Suicide is devastating and has many victims. If you are feeling hopeless or feel that you have nowhere to turn, call 1-800-273-TALK (1-800-273-8255), 24/7. You can also log onto the National Suicide Prevention Lifeline. Or  go to your local hospital emergency room.

If you are worried about a friend, please visit this site. If you are a parent, relative, teacher or mentor to a young person and you are worried about him or her, please visit this site.

Dr. Alec Miller is with us again to talk about his work with suicidal teens using dialectical behavioral therapy.

He identifies 5 important skill-sets that help suicidal teens and their families address their emotional vulnerability and the invalidating environment.

Welcome, Dr. Miller. Tell us a bit about Dialectical Behavior Therapy and the 5 Skill Sets.

DBT is an evidence-based treatment for suicidal multi-problem patients. The emotionally vulnerable individual experiences the environment as not “understanding their experiences as valid” and instead experiences the world around them as often critical and neglectful. DBT teaches skills to teens and parents that to address their emotional vulnerability and the invalidating environment.

There are 5 skills sets that are taught in a multi-family skills training group:

  1. mindfulness skills
  2. emotion regulation skills
  3. distress tolerance skills
  4. interpersonal effectiveness skills
  5. walking the middle path skills.

Each teen is also assigned an individual therapist who functions also as a coach between sessions to help the teen apply these skills in real situations in real time.

Can you tell us how you began using DBT in the treatment of suicidal adolescents?

In 1995, I was invited to direct a subspecialty outpatient program at Montefiore Medical Center named the Adolescent Depression and Suicide Program. I recognized there was not a single evidence-based treatment for suicidal multi-problem youth so my colleague, Jill Rathus, PhD, and I, went to Seattle Washington to get trained in Dialectical Behavior Therapy by the treatment developer Marsha Linehan, PhD.

DBT was the first evidence-based treatment established for suicidal adults and Jill, Marsha, and I decided to adapt, research and apply DBT for teens and families which is described in our book, “DBT with Suicidal Adolescents” (Miller, Rathus, & Linehan, 2007).

We have also been adapting DBT for school settings and for medical settings. In school settings, many providers need a structured treatment and common language to help youth better cope with their distress, manage emotions and relationships in school.

Youth with chronic medical conditions are often chronically non-compliant with their medical regimen and appointments.  Thus, we have been working at Montefiore Childrens’ Hospital on adapting DBT for this population, including kids with chronic kidney disease.  The pilot data is promising in that 6 out of 6 youth who had previously been non-compliant are now much more compliant and eligible for kidney transplantation.

Do safety plans and no-suicide contracts have a role to play in treatment? What works?

No-suicide contracts are not necessarily effective. In fact, the research is equivocal on them. Thus, you cannot rely on that as “the intervention.” However, clinically, in combination with other interventions, I often ask them to give me a commitment to no suicidal or non-suicidal self-injurious behaviors for the duration of our treatment. If they cannot agree to that specific time frame, I ask them what they can commit to and work backwards. The minimum I settle for is 1 week.

In addition, I offer them coaching 24 hours/day 7 days/week in case their urges arise and they want help figuring out what replacement behaviors that can practice using.  The ‘crisis survival skills’ in DBT include distraction, self-soothe, pros and cons, and they are relied upon to help teens in the face of suicidal crises.

Please tell us about your book, Dialectical Behavior Therapy with Suicidal Adolescents.

Our book, referenced above, is the first text book to describe our clinical adaptation of DBT for adolescents. It provides a rationale for our adaptation, specific case vignettes and a review of a treatment course from beginning to end, to help providers and families better understand how this treatment works from soup to nuts.

In addition, we developed a new set of skills for teens and families called, “walking the middle path skills.” This module was developed to address a void in the adult treatment. Thus, we teach 3 new skills: a) learning principles, b) validation of self and other, and 3) dialectical thinking and acting.  These skills appear to be important and well received by teens and families and often rated as most helpful among all of the DBT skills being taught.

Thanks so much, Dr. Miller.

Alec L. Miller, PsyD, is Professor of Clinical Psychiatry and Behavioral Sciences, Chief of Child and Adolescent Psychology, Director of the Adolescent Depression and Suicide Program, and Associate Director of the Psychology Training Program at Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York. Dr. Miller has published widely on topics including DBT, adolescent suicide, childhood maltreatment, and borderline personality disorder, and has trained thousands of mental health professionals in DBT. He co-founded Cognitive and Behavioral Consultants of Westchester, LLP, which is a private group practice in White Plains, NY.