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Dialectical Behavior Therapy With Suicidal Adolescents
Reviewed by GEORGE R. JACOBSON
Am J Psychiatry 2008;165:653-654. doi:10.1176/appi.ajp.2008.08010006

by Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan. New York, Guilford, 2006, 354 pp., $40.00.

Whoever saves a life...saved the entire world.

Talmud, Sanhedrin (37a)

After 37 years of working in a variety of hospitals and clinics, I get a strong emotional distress signal in my throat, chest, and stomach whenever I hear or read about a kid committing suicide. So when a book that describes a treatment method and program purporting to deal successfully with suicidal adolescents becomes available, this book is worth my time and attention, and yours as well.

As the authors point out, suicide is the third most frequent cause of death among adolescents, with more than 2,000 fatalities per year in the United States and at least an additional 100 to 200 attempts for each completion—representing 1 million teenagers, 700,000 of whom receive medical attention as a result of self-injury. Therefore, the first two chapters of the book concentrate on identifying and describing the population at risk, including those who complete suicide, those who make unsuccessful attempts, and those who are involved in non-suicidal self-injurious behavior and related actions; and available treatments (e.g., treatment as usual) and outcomes (e.g., dropout rates or subsequent suicide attempts). Chapters 3 through 11 focus on the treatment itself, dialectical behavior therapy, in all of its myriad details and intricacies.

This book is written clearly and lucidly and in a simple, direct, and unambiguous style that should preclude confusion for most readers. But do not be misled by appearances, for it is a difficult text to read; it is so thorough, explicit, comprehensive, and detailed that one ought not try to take in too much at one time (for example, I am a painfully slow and methodical reader of clinical material, and I could not concentrate on the material for more than 1.5 hours at a time, ultimately requiring over 24 hours to complete the text). This text does not strike me as one primarily for scholars or scientists but rather for clinicians/practitioners who are in the trenches on a daily basis. This book is not only part of the “how-to” genre but, more encompassingly, discusses when, where, why, etc. For example, the authors recommend details of who should be treated, in how long of a session, how many sessions, with what sort of homework assignments, when to contact a patient who misses a session, how to speak to that patient, whether to contact parents of minors, and so on, exhaustively. There is a lot of redundancy built into the book—normally a useful didactic tool—but at times it almost verges on excessive repetition. Generally, however, reading this book felt like having an experienced clinician or teacher at my side. Nevertheless, do not expect to become adept in dialectical behavior therapy by reading only this book, for the authors also recommend two previous books by Dr. Linehan (1, 2) and participation in at least one intensive workshop, appropriate supervision, an ongoing self-study group, and other education/training activities.

At the very least, however, this book should help readers decide if they can, and if they want to, provide dialectical behavior therapy to suicidal adolescents, many of whom will have already been diagnosed with borderline personality disorder and/or other complicating comorbid disorders. As the authors succinctly put it, “[dialectical behavior therapy] is not for the faint of heart” (p. 82). Nor is it, as the authors frequently note, appropriate for solo practitioners who do not have the clinical resources the authors so thoroughly describe in several chapters (e.g., behavioral skills trainers, family therapists, multifamily group therapists, consultants and colleagues to provide therapy for the treating therapist, and time for telephone consultation between appointments).

As the authors so lyrically state, “[dialectical behavior therapy] is the treatment of a community of clients by a community of therapists” (p. 81), and therefore, “the suicide of one therapist’s client is the suicide of a client of all therapists” (p. 82). The authors dedicate multiple sections of their next eight chapters to describing the nature and function of those community elements needed to get the job done, including 1) individual therapists and how they initiate and maintain the therapeutic dialectic, how they are authoritative without being authoritarian, and how they are accepting and validating while keeping the patient motivated to change; 2) behavioral skills trainers and how they teach core mindfulness skills, distress tolerance skills, interpersonal effectiveness skills, emotion regulation skills, and walking the middle path skills; 3) family therapists and how they know when to include and exclude parents, grandparents, and siblings; 4) a dialectical behavior therapy consultation team and how they provide therapy to the treating therapist; 5) school counselors and the information they can provide; 6) prescribing physicians and how they deal with issues of medication compliance; and 7) other members of the integrated community.

The final two chapters of the book detail the ways in which patient progress is assessed, when and how to terminate treatment and transition into follow-up, or “graduate,” groups, how to deal with administrative and personnel issues and training and supervision matters, and other related concerns. Again, the level of specificity is remarkable, as in the section on dealing with the suicide of a patient: “call the family promptly…offer condolences…kindly and empathetically…go to the funeral…plan a tribute session or memorial ceremony…[and] model a balance between grieving and moving forward” (p. 251).

Awareness of the precursors of dialectical behavior therapy and the multiple genealogies of its family tree make it easier to understand, practice, and teach. Eastern philosophies and techniques pertaining to mindfulness, awareness, acceptance, and balance are important parts of dialectical behavior therapy (and perhaps warrant an expanded review in future revisions of the book). Traditional American behaviorism, including constructs of reinforcement, extinction, successive approximation (“shaping”), motivation, and related topics are reasonably well explicated. The therapeutic innovations of Ellis, Beck, Maultsby, and others who developed the interrelated lineages of rational-emotive therapy, rational-behavioral therapy, cognitive-behavioral therapy (CBT), and dialectical behavior therapy should perhaps be elaborated, especially since “[dialectical behavior therapy] is a version of CBT; therefore one needs training in CBT as a base. For staff members…already trained in CBT, [dialectical behavior therapy] is an easy leap” (p. 272). On the other hand, I would direct readers’ attention to the particularly valuable content pertaining to dialectical strategies in therapy and the examination of patients’ and therapists’ “in-session dysfunctional behavior” (which, in another era, might have been called resistance, countertransference, or some other type of interference).

Finally, and in a class of their own, I would draw attention to all of the useful charts, tables, homework assignments, explanatory handouts, daily diary cards, and related documents provided by the authors. These materials add substantively to the value of dialectical behavior therapy and the explicitness of its procedures. Among these materials are 30 mindfulness exercises and lecture notes on dialectics, behaviorism, walking the middle path, and other utilitarian therapy aids. This book is so thorough that the authors have even provided the necessary copyright notices so the take-home materials can be duplicated.

Concluding with approximately 365 references and a well-organized index, this challenging and worthwhile volume (aha! I’ve learned the dialectic!) belongs on the desk of anyone working with—or thinking about working with—suicidal, self-injuring, or other complexly disturbed adolescents.

1.Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
 
2.Linehan MM: Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford, 1993
 
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References

+Book review accepted for publication January 2008 (doi:10.1176/ appi.ajp.2008.08010006).

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References

1.Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
 
2.Linehan MM: Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford, 1993
 
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