunction in Borderline Personality Disorder

A person with BPD commonly has dysfunction in five domains. According to Linehan (1993a), the central problem is emotional dysregulation. Consequently, individuals with BPD commonly struggle with anger and emotional dyscontrol. These difficulties contribute to four other domains of dysfunction-interpersonal dysregulation, self-dysregulation, cognitive dysregulation, and behavioral dysregulation. The individual struggles with fears of abandonment and chaotic relationships. Emotional and relationship instabilities may lead to self-dysregulation and confusion about one's identity, values, and/or feelings in addition to a chronic sense of emptiness. Cognitive dysregulation in the form of rigid thinking, irrational beliefs, paranoid ideation, and dissociation may also occur. Finally, as a consequence of emotional dysregulation, or as an attempt to regulate emotions, behavioral dysregulation in the form of impulsivity and parasuicidality is common (Koerner et al., 1998).