Mental health professionals play an important role in efforts to prevent suicide, as about one-third of individuals who die by suicide had contact with mental health services in the year before their death (Luoma, Martin, & Pearson, 2002). The U.S. National Strategy for Suicide Prevention emphasizes the importance of providing evidence-based psychotherapies (EBPs) that directly address suicide risk to high-risk clients, particularly those with a history of attempting suicide.
Dialectical Behavior Therapy (DBT) is one of relatively few EBPs that has been found to be effective in reducing suicidal ideation and behaviors. For example, among recurrently suicidal individuals with borderline personality disorder, DBT has been found to reduce the rate of suicide attempts by 50% compared to non-behavioral therapy by community experts (Linehan et al., 2006). Within the larger DBT model, there are several important principles that guide treatment for clients at high risk for suicide.
- Target suicide directly. In contrast to approaches that attempt to reduce suicide risk indirectly by targeting underlying disorders (e.g., depression), DBT directly targets suicidal thoughts and behaviors as the key problem to be solved. This involves directly assessing the factors that are causing or maintaining specific episodes of suicidal thoughts and behaviors and generating solutions to address these factors.
- Thoroughly assess suicide risk. We cannot effectively intervene to reduce suicide risk unless we know that suicide risk is present. Therefore, it is critical that mental health professionals routinely conduct suicide risk assessments, ideally using an evidence-based approach such as the Linehan Risk Assessment and Management Protocol (LRAMP) that is used in DBT. A thorough suicide risk assessment should be conducted at intake with all new clients and when clinically indicated during ongoing treatment (e.g., when a client reports an increase in suicidal ideation). When conducting a suicide risk assessment, it is important to assess direct indicators of suicide risk (e.g., suicidal ideation, plans, and preparation), indirect indicators of suicide risk (e.g., severe hopelessness, access to lethal means), and protective factors (e.g., responsibility to family, belief that suicide is immoral).
- Routinely monitor suicidal thoughts and urges. For individuals at high risk for suicide, suicidal thoughts and urges may fluctuate weekly, daily, or even hourly. In addition, high-risk clients may experience weeks or months without any suicidal thoughts only to have those thoughts re-emerge at a later point. It is therefore important that mental health professionals routinely monitor suicidal thoughts and urges, particularly among clients with a history of suicidal behavior. This is done in DBT by having clients complete a diary card that includes daily ratings of urges to kill oneself. In addition, DBT therapists ask clients to provide a rating of current urges to kill themselves at the beginning of each therapy session. This kind of routine monitoring is critical to enable therapists to intervene when suicide urges are high, as well as to assess the factors that lead to increases and decreases in suicidal urges over time.
- Reduce the use of psychiatric hospitalization. DBT aims to provide treatment to high-risk clients in the least restrictive setting possible. This means that DBT therapists do not typically recommend or rely on psychiatric hospitalization when suicide risk is high. This approach is based on the lack of empirical evidence that psychiatric hospitalization reduces suicide risk, and concern that it may increase long-term risk. In addition, the DBT model assumes that people cannot have a reasonable quality of life if they are constantly going in and out of psychiatric hospitals, and that clients must learn how to reduce suicide risk while remaining in their natural living environments. Accordingly, many studies have shown that DBT greatly reduces the use of costly crisis services, such as psychiatric hospitalizations and emergency room visits, while simultaneously reducing suicidal behaviors.
- Provide skills-based solutions to reduce acute suicide risk. In DBT, suicide is viewed as the client’s effort to solve a problem, typically intense emotional pain that the client feels unable to change or tolerate. To reduce immediate suicide risk, the therapist must help the client to identify and implement alternative solutions to the problem. DBT teaches clients four sets of behavioral skills to increase their ability to regulate emotions, tolerate distress, improve relationships, and live mindfully. The goal is for clients to use these skills to prevent suicide urges from increasing and to not act on suicide urges when they are present. Research has shown that use of DBT skills leads to reductions in suicidal and self-injurious behaviors (e.g., Neacsiu, Rizvi, & Linehan, 2010), indicating that learning and using skillful coping strategies is critical to reducing suicide risk.
- Identify and work towards long-term solutions to suicide. Although solutions to address acute risk are critical, it is equally important for therapists to help clients identify solutions that will reduce suicide risk in the long term. In DBT, the ultimate goal of treatment is to help clients build a life worth living. Simply put, we must help clients develop a life in which suicide is no longer viewed as a viable or necessary option. To do this, therapists must understand what exactly would need to be different for the person to want to be alive, and then tenaciously work with clients to achieve those life changes. Often this involves working on value-driven goals that may be slower to change, such as developing positive and lasting relationships, finding ways to make meaningful contributions to others, and achieving financial stability. Success stories of DBT clients provide hope that it is indeed possible for highly suicidal people to build lives worth living.
- Therapists must be available to clients between sessions. Individuals at high risk for suicide often require in-the-moment coaching to navigate difficult situations without resorting to suicide. In DBT, this is done by making therapists available to clients for phone coaching between sessions. Coaching calls are typically brief and focused on helping clients identify skills to effectively manage current and ongoing difficult situations. Importantly, DBT includes several strategies to reduce the likelihood that these between-session contacts may inadvertently reinforce suicidal behavior. For example, DBT uses the “24-hour rule” that makes therapists unavailable for between-session contact for 24 hours after any suicide attempt or non-suicidal self-injurious behavior. This rule is designed to make sure that these behaviors are not inadvertently reinforced by contact with a caring therapist immediately afterwards.
- Therapists require support and consultation. Mental health professionals working with high-risk clients need support. It can be scary and exhausting to live with the constant worry that one’s clients may die by suicide. In addition, being available to high-risk clients between sessions means that therapists must be prepared to intervene in a suicidal crisis at any moment. When working with high-risk clients, it is also recommended that therapists seek consultation to determine the most effective way to intervene. To address this, DBT requires therapists to participate in a therapist consultation team consisting of a team of providers working together to deliver DBT to a community of clients. The primary functions of the therapist consultation team are to provide therapists with support, increase therapist motivation and reduce burnout, and increase therapist competence. Ideally, the therapist consultation team helps therapists feel ready and able to stay engaged in this challenging yet highly rewarding work.
Melanie S. Harned, Ph.D., ABPP, is a Psychologist and Coordinator of the DBT Program at the VA Puget Sound Health Care System and a Senior Research Scientist in the Department of Psychology at the University of Washington. Dr. Harned has previously worked as the Research Director of Dr. Marsha Linehan’s Behavioral Research and Therapy Clinics at the University of Washington (2006-2018), Director of Research and Development for Behavioral Tech, LLC (2014-2017), and Director of Behavioral Tech Research, Inc. (2013-2016). Dr. Harned’s research focuses on the development and evaluation of a protocol to treat PTSD during DBT as well as methods of disseminating and implementing this and other evidence-based treatments into clinical practice. She regularly provides training and consultation nationally and internationally in DBT and DBT PE. She has published numerous articles and book chapters and is licensed as a psychologist in the state of Washington.