A third type of treatment, one that takes place over a longer period of time is called dialectical behavior therapy or DBT. A full course of DBT is usually six months to a year and clients will often stay in therapy for a longer time if needed. DBT was developed by Dr. Marsha Linehan in the 1990s. She developed the therapy when she was trying to use traditional cognitive behavioral therapy to help individuals struggling with chronic suicidal experiences. As it turned out, many of these patients were suffering from borderline personality disorder. Personality disorders are psychiatric conditions characterized by patterns of thoughts, feelings, and actions that tend to persist over time and lead to distress and problems in everyday functioning, in things like relationships at jobs, etc. In contrast to other illnesses like depression or a bipolar disorder, personality disorders are less episodic and more consistent across situations. Borderline personality disorder involves instability in several areas of life, including relationships, emotions, identity, thinking patterns, and mental states. It's often characterized by experiencing emotions more quickly, intensely, and for a longer time than other people, struggling with impulsive behaviors, having difficult interpersonal relationships, and also a high incidence of non suicidal self-injury, as well as suicidal thoughts and behaviors. Dr. Linehan found that CBT alone wasn't working well with this population and started to combine those pragmatic and skill-based strategies from CBT with mindfulness practice and exercises. This combination of working towards change and at the same time working towards acceptance proved to be more useful. Her treatment really coalesced around the idea of dialectics, or the idea of holding two contradictory ideas in one's mind at the same time. For example, the idea that one both needs to accept and also to change, or that one is trying the hardest and also needs to try harder. DBT, as it was named, focuses on both developing new skills and strategies, as well as emphasizing the therapeutic relationship. The goal of treatment overall is not to prevent suicide or change behavior, but to help the client build a life worth living, a life that they don't desire to escape from. Skills training, a key part of DBT focuses on learning and practicing four types of skills that we'll go over now. These include mindfulness or the practice of being fully aware and present in the current moment. The goal of mindfulness exercises is to increase self-awareness of thoughts, feelings, and urges. Interpersonal effectiveness skills, teach one how to ask for what they want and how to say no, while still maintaining self-respect and maintaining relationships with others. Distress tolerance skills are very important in that they help the individual tolerate painful emotions in difficult situations without needing to change the situation or engage in behaviors that make the situation worse. Finally, emotion regulation skills teach individuals how to better identify their emotions and change the emotions that they want to change. Full program DBT includes four components that we'll go over next. The first is weekly individual therapy. Individual therapy allows the client to identify and work towards their own personal goals, to check in with their therapist weekly about their progress and roadblocks, to practice these new interpersonal skills within the therapeutic relationship, and to get support both via validation and encouragement to change. The second component is a weekly two-hour long skills group. It takes about six months to complete a full cycle of the DBT skills lessons. These skills lessons teach the mindfulness, interpersonal, skillfulness, distress tolerance, and emotion regulation skills we just talked about. They're set up like a class, and these skills training sessions involve weekly homework, homework check-ins, lectures, in class activities, and an opportunity to learn from other clients who are also struggling with and learning about similar things. The third component of DBT is skills coaching. DBT clients are usually able to call their therapists outside of their weekly sessions to get coaching on changing a behavior or using a skill in their day-to-day life and also during times of crisis. The final component of DBT is consultation team. This is actually a weekly meeting amongst the team of DBT therapists. They work together to support each other, working with many individuals who are struggling with suicidalities is hard work, and the more support and ideas the therapists can get, the better they can support their clients and stick with the treatment. It also helps the client benefit by having more brains working on a case as each individual therapist can bring challenges or stuck points to the other therapists for additional brainstorming. Overall, doing full program DBT as it was originally designed, takes a client about 3-4 hours a week. It's more time in terms of treatment than the others we've discussed so far, but the goal is to be able to work with these very challenging and potentially life threatening problems while the client gets to stay at home and continue engaging in their daily life. There are also residential or intensive outpatient DBT programs for clients who need more support staying safe. DBT is one of the therapies with the strongest evidence base for helping to reduce chronic suicidal thoughts and behaviors. However, more work is being done to try to understand which elements of DBT are the active ingredients, and for what types of clients and diagnoses DBT is the most effective. Across all of the empirically supported interventions we've discussed, there's a lot of differences, as I'm sure you've seen, but also there's really important areas of overlap. One similarity and something that's different from many of the treatments for suicide that came before is that all of these interventions focus, at least initially, squarely on suicidality rather than potentially related mental health diagnoses like depression or anxiety. Another area of similarity and emphasis is the focus on empathetic, non-judgmental, non blaming relationships between the therapist and the client. In all of the interventions described, the stance of the therapist is as a genuinely curious and concerned professional, seeking the client's expertise and understanding their own suicidal experience and combining that with a therapist expertise in psychological skills. Therapists who work effectively with suicidal clients don't let their own fears get in the way of the work. Additionally, all of these treatments are also present and future focused. They're also all skills-based, seeking to help clients identify the skills they already have and to learn new ones that will help them cope in the future. Finally, all of these interventions include a pragmatic plan for how to cope with a future crisis. While clients are working on the underlying drivers of their pain and hopelessness, they are equipped with a plan as to what they should do should they encounter a suicidal crisis in the meantime. These common elements suggest some possible mechanisms for what might be helping in these treatments. There was call, of course, as I've said before, to know for sure more research is needed.
