P S Y C H O S O C I A L I N T E R V E N T I O N S F O R S U I C I D A L Y O U T H A N D T H E I R F A M I L I E S J O N A T H A N B . S I N G E R , P H . D . , L C S W

A G E N D A

o Evidence-based interventions for suicidal youth and their families○ Cognitive-behavioral therapy for suicide prevention (CBT-SP, I-

CBT, and DBT-A)○ Attachment-based family therapy (ABFT) for depressed and

suicidal youtho References

T E C H N O L O G Y A S S E S S M E N T• Assessing client’s technology use

• Self/family/relationship to tech, etc.

• How do they signal suicidal intent online?

• Telephony and webcam allow for flexibility:

• Have them take you on a tour of their house/apt/room

• Ask them to take a walk while you’re talking

• Whiteboard on Zoom

• Review chat history / transcription

3

C O G N I T I V E B E H A V I O R A L T H E R A P I E SC B T- S PI - C B TD B T- A

C B T- S P

Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP)o Phase 1: risk assessment, treatment, or recovery plan development; safety planning; and

crisis stabilization. o Phase 2: identifying and challenging the client's maladaptive beliefs and self-statements

that contribute to suicidal behavior such as hopelessness, perceived burdensomeness, and feeling trapped.

o Phase 3: relapse prevention. Although it has a cognitive foundation, the final phase uses concepts from motivational interviewing and behavioral skills training to reinforce new behaviors and skills for managing future distress. (Bryan, 2019)

I N T E G R A T I V E C B T

o Integrated Cognitive Behavioral Therapy (I-CBT; Esposito-Smythers, Spirito, Kahler, Hunt, & Monti, 2011) is an intervention for adolescents with comorbid suicide-related thoughts and behaviors and substance abuse.

o The I-CBT protocol targets the maladaptive behaviors and beliefs that are common in the two problems in order to reduce the amount and severity of problems in both areas simultaneously.

o Integrative treatment acknowledges that ways that substance use and STB can exacerbate each other. Note: recent studies have not found MI to improve post-hospitalization follow-up or reduction of suicide ideation in a family therapy context (Esposito‐Smythers et al., 2021; Grupp-Phelan et al., 2019)

o CBT techniques used in I-CBT are common with the other CBT approaches, so let’s look at some motivational interviewing techniques borrowed from the substance use field.

M I T E C H N I Q U E S

o Decisional Balanceo Change plans

D I A L E C T I C A L B E H A V I O R T H E R A P Y

o DBT-A was adapted from Dialectical Behavior Therapy (Linehan, 1993), a treatment modality that combines principles of behavioral science, dialectical philosophy, and Zen practice (Miller et al., 2007).

o DBT-A has been used in both inpatient and outpatient treatment centers and has been adapted to a school-based curriculum called DBT-STEPS-A (Mazza, Dexter-Mazza, Miller, Rathus, & Murphy, 2016)

o Core assumptions○ Successful treatment involves helping the client recognize, synthesize, and integrate

ideas that seem to be in opposition to each other, aka “dialectic.”○ Adolescents express emotions through self-harming behaviors because they have a

systemic problem with emotion dysregulation.

K E Y C O N C E P T S

Emotion Regulationo Self-harming behaviors and suicidal thoughts stem from core problems with emotion

regulation. o Mindfulness refers to experiencing thoughts and feelings without attaching judgment or

negativity 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).

o DEAR MANDistress Toleranceo Distress = the need for action o Radical acceptance refers to the idea that in order to move forward from pain, one must

accept it and experience it in its entirety. o Distress tolerance techniques in DBT-A target the adolescent’s ability to tolerate painful or

difficult situations.

C H A I N A N A L Y S I S

Identify Identify stressors and vulnerabilities in order to develop a case conceptualization

Identify Identify precipitants, motivation, intent, current reaction, reaction of the environment

Freeze Frame Talk about the event as if we’re watching a movie

Reconstruct Reconstruct events, thoughts, feelings leading up to the suicide attempt

D B T- I N S P I R E D T E C H N O L O G Y M E D I A T E D - P R A C T I C Eo Can’t get out of bed

○ Opposite Action. Put phone in another room

o Emotionally numb○ Practice distraction by watching a funny video together

o Disconnected○ Caring texts

(see Whiteside, 2020 for more details: http://zerosuicide.edc.org/resources/outreach-time-covid19-matching-patient-experience-guided-intervention)

11

A T TA C H M E N T- B A S E D F A M I LY T H E R A P Y

F O R S U I C I D A L A N D D E P R E S S E D Y O U T H

Y O U M I G H T S E E Y O U R C H I L D A S T H E P R O B L E M ,

B U T W E S E E Y O U R FA M I LY A S T H E S O L U T I O N

- G U Y D I A M O N D

C O - D E V E L O P E R O F

A T T A C H M E N T - B A S E D F A M I L Y T H E R A P Y

T A S K 1 : R E L A T I O N A L R E F R A M E

oBond: Join, build therapeutic allianceoGoal: Reframe

○ Shifting from patient as problem to family relationships as solution○ Highlight the rupture in the relationship

■ “When you are feeling so sad and afraid, why don’t you go to your mom for support?”■ “What gets in the way of your daughter seeing that you want to be there for her?”

○ Put responsibility for change on all family memberso Task: Establish a treatment contract

○ I can help you two rebuild love and trust

Acceptance of negative emotion, validation,

negotiation and compromise rather than

submissiveness and disengagement.

Why don’t you go to your parent when suicidal?

Traumatic events (CAN)Negative family interactions

(critical or dismissive)Parental psychopathology

(schizophrenia, etc.)

T A S K 2 : A L L I A N C E W I T H A D O L E S C E N T

o Bond: Getting to know the teen and building trusto Goals: Identify core conflicts

○ Identify breaches of parental trust○ Link depression/suicide to family relationships○ Amplify entitlement to address unsatisfied needs○ Gaining Trust that therapist will help the conversation to be different

o Task: Prepare adolescent for attachment task○ What to say and how to say it○ Possible challenges

■ Prepare for parent’s reaction■ Understand own reaction (takes two to tango)

E X A M P L E S O F

R U P T U R E S

• Traumatic events

• My mom didn’t protect me when dad was abusing us, how can I trust her now?

• Negative family interactions

• My dad does not take me seriously, ridicules me

• My mom yells at me

• Parental psychopathology

• My mom gets too anxious and cannot handle it when I tell her my problems

• I don’t want to burden my mom, she has enough on her plate

T A S K 3 : A L L I A N C E W I T H P A R E N T

oBond: Understanding current stressors and parent’s own history of attachment failures.oGoals:

○ Increase empathy towards adolescent○ Get a commitment from them to protect adolescent from further harm○ “It must be hard raising an adolescent, let alone a depressed one, when you are

juggling with so much.”○ “Nobody was there for you when you were growing up, and now you don’t know how

to be there for your son”o Task: Preparation for attachment task

○ Emotion coaching

T A S K 4 : A T T A C H M E N T

o Bond: Continued trust of therapist to help facilitate conversationo Goals: facilitate discussion about core attachment ruptureso Process: Enactment

○ Adolescent uses new affect regulation and interpersonal problem-solving skills; parents use more emotional coaching. ■ Adolescent discloses and discusses core ruptures■ Parents offer empathy and acknowledgement■ Therapist redirects conversation as necessary

■ Mutual responsibility and commitment to change■ More confidence that they can work through difficult problems together ■ Adolescent feels safe turning to parents for help

T A S K 5 : C O M P E T E N C Y

o Goal: Build competency in communication skills between parents and adolescento Parents are now viewed as a secure base and should be used to support the adolescent in

building competency and set reasonable expectationso Normative problem-solving possible because parents and adolescents are now willing to

engage each other o Continue to practice improved communication skills between parents and adolescento Building other adolescent competencies as a buffer against stress

T A S K 5 : C O M P E T E N C Y

o Identifying appropriate challenges○ Social considerations○ Academic considerations○ Extracurricular, Interests, and Skills

o Identity Development○ Romantic Relationships and Sexuality○ Ethnicity, Race, Class○ Religion and Spirituality

o Teens learn to expect to receive support, care, and help exploring and building in these areas of their lives (Parents as secure base/safe haven).

o When parents can help their teens in these areas, they feel most like good parents-it can become a positive reinforcement cycle.

R E F E R E N C E SA S A M P L E O F T H E E V I D E N C E - B A S E

C B T

o Bryan, C. J. (2019). Cognitive behavioral therapy for suicide prevention (CBT-SP): Implications for meeting standard of care expectations with suicidal patients. Behavioral Sciences & the Law, 0. https://doi.org/10.1002/bsl.2411

o Bryan, C. J., & Rudd, M. D. (2018). Brief Cognitive-Behavioral Therapy for Suicide Prevention (1 edition). The Guilford Press.

o Stanley, B., Brown, G., Brent, D. A., Wells, K., Poling, K., Curry, J., Kennard, B. D., Wagner, A., Cwik, M. F., Klomek, A. B., Goldstein, T., Vitiello, B., Barnett, S., Daniel, S., & Hughes, J. (2009). Cognitive-behavioral therapy for suicide prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48(10), 1005–1013. https://doi.org/10.1097/CHI.0b013e3181b5dbfe

I - C B T

o Esposito‐Smythers, C., Wolff, J. C., Liu, R. T., Hunt, J. I., Adams, L., Kim, K., Frazier, E. A., Yen, S., Dickstein, D. P., & Spirito, A. (2021). Family-focused cognitive behavioral treatment for depressed adolescents in suicidal crisis with co-occurring risk factors: A randomized trial. Journal of Child Psychology and Psychiatry, 0. https://doi.org/10.1111/jcpp.13095

o Spirito, A., Esposito-Smythers, C., Wolff, J., & Uhl, K. (2011). Cognitive-behavioral therapy for adolescent depression and suicidality. Child and Adolescent Psychiatric Clinics of North America, 20(2), 191–204. https://doi.org/10.1016/j.chc.2011.01.012

D B T

o Little, H., Tickle, A., & das Nair, R. (2018). Process and impact of dialectical behaviourtherapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder. Psychology and Psychotherapy, 91(3), 278–301. https://doi.org/10.1111/papt.12156

o Mehlum, L., Ramberg, M., Tørmoen, A. J., Haga, E., Diep, L. M., Stanley, B. H., Miller, A. L., Sund, A. M., & Grøholt, B. (2016). Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: Outcomes over a one-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 55(4), 295–300. https://doi.org/10.1016/j.jaac.2016.01.005

o Yeo, A. J., Germán, M., Wheeler, L. A., Camacho, K., Hirsch, E., & Miller, A. (2020). Self-harm and self-regulation in urban ethnic minority youth: A pilot application of dialectical behavior therapy for adolescents. Child and Adolescent Mental Health, 25(3), 127–134. https://doi.org/10.1111/camh.12374

A B F T

o Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-based family therapy for depressed adolescents. American Psychological Association.

o Diamond, G. S., Kobak, R. R., Krauthamer Ewing, E. S., Levy, S. A., Herres, J. L., Russon, J. M., & Gallop, R. J. (2019). A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal. Journal of the American Academy of Child & Adolescent Psychiatry, 58(7), 721–731. https://doi.org/10.1016/j.jaac.2018.10.006

T H A N K Y O UJ O N A T H A N B . S I N G E R , P H . D . , L C S W

PRESIDENT, AMERICAN ASSOCIATION OF SUICIDOLOGY

ASSOCIATE PROFESSOR LOYOLA UNIVERSITY CHICAGO SCHOOL OF SOCIAL WORK