Discussion

Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks and Intervention Techniques

Jonathan B. Singer1 • Kimberly H. McManama O’Brien2 • Mary LeCloux3

Published online: 13 August 2016

� Springer Science+Business Media New York 2016

Abstract Suicide is the second leading cause of death

among youth, and as many as one in five youth report

having had at least one serious thought of suicide in the

past year. Despite the enormous emotional pain and suf-

fering associated with suicidal thoughts and behaviors, up

to 40 % of suicidal youth never receive treatment. Given

that social workers are employed in multiple settings where

suicidal children and adolescents are encountered (e.g.

schools, homeless shelters, emergency departments, out-

patient mental health agencies, private practice), they play

a critical role in the identification and treatment of suicidal

youth. In the past decade, evidence has emerged that

attachment-based family therapy, integrated cognitive

behavioral therapy, and dialectical behavior therapy can

reduce suicidal ideation and/or suicide attempt in youth.

The purpose of this article is to review the theoretical

assumptions, conceptual frameworks and key intervention

techniques for these three interventions so that clinicians

can integrate these approaches into their practice with

suicidal youth and families. Implications for practice are

integrated throughout the review.

Keywords Youth suicide � Empirically-supported interventions � Attachment-based family therapy � Integrated-cognitive behavioral therapy � Dialectical behavior therapy

Suicide is the second leading cause of death among youth

ages 10–24 years, and 12 % of youth report having serious

thoughts of suicide in their lifetime (Centers for Disease

Control and Prevention, 2014; Nock et al., 2013). Reducing

suicide deaths and improving quality of life has been the

focus of federal suicide prevention programs like the Garrett

Lee Smith Memorial Act, public–private partnerships like

the National Action Alliance for Suicide Prevention, and

private initiatives like Zero Suicide. Key components of the

2012 National Strategy for Suicide Prevention include

training service providers in assessment and referral and the

delivery of high-quality mental health services (U.S.

D.H.H.S, 2012). Given that nearly half of all mental health

workers in the United States are social workers who work in

nearly every service sector (Bureau of Labor Statistics,

2016), social workers are essential in achieving the National

Strategy objectives by identifying and assessing suicide risk,

and providing high quality ongoing management and treat-

ment (Erbacher, Singer, & Poland, 2015).

Despite the development of several psychosocial inter-

ventions for suicidal youth, there is evidence that social

workers are not receiving the training and education nee-

ded to deliver these potentially life-saving interventions. A

2012 study found that although MSW program adminis-

trators and faculty agreed that suicide-related education is

important, most social work students receive 4 or fewer

hours (Ruth, Gianino, Muroff, McLaughlin, & Feldman,

2012). This is problematic because Over 90 % of social

workers will work with a suicidal client in their career

& Jonathan B. Singer jsinger1@luc.edu

1 Loyola University Chicago School of Social Work, Water

Tower Campus, 820 N. Michigan Avenue, Chicago,

IL 60211, USA

2 Simmons School of Social Work, Boston Children’s

Hospital, Harvard Medical School, 300 The Fenway, Boston,

MA 02115, USA

3 West Virginia University School of Social Work,

P.O. Box 6830, Morgantown, WV 26506, USA

123

Child Adolesc Soc Work J (2017) 34:95–106

DOI 10.1007/s10560-016-0453-5

(Feldman & Freedenthal, 2006) and mental health profes-

sionals consistently rate working with suicidal clients as

among the most stressful of all practice situations (Ting,

Jacobson, & Sanders, 2008). To our knowledge there are

only two MSW programs in the USA that offer a course on

suicide and have evaluated pre- to post-course outcomes,

which indicated significant increases in knowledge, confi-

dence, and skills as a result of the course (Almeida,

O’Brien, Gross, & Gironda, in press; Scott, 2015). If fac-

ulty members are not likely to develop and offer stand-

alone courses on suicide-related issues, then it is essential

to have resources that they can integrate into existing

courses. Currently, faculty members have access to several

excellent reviews of suicide risk assessment (Barrio, 2007;

Joiner & Ribeiro, 2011; Ribeiro, Bodell, Hames, Hagan, &

Joiner, 2013; Shea, 2002) and several high quality sys-

tematic reviews and meta-analyses of psychosocial inter-

ventions for suicidal and self-harming youth (see Brent

et al., 2013; Calear et al., 2016; Corcoran, Dattalo, Crow-

ley, Brown, & Grindle, 2011; O’Brien, Singer, LeCloux,

Duarté-Vélez, & Spirito, 2014; Robinson et al., 2013). This

article builds off that knowledge base by providing a

concise review of theoretical assumptions and key inter-

vention techniques for psychosocial interventions for sui-

cidal youth while incorporating a key requirement in social

work education: the integration of theory and practice.

The Relationship Between Theory and Empirically-Supported Treatments

Social work students and practitioners are expected to

understand, explain and integrate practice and theory (Na-

tional Association of Social Workers, 1996/2008; Council

on Social Work Education, 2015). In social work education,

classroom professors emphasize theory while field supervi-

sors focus on practice. A perpetual challenge for students,

practitioners, and professors is how to best integrate the two

so that theory informs practice, and practice informs theory.

Understanding the relationship between theory and practice

is particularly important when working with people who are

suicidal because of the possibility of lethal outcomes. This is

due, in part, to the fact that there are many reasons why

adolescents might want to die, and many pathways to help

adolescents discover a life worth living. Since theory ‘‘at-

tempts to retrospectively explain and to prospectively pre-

dict’’ (Thyer, 2001, p. 16), theoretically-informed treatments

provide a roadmap for where to go and how to get there. The

manualized treatments discussed in this article provide

insight into whether you should spend time addressing

affect, behavior, or cognition; whether you should focus on

the past, present, or future; and whether you should focus on

the individual, family, or group. Few social workers,

however, are trained in such treatments. Unless a practi-

tioner has been trained to fidelity in a treatment, it can be

difficult to understand how the theoretical assumptions and

constructs inform the intervention techniques.

According to Singer and Greeno (2013), frequently

noted barriers to implementing manualized treatments

include: provider concern that the treatment was not

developed with or for low-income, ethnically diverse

populations; concern that the treatment will not have better

outcomes than treatment-as-usual; the time and expense

required to get trained in manualized treatment; lack of

training opportunities and organizational support for

implementation; and a disconnect between the theoretical

orientation of the treatments and that of the provider.

Knowing which theories are associated with which inter-

ventions will help social workers decide which model best

fits their practice approach and make it easier to identify

whether they would like to pursue advanced training in

ABFT, I-CBT, or DBT-A.

Identification and Inclusion of Studies

The three treatments discussed in this article were identi-

fied based on a search of the empirical literature using

PsycINFO, PubMed and Google Scholar. Initial search

terms included: (psychotherapy OR psychosocial OR

clinical OR intervention) AND (suicid$) AND (youth OR

adolescen$). The search was limited to peer-reviewed

journal articles in English published between 1996 and

2016. This result yielded 2282 articles. Studies were

excluded if reduction of suicidal ideation, suicide attempt,

suicide or self-harm was not the primary focus of the

intervention; if they combined self-harm and suicidal

ideation/suicide attempt; if they focused only on caregivers

and not youth; if the program leader was not a clinician

(e.g. teacher implementing a school-based screening or

researcher showing video psychoeducation or mailing a

postcard); if the treatment manual was in a language other

than English; or if there was no control condition. After

applying exclusion criteria and eliminating duplicates, we

were left with 33 articles. We compared these results to

SAMHSA’s National Registry of Evidence-based Pro-

grams and Practices (http://nrepp.samhsa.gov/); the Suicide

Prevention Resource Center’s Best Practice Registry

(http://www.sprc.org/strategic-planning/finding-programs-

practices) and recent meta-analyses, systematic reviews,

and narrative reviews of psychosocial interventions for

suicidal youth (Brent et al., 2013; Calear et al., 2016;

Corcoran, Dattalo, Crowley, Brown, & Grindle, 2011;

O’Brien et al., 2014; Robinson et al., 2013).

Nine treatments met criteria for inclusion (Asarnow

et al., 2011; Diamond et al., 2010; Donaldson, Spirito, &

96 J. B. Singer et al.

123

Esposito-Smythers, 2005; Esposito-Smythers, Spirito,

Kahler, Hunt, & Monti, 2011; Harrington et al., 1998;

Huey et al., 2004; Mehlum et al., 2014, 2016; Rossouw &

Fonagy, 2012; Stanley et al., 2009). Of these, three were

excluded because they reported no significant difference in

outcomes between the control and experimental condition

(Asarnow et al., 2011; Donaldson et al., 2005; Harrington

et al., 1998). Among the five studies that reported signifi-

cant differences, we eliminated two (Huey et al., 2004;

Rossouw & Fonagy, 2012) from the review for the fol-

lowing reasons: Multi-systemic therapy (MST; Huey et al.,

2004) is not a theoretically-based treatment with specific

interventions. Rather, it is a framework for providing

interventions across multiple systems. Mentalization-based

therapy for adolescents (MBT-A; Rossouw & Fonagy;

2012) is an adolescent modification of a psychodynamic

therapy developed in Great Britain for adults with bor-

derline personality disorder. It is unclear whether MBT-A

is effective at reducing suicidal ideation and/or attempt

because the outcome measure is a broad category of self-

harm that includes suicidal ideation and attempt as well as

non-suicidal self-injury. Additionally there are currently no

MBT-A training opportunities in the USA.

The three remaining treatments, attachment-based fam-

ily therapy (ABFT; Diamond et al., 2010; G. S. Diamond,

G. M. Diamond, & Levy, 2013), integrated-cognitive

behavioral therapy (I-CBT; Spirito, Esposito-Smythers,

Wolff, & Uhl, 2011), and dialectical-behavior therapy for

adolescents (DBT-A; Fleischhaker et al., 2011; Mehlum

et al., 2014, 2016; Miller, Rathus, & Linehan, 2007)

demonstrated better suicide-related outcomes than control

conditions, were theoretically-based, had specific inter-

ventions, and addressed domains and problem areas com-

mon to social work that also increase risk for suicide:

depressed mood, a rupture in the parent–child relationship

(Donath, Graessel, Baier, Bleich, & Hillemacher, 2014),

substance use (Wong, Zhou, Goebert, & Hishinuman,

2013), emotion dysregulation (Pisani et al., 2013), and non-

suicidal self-injury (Klonsky, May & Glenn, 2013).

Empirical support, theoretical assumptions, and specific

interventions for each of the three treatments are presented.

Attachment-Based Family Therapy (ABFT)

Attachment-Based Family Therapy (ABFT; Diamond

et al., 2013) is the only family-based therapy designed to

reduce depression and suicide risk in adolescents. ABFT is

a 12–16 week family therapy model that integrates con-

cepts from family systems theory and attachment theory.

ABFT has demonstrated efficacy in reducing suicidal

ideation in 5 clinical trials (G. M. Diamond et al., 2012;

Diamond et al., 2010; Diamond, Creed, Gillham, Gallop, &

Hamilton, 2012; G. S. Diamond, Reis, G. M. Diamond,

Siqueland, & Isaacs, 2002).

A core assumption of family systems theory is that

interactions between family members follow pre-

dictable patterns. Interrupting and altering these patterns

results in long-lasting changes for individuals and the

family as a unit. ABFT assumes interaction patterns can

either exacerbate or reduce suicide risk. ABFT integrates a

family systems approach with attachment theory through

the parent-adolescent relationship. ABFT subscribes to the

notion that attachment is a biological instinct, with roots in

infant development, which is shaped by interpersonal

interactions throughout the lifespan (Ainsworth & Bowlby,

1991). There are two basic attachment styles—secure and

insecure. Secure attachments develop when a primary

caregiver consistently addresses an infant’s basic needs

(hunger, boredom, soothing, love, affection, etc.). Insecure

attachments develop when a primary caregiver is incon-

sistent or does not meet these basic needs. Research has

found that attachment styles are fairly stable across cultures

and across the lifespan (McConnell & Moss, 2011).

However, because they are shaped by the interpersonal

environment, attachment styles can change. A child with a

secure attachment whose sense of safety and security is

repeatedly violated (e.g. through abuse or neglect) might

develop an insecure attachment style. Conversely, a child

with an insecure attachment who experiences a primary

caregiver meeting basic needs can ‘‘earn’’ security (Main,

Hesse, & Kaplan, 2005). The capacity to earn security is

central to the effectiveness of ABFT. ABFT assumes that

one of the best ways to reduce suicide risk is to strengthen

the adolescent-parent attachment. During a course of

ABFT, which includes five treatment tasks, the therapist is

constantly listening and looking for ways for adolescents to

earn security or strengthen an already secure attachment.

Two of the techniques used to achieve this goal are called

‘‘Relational Reframe,’’ and ‘‘Attachment’’ (Diamond,

2014).

ABFT Techniques

Relational Reframe

The first intervention used in ABFT is a relational reframe

(Diamond, 2014; G. S. Diamond, G. M. Diamond, & Levy,

2014). Consistent with ABFT’s family systems perspec-

tive, the purpose of the relational reframe is for family

members to reframe adolescent suicide risk as a relational

rather than individual issue. The family might come to

therapy seeing the adolescent as the problem (e.g., ‘‘can

you help him with his depression?’’), but the reframe

ensures that they leave understanding that the family is the

Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks… 97

123

solution. During the first session, the therapist elicits

information from the suicidal adolescent and their par-

ent(s) about what has contributed to the current suicidal

crisis, and then works with the family to see how the

interaction between the parent and the child can be a

solution to the crisis. For example, the adolescent might

say, ‘‘When I’m feeling bad I just want to go to my room. I

don’t want to talk to anyone, especially my parents. It

would be embarrassing. Dad wouldn’t know what to say

and mom would just blame herself.’’ The therapist reflects

back that it seems like he’d rather kill himself than feel

embarrassed, or make his parents uncomfortable. The

therapist notes the affect in the room (typically sad or

anxious), and draws out the parents’ longing and desire for

their adolescent to see them as safe people to turn to.

Drawing out emotion, rather than tapping into cognitions,

is consistent with the attachment-focus of the treatment.

The therapist assumes that the parents’ attachment instincts

will be triggered upon hearing their child’s pain and sad-

ness. The therapist makes the connection that both the

adolescent and parents are in pain and long for a different

kind of relationship. The therapist assures the family that

there are things they can do differently that would make it

more likely that their son would talk with them when he is

depressed or suicidal. By the end of the session, an ideal

outcome for the relational reframe is for the adolescent and

parent(s) to acknowledge a desire to be closer to each

other. The therapist then contracts with the family to work

on that goal. If the adolescent or the parent(s) is unable or

unwilling to agree to that goal, the therapist ‘‘steps down’’

to a relational goal that might be less threatening, such as

improving parent–child communication.

Attachment

The attachment task typically occurs halfway through

treatment. This intervention is a core ABFT technique

which involves a conversation between the adolescent and

his or her parent. After the relational reframe in the first

session and the attachment task, the adolescent and par-

ent(s) have been prepared to address the question, ‘‘what

makes it so difficult for the adolescent to go to the par-

ent(s) when feeling depressed and suicidal?’’ Part of the

preparation for the attachment task is providing the ado-

lescent with a narrative that frames their current struggles

as attachment issues. For example, if the adolescent does

not feel safe sharing intense emotions with a parent

because of the parent’s emotional instability, then the

attachment reframe is that the parent cannot meet a basic

need for protection and comfort. During the attachment

task the adolescent will tell the parent why it has been

difficult to come to them when depressed or suicidal. The

adolescent might say, ‘‘I don’t go to you because I’m afraid

you will freak out and start crying, which will make me

feel worse.’’ ABFT recognizes that parents might react

with statements that could be invalidating (e.g. ‘‘No, I

wouldn’t’’), critical (e.g. ‘‘How would you know if you

never do it?’’), dismissive (e.g. ‘‘You don’t understand’’) or

self-involved (e.g. ‘‘I’m a terrible parent, of course you

wouldn’t want to talk to me’’). These are not attachment

repairing statements. In order to prepare the parents to

respond in ways that will demonstrate that they are capable

of providing validation, affirmation, love and support, the

parent has received emotion coaching (e.g. asking for more

details, labeling emotions, providing validating statements

such as ‘‘it makes sense why you would be worried to come

to me’’). The therapist’s role is to redirect the conversation

when necessary and provide affirmation when the parent

and adolescent are having the conversation. After the

adolescent feels heard and validated, and the parent feels

successful in meeting their adolescent’s needs, there is a

shift in the attachment pattern. If the adolescent was pre-

occupied, i.e., always worried about the parent being

available, the attachment task would provide a small but

profound experience of the parent being there. The

assumption is that this shift in the mental model of the

parent–child relationship will reduce suicide risk by

increasing the adolescent’s sense of security, safety, and

protection; and the parent’s sense of competence and

connection (Diamond 2014). The gains from this inter-

vention are solidified over the second half of therapy (i.e.,

Task 5), as the adolescent repeatedly experiences the par-

ent as a safe and secure base with whom they can work

through a variety of psychosocial issues, ranging from the

least to most distressing.

Integrated Cognitive Behavioral Therapy (I-CBT)

Suicide-related thoughts and behaviors and substance use

are interrelated in adolescents (Bagge & Sher, 2008;

Goldston, 2004) and increase markedly during this devel-

opmental period, demonstrating the importance of inter-

vention during this time (Daniel & Goldston, 2009; Galaif,

Sussman, Newcomb, & Locke, 2007). Despite the strong

link between suicide-related thoughts and behaviors and

substance use, the standard of care is to treat these two

problems separately (Esposito-Smythers et al., 2012).

However, integrated services have demonstrated greater

promise than serial or parallel treatment for comorbid

substance abuse and psychiatric disorders (Esposito-Smy-

thers & Goldston, 2008; Hawkins, 2009; Sher & Zalsman,

2005). Integrated Cognitive Behavioral Therapy (I-CBT;

Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011)

is one such intervention for adolescents with comorbid

suicide-related thoughts and behaviors and substance abuse.

98 J. B. Singer et al.

123

I-CBT uses a social cognitive learning theory perspec-

tive (Bandura, 1986) to promote change in adolescents by

helping them to relearn adaptive ways of relating to

themselves and others and develop self-efficacy in their

ability to utilize these skills. The I-CBT protocol targets the

maladaptive behaviors and beliefs that are common to the

two problems of substance use and suicide-related thoughts

and behaviors, in order reduce the amount and severity of

problems in both areas simultaneously (Esposito-Smythers

et al., 2011). When treating substance use and suicide-

related thoughts and behaviors in an integrated manner, it

is important to understand how each can exacerbate the

other. For instance, alcohol and other drug use may serve

as a means of self-medication (Kuntsche, Knibbe, Gmel, &

Engels, 2005), as a coping mechanism for depression

(Galaif et al. 2007; Sher & Zalsman, 2005), or as a way to

reduce or relieve negative affect. There is also evidence

that alcohol and other drug use facilitates suicide-related

thoughts and behaviors. Alcohol use causes disinhibition

which can increase the likelihood of acting impulsively on

suicidal thoughts (Sher, 2006), especially in the context of

heavy episodic drinking, which has been found to be

associated with increased risk of suicide attempts among

suicidal adolescents (Schilling, Aseltine, Glanovsky,

James, & Jacobs, 2009). With respect to maladaptive

cognitions and behaviors, alcohol may inhibit the cognitive

ability to use effective coping skills to deal with suicidal

thoughts, which contributes to an elevated risk for a suicide

attempt in the context of suicidal thoughts (Sher, 2006).

Therefore, when addressing alcohol and other drug use in

treatment with suicidal youth, it is critical to draw attention

to the relationship between the two problems, and by doing

so in a collaborative and informative way that does not

come across as a lecture or as telling adolescents what they

should be doing with respect to their drug and alcohol use.

To enhance collaboration and commitment to treatment,

I-CBT uses many Motivational Interviewing (MI) tech-

niques. MI is a client-centered, directive method for

enhancing intrinsic motivation to change by exploring and

resolving ambivalence (Miller & Rollnick, 2013). MI has

been used effectively with adolescents with comorbid

substance use and psychiatric symptoms (Brown et al.,

2009) because of its ability to create a therapeutic atmo-

sphere that acknowledges the choice and ambivalence of

the adolescent and supports personal change goals rather

than institutional or counselor-based goals. Because MI

uses a nonjudgmental and nonconfrontational style, it may

be particularly useful for engaging adolescents who have

not yet considered change, or may have an apparent lack of

motivation to change, their substance use or other problem

behaviors related to their suicide-related thoughts or

behaviors. Even a brief motivational interviewing inter-

vention can serve to increase negative expectancies (i.e.,

the belief that using substances will have negative effects

and consequences), increase situational confidence (i.e.,

confidence in the ability to resist the urge to use substance

in certain situations), and increase mental health and sub-

stance use treatment engagement. In doing so, brief sub-

stance use interventions have the ability to decrease

likelihood of substance use, which in turn will decrease the

frequency of substance-related suicidal thoughts and

behaviors.

I-CBT works under the premise that reduction of

suicide and substance abuse risk requires coordinated

efforts with adolescents and their parents. Individually

with the adolescent, I-CBT addresses issues with cogni-

tive distortions, coping, and communication, by working

with the adolescent on cognitive restructuring, problem

solving, affect regulation, and communication skills

(Esposito-Smythers et al., 2011). For instance, one

common cognitive distortion among suicidal adolescents

is the belief that ‘‘I am worthless.’’ This self-deprecation

can increase the likelihood of adolescents engaging in

risky behaviors such as substance use because they want

to use the substance to align themselves with these

negative views of self, distract themselves from their

distressing thoughts, or to numb themselves from their

accompanying emotions. Substance use in this context

exacerbates suicide risk by inhibiting their ability to use

coping skills and facilitating the transition from suicidal

thoughts to action.

Parental involvement has been show to enhance the

effectiveness of treatment with suicidal adolescents (Brent

et al., 2013). Strategies for inclusion of parents in the

I-CBT protocol typically involve a parent training session

about psychoeducation about emotion regulation, as well

as the importance of parental monitoring and communi-

cation (Esposito-Smythers et al., 2011). Teaching parents

about what their adolescent is experiencing, as well as

how they can effectively communicate with their ado-

lescent during times of heightened emotional distress,

increases the likelihood that parents can be a buffer,

rather than a trigger, to adolescents future suicidal crises.

Additionally, teaching parents about the importance of

monitoring their adolescents’ whereabouts, including the

peers with whom they are spending their time, influences

the likelihood that their adolescents will be spending time

with peers who don’t use substances which will in turn

decrease the likelihood of their own adolescents using

substances. Family sessions in I-CBT typically focus on

improving communication and behavioral contracting

(Esposito-Smythers et al., 2011). Addressing the suicide-

and substance-related treatment goals of the adolescent

together with the parent serves to align the parent with the

adolescent, building up the parents as a support in

achieving their treatment goals.

Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks… 99

123

Through the simultaneous improvement in overall ado-

lescent and parent skills, adolescents can then demonstrate

reductions in substance use and suicide-related thoughts

and behaviors. For instance, in their randomized trial,

Esposito-Smythers et al. (2011) found I-CBT, relative to

enhanced treatment as usual (E-TAU), to be associated

with significantly fewer heavy drinking days and days of

marijuana use. Less global impairment as well as fewer

suicide attempts, inpatient psychiatric hospitalizations, and

emergency department visits were reported by adolescents

receiving I-CBT as compared to those receiving E-TAU.

I-CBT Techniques

In their meta-analysis of the effectiveness of brief alcohol

interventions for adolescents, Tanner-Smith and Lipsey

(2015) found the specific components of decisional balance

and goal-setting exercises to be associated with larger

reductions in alcohol consumption and alcohol-related

problems. Therefore, suggested adaptations of these

modalities for adolescents with comorbid suicide-related

thoughts and behaviors will be presented here. These

techniques are currently being utilized in a clinical trial of a

brief alcohol intervention with adolescent inpatients fol-

lowing a suicidal event (O’Brien & Spirito, 2014).

Decisional Balance

The decisional balance is a MI technique used to consider

options and systematically evoke the advantages and dis-

advantages of each (Miller & Rollnick, 2013). The deci-

sional balance typically uses four quadrants to ask about

the pros and cons regarding a decision (e.g., ‘‘what do you

like about alcohol,’’ ‘‘what don’t you like about alcohol,’’

‘‘what would be the bad things about changing your

drinking,’’ and ‘‘what would be the good things about

changing your drinking’’). The diagonal boxes are com-

plementary and may contain similar entries. Some ado-

lescents may find it confusing to distinguish between the

two, in which case, a simple pros and cons list may be more

effective. When completing the decisional balance with

adolescents, it is important to first elicit what it is they like

about their substance of choice (or other problem behavior)

before asking them about what they don’t like. It is critical

that while they are telling you what they like, you maintain

a nonjudgmental and nonconfrontational stance. Some

common reasons suicidal adolescents cite for why they like

drinking or other drug use include ‘‘helps me feel more

comfortable to talk to people at a party,’’ ‘‘makes me forget

about all the bad things going on,’’ or ‘‘like the way it

feels.’’ Reasons they don’t like drinking or other drug use

frequently include ‘‘get sick,’’ ‘‘feel sad or down the next

day,’’ or ‘‘feel bad the next day about something I did when

I was drunk.’’ Knowing these reasons can help you in the

therapeutic process to understand the functions the alcohol

or other drugs are serving for the adolescent, especially

with respect to their suicide-related thoughts and behaviors.

Clinicians must remember that this relationship is not

always unidirectional; in fact, many adolescents endorse a

bidirectional relationship between their substance use and

suicide-related thoughts and behaviors. Once this rela-

tionship is understood, then the clinician can work with the

adolescent to identify alternate ways to replace the function

that the alcohol is serving for the adolescent, especially in

cases where it is contributing to the exacerbation of sui-

cide-related thoughts and behaviors. In the I-CBT protocol,

the decisional balance is typically used in session 3 (of 13

or more sessions), but because of its flexibility, it can be

adapted for a wide range of uses in both brief and long term

treatment modalities.

Goal-Setting Exercises

In MI, goal setting exercises, such as making a change

plan, are conducted only when the client demonstrates

sufficient readiness (Miller & Rollnick, 2013). Change

plans can take many forms, but they typically include a list

of goals and steps to take to achieve those goals. It is

important that adolescents develop their own goals to

emphasize their autonomy and therefore increase motiva-

tion to adhere to the change plan. Goals often relate to

substance use or other problem behaviors that affect their

suicide-related thoughts and behaviors, but are not limited

to these areas. For example, suicidal adolescents may

decide to make a plan to reduce their alcohol use at a party,

rather than stop use altogether. They may choose to do

reduce use because they want to be able to drink a little so

they can feel comfortable at a party, but not so much that

they get drunk and do something they regret the next day. It

is recommended that the change plan identifies adults who

can help the adolescent achieve their goals, as well as

barriers that could get in the way of the adolescent’s goal

attainment. It can be helpful for the clinician to talk with

the adolescent about how the parent can be of assistance in

the change plan process. Adolescents often come up with

unique ideas that you, as the clinician, could not think up

on your own. With respect to barriers, it can be useful to

have the adolescent take you step-by-step through a situ-

ation where they typically use substances in order to

identify what the specific barriers are for that adolescent.

Once a barrier has been identified, the clinician can then

brainstorm with the adolescent what they can do they next

time the situation comes up. In the I-CBT protocol, the

change plan is typically completed at the end of session 3,

100 J. B. Singer et al.

123

but can be revisited throughout the remainder of treatment

when appropriate.

Dialectical Behavior Therapy for Adolescents (DBT-A)

DBT-A was adapted from Dialectical Behavior Therapy

(DBT; Linehan, 1993), a treatment modality that combines

principles of behavioral science, dialectical philosophy,

and Zen practice (Miller et al., 2007). DBT was initially

developed in the 1980’s to address self-harming behaviors

in women, many of whom met criteria for borderline per-

sonality disorders. DBT-A is a version of DBT that was

adapted for use with adolescents who struggle with suici-

dality, self-harm, and chronic emotion dysregulation.

These adolescents are often struggling with one or more

additional comorbid disorders, such as substance use, dis-

ordered eating, mood and anxiety disorders, and disruptive

behavior disorders (Miller et al., 2007).

DBT-A is a versatile treatment that can be used in both

inpatient and outpatient treatment centers and has also

recently been adapted to a school-based curriculum

(Mazza, Dexter-Mazza, Miller, Rathus, & Murphy, 2016).

Clinical trials of DBT-A have found it is associated with

improvements in overall psychiatric functioning, and sig-

nificant decreases in suicidal ideation and behaviors as well

as comorbid symptoms, such as non-suicidal self-injury

(NSSI) and depression (MacPherson, Cheavens, & Fristad,

2013). Additionally, a recent review and meta-analysis of

suicide-related treatments for adolescents found that, along

with CBT, DBT-related treatments had the largest effect

sizes in relation to clinical improvements (Ougrin, Tranah,

Stahl, Moran, & Asarnow, 2015).

One of the core assumptions of DBT-A is that successful

treatment involves helping the client recognize, synthesize,

and integrate ideas that seem to be in opposition to each

other;his is the main idea behind the word ‘‘dialectic.’’ In

DBT-A, the adolescent is coached to be able to tolerate

painful feelings and simultaneously contemplate the possi-

bility for change. For example, a teen who reports feeling

suicidal due to poor peer and parental relationships might

work on the following dialectic: ‘‘I might not be responsible

for all the things that are bad about my relationships, but I am

responsible for working on them to make them better.’’ A

teen whose suicidal ideation is triggered by not meeting

academic expectations (either internally or externally con-

ceived) might work on the following dialectic: ‘‘I am doing

the best I can, but I can dobetter.’’ The therapist uses a variety

of cognitive strategies in therapy throughout treatment that

allow adolescents to explore and synthesize these sorts of

dialects as they are relevant to their treatment targets.

A second core assumption of DBT-A is that adolescents

express emotions through self-harming behaviors because

they have a systemic problem with emotion dysregulation.

Systemic emotion dysregulation, according to Linehan

(1993), develops as the result of a combination of biolog-

ical pre-disposition and exposure to an ‘‘invalidating

environment.’’ The ‘‘invalidating environment’’ involves

having primary caregivers early in life who react to a

child’s emotions and behaviors with either erratic, inap-

propriate, or invalidating responses (Linehan, 1993), which

makes it difficult for children to develop the ability to

appropriately identify and modulate emotions and self-

soothe in response to distress. These individuals also have

difficulty appropriately identifying the emotions of others,

selecting appropriate responses, and/or modulating their

affect, which results in the inability to maintain a

stable sense of self (Linehan, 1993). Adolescents with a

pre-disposition to emotional dysregulation and who are

exposed to an ‘‘invalidating environment,’’ typically

develop extreme difficultly tolerating conflict, may engage

in ‘‘all or nothing’’ thinking, and/or will have irrational

fears of abandonment. As a result, they can develop

behaviors that alienate others and/or sustain dysfunctional

social relationships (Miller et al., 2007).

In DBT-A, it is assumed that suicide-related affect,

thoughts, and behaviors are ways of directing anger

towards the self and/or escaping from extreme hopeless-

ness or despair (Miller et al., 2007). Suicide-related

thoughts and behaviors and non-suicidal self-injury (NSSI)

are categorized as ‘‘life threatening behaviors’’ which are

targeted with similar interventions, and are considered one

of the first targets of treatment (Miller et al., 2007). They

are prioritized and addressed with a multi-modal approach,

which is described further below.

DBT-A Techniques

‘‘Life threatening behaviors’’ are addressed in DBT-A

through a multi-modal approach that includes individual

treatment, psychopharmacology, skills training, phone-

consultation, family work, and consultation with other

significant providers in the adolescent’s life (such as school

personnel) (Miller et al., 2007). The following section

gives a brief overview of some of the DBT-A techniques

formulated by Miller et al. (2007) that can be applied to

work with suicidal adolescents in either inpatient or out-

patient settings. While all of the techniques described

below can be integrated into individual therapy, DBT-A

skills are typically taught through skills-based training

groups on either inpatient or outpatient settings, or with a

DBT-A skills coach, so that individual therapy can focus

Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks… 101

123

on assessing safety and monitoring the use of these skills to

manage distressing situations (Miller et al., 2007).

Emotion Regulation

One of the major assumptions of DBT is that self-harming

behaviors and suicidal thoughts stem from core problems

with emotion regulation and many of the strategies and

skills employed in DBT-A attempt to improve adolescents’

abilities to tolerate and regulate difficult emotions. One key

emotion regulation skill that is taught in DBT-A is the

concept of mindfulness. Mindfulness refers to experiencing

thoughts and feelings without attaching judgment or neg-

ativity to them. The assumption is that if one is unable to

fully experience one’s feelings, one cannot ever learn to

regulate them (Linehan, 1993). An adolescent, for exam-

ple, who experiences conflicting feelings of ‘‘love’’ and

‘‘hate’’ for an abusive parent might be encouraged to feel

each of these feelings fully, without attaching judgment or

blame to either one. The general concept of mindfulness is

found in many of the DBT-A skills, but can be integrated

into the individual therapy regularly as well by using

techniques similar to the example described above.

There are several DBT-A skills-based exercises that

teach mindfulness. In the Describe, Express, Assert,

Reinforce, (stay) Mindfully, Appear confident, Negotiate

(DEAR MAN) exercise, for example, youth are asked to

describe a situation without judgment, express their feel-

ings or emotions about it, discuss ways they could have

appropriately asserted their wishes, and to reward or rein-

force people who do respond positively to them. Being

‘‘mindful’’ refers to the ability to keep focus by repeating

their requests and ignoring attacks or threats from the other

party. This is often done with the aid of a Diary Card, in

which adolescents are asked to keep track of target

behaviors (including self-harm) and the skills they have

used each week to manage them.

Distress Tolerance

The DBT concept of radical acceptance refers to the idea

that in order to move forward from pain, one must accept it

and experience it in its entirety. Distressful feelings are

reframed as a way the psyche informs an individual of the

need for action (Linehan, 1993). In conjunction with rad-

ical acceptance, DBT-A focuses on helping adolescents

develop core skills that help them make pain more toler-

able. The distress tolerance techniques in DBT-A target the

adolescent’s ability to tolerate painful or difficult situa-

tions. One way this can be accomplished is by teaching the

adolescent ways to self-soothe when faced with difficult or

distressing feelings. The Vision, Hearing, Smell, Taste,

Touch exercise, for example, encourages adolescents to

find ways to engage and soothe each of the five senses. By

engaging in behaviors that ‘‘soothe the body,’’ adolescents

are taught that they can learn to tolerate difficult feelings

without becoming overwhelmed by them. Other examples

of this sort of technique include using positive imagery,

prayer, and relaxation to replace negative experiences with

positive ones. An adolescent who is feeling overwhelmed

and anxious by a distressing conversation with a significant

other, for example, might be encouraged to imagine an

‘‘alternate experience,’’ where the conversation progressed

to what is considered a positive (and safe) end. Another

example might be encouraging an adolescent to use a

progressive muscle relaxation technique when feeling dis-

tressed. In this way, the adolescent can create a more

positive physical feeling in his or her body, making it

easier to tolerate difficult feelings.

Behavioral or Chain Analysis

Another core tenet of DBT is that problematic behaviors

often result from a deficiency in coping and problem

solving skills (Rizvi & Ritschel, 2014). Adolescents may

engage in self-harm, for example, when feeling over-

whelmed by emotion and unable to cope. Alternatively,

they may use self-harming behaviors as a way to com-

municate distress when feeling unable to assert their needs

effectively. One well-known cognitive-behavioral tech-

nique that has been adapted to DBT-A that attempts to

address these issues is called behavioral or chain analysis

(Miller et al., 2007).

A chain analysis can be completed at any time in

treatment, but is intended to be the first step in identifying

problematic situations that trigger a self-harming or suici-

dal event in order to generate solutions. The chain analysis

documents what happened internally and externally leading

up to a suicidal or self-injurious event (this can include

thoughts and/or behaviors), and is sometimes referred to as

a video which is stopped at every frame to identify what is

going on. Although the chain analysis technique is pri-

marily done with the adolescent, a chain analysis can be

done with the parents as well in order to gather the fullest

picture possible of what happened and what lessons can be

learned to prevent future events. The chain analysis is a

time-intensive process and typically takes a minimum of

30 min. The clinician very methodically goes through the

events with the adolescent, writes down what happened

when, and asks clarifying questions such as, ‘‘and after he

said that, how did you feel? What did you do then?’’ The

chain analysis is complete once a thorough picture is

obtained of what happened leading up to the suicide-related

event.

One goal of this technique is to identify vulnerabilities

as well as draw out strengths, resources, and solutions that

102 J. B. Singer et al.

123

the adolescent might not have previously recognized. A

chain analysis can also be useful because it helps the

therapist and adolescent identify ‘‘solution’’ or ‘‘change’’

procedures that address the suicide-related behavior. The

particular focus of the change procedures often differs

depending upon the findings in the chain analysis. For

example, for an adolescent who reports engaging in self-

harming behavior after becoming enraged during a fight

with a parent, the therapist might work on helping the

adolescent identify some distress tolerance techniques to

manage emotions in the moment as well as some inter-

personal effectiveness skills that could have been used to

make the interaction with the parents more productive.

The chain analysis also allows the adolescent to re-ex-

perience situations involving difficult or painful feelings in

a safe and removed way. During the chain analysis, the

therapist can help adolescents tolerate difficult feelings

without engaging in self-harming behaviors and help the

teen learn to manage his or her affect (Rizvi & Ritschel,

2014). In this way, the chain analysis technique is also very

much consistent with the DBT concepts of radical accep-

tance and distress tolerance. In the example above, in

addition to identifying antecedents and alternative strate-

gies to the situation, the therapist might help the youth

modulate feelings of anger, frustration or sadness triggered

by the argument with the parent. Additionally, the therapist

could encourage the use of mindfulness and distress tol-

erance techniques that could be used to fully experience

these feelings while still learning to manage them.

Discussion

Despite the value placed on understanding the intersection

between theory and practice, there are very few resources

that provide students and practitioners with insight into this

intersection with specific treatments (for a comparable

article on substance use disorders see Wells, Kristman-

Valente, Peavy, & Jackson, 2013; see also the Springer and

Rubin book series ‘‘Clinician’s Guide to Evidence-Based

Practice’’). This review provides the theoretical assump-

tions, conceptual frameworks, and key intervention tech-

niques for three probably efficacious psychotherapies for

suicidal youth: attachment-based family therapy (ABFT),

integrated-cognitive behavioral therapy (I-CBT) and

dialectical behavior therapy (DBT). The selection of these

three treatments was based on several criteria, including:

empirical support for reduction of suicidal ideation or

attempt; an explicit relationship between the interventions

and the theories; theoretical diversity (ABFT is an emo-

tion-focused, attachment-oriented family-based interven-

tion; I-CBT and DBT are grounded in cognitive-behavioral

theory with humanistic and mindfulness components);

evaluation with low-income people of color; and avail-

ability of a treatment manual for further study. In addition

they address clinical issues that are regularly addressed by

social workers including mood disorders, parent–child

conflict, substance use, emotion dysregulation, and non-

suicidal self-injury.

Considerations and Limitations

One important consideration related to these treatments is

the feasibility of implementing them with fidelity in day-to-

day social work practice (Singer & Greeno, 2013).

Becoming certified in each of these treatments, for exam-

ple, can take several years and thousands of dollars.

Practitioners cannot say they are providing ‘‘DBT, ABFT,

or I-CBT’’ unless they have received the requisite formal

training. Attending online or in-person non-certification

continuing education workshops allows practitioners to

learn and integrate approach-specific techniques and to say

that their practice is ‘‘informed’’ by these manualized

treatments.

Secondly, there are several limitations to the existing

research-base and the conceptual frameworks for each of

these treatments. For ABFT, research participants in the

United States have primarily been low-income African

American families living in Philadelphia which might limit

generalizability to more affluent or racially diverse sam-

ples. The primary outcome of ABFT research has been

reduction in suicidal ideation and depression which means

it has never been evaluated for preventing suicide attempts

or deaths. As with all manualized treatments, ABFT has a

specific theoretical orientation (attachment and systems

theory). ABFT therapists enter the treatment relationship

with the intention of helping families see the current sui-

cidal crisis through an attachment lens. Clinicians who

practice from a solution-focused or narrative perspective

might find this a priori assumption to be counter to their

client-centered treatment approach. Indeed, ABFT is

described as ‘‘client-respectful,’’ rather than ‘‘client-cen-

tered’’ (Diamond et al., 2010). With I-CBT, the role of

medication management is not explicitly addressed in the

protocol (Esposito-Smythers et al., 2012), which is

important because of the possibility of abusing prescription

medication, and the ongoing controversy about the role of

medication and increased suicide risk (Sharma, Guski,

Freund, & Gøtzsche, 2016). Another possible limitation of

I-CBT is that the focus on substance use and suicide may

lead other risky behaviors to be ignored if not observed or

asked about in the context of treatment. In addition,

replication of I-CBT in randomized trials with other sam-

ples (e.g., juvenile justice) is warranted. Criticisms of DBT

have included concerns that change mechanisms may be

Three Psychotherapies for Suicidal Adolescents: Overview of Conceptual Frameworks… 103

123

related more to the structure of DBT (e.g., high levels of

supervision, consistency and stability of treatment, and the

high level of motivation of providers) as opposed to the

techniques themselves (Scheel, 2000), as well as the need

for a high level of organizational support in order for the

treatment to be effective (Swales, Taylor, & Hibbs, 2012).

Additionally, while there is initial empirical support for the

effectiveness of DBT-A, more randomized clinical trials

are needed (MacPherson et al., 2013).

We hope that by addressing theory in detail, this review

addresses some of the concerns about fit between the

treatment’s and the provider’s theoretical orientation.

Although there is great utility in understanding how and

why these psychotherapies address suicide risk, individual

and family therapies are not the only modalities that have

seen support in reducing suicide risk. For example, two

recent studies analyzed outcomes from community-based

youth suicide prevention programs across the USA and

found that these programs reduced youth suicide attempts

and deaths (Garraza, Walrath, Goldston, Reid, & McKeon,

2015; Walrath, Garraza, Reid, Goldston, & McKeon,

2015).

Although all three therapies have the goal of reducing

suicide risk in youth, the differences in theoretical

assumptions have important implications for how and when

to intervene. Whereas ABFT and I-CBT provide guidance

for when and how to work with families, DBT provides

guidance for when and how to work in groups. ABFT is an

affective-based therapy, whereas I-CBT and DBT are

cognitive-based interventions. Although all three include

skill-building, ABFT teaches skills to parents, and I-CBT

and DBT teach skills to youth. While all treatments have

been evaluated in outpatient settings, only DBT-A has been

evaluated in an inpatient setting. Each therapy was devel-

oped to address suicide risk within different psychiatric

disorders, including depression (ABFT), substance abuse

(I-CBT) and borderline personality disorders (DBT). These

differences are not the eccentric whims of the developers,

but are based on differing theoretical assumptions about

what leads to change. When social workers understand the

theoretical differences, they can make decisions about

which interventions are theoretically consistent and which

are not.

In sum, working with suicidal youth is complex and

fraught with anxiety for both the client and the clinician.

Potentially efficacious treatments reduce some of that

burden by providing a theoretically-informed pathway to

navigating this complex and potentially life-threatening

situation. Social work education programs can accelerate

the speed with which providers are able to deliver treat-

ments for suicidal adolescents by offering semester-long

electives in any of the interventions listed in this article,

post-graduate certificate programs in partnership with the

model developers, and technology mediated learning such

as webinars or podcast series.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no conflict of interest.

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