Alec Miller is a jazz pianist. A jazz musician holds tight to his fundamentals and improvises within the rules. That’s exactly what it takes to adapt an evidence-based treatment to a new population.
Jill Rathus is a mother of twins. A parent of twins seeks balance and searches for truth in opposing perspectives. That’s just what it takes to work dialectically with multiproblem, suicidal teens and their families.
Dialectical behavior therapy (DBT) evolved from Marsha Linehan’s own application of standard cognitive-behavioral therapy (CBT) to individuals with suicidal and self-injurious behaviors. It did not work. The patients, typically of a highly sensitive and emotionally reactive nature, and having endured years feeling misunderstood and judged by those around them, felt “corrected” and invalidated by the direct focus on behavioral change. Weekly crises trumped problem-solving procedures. But guided by a steady focus on behavioral outcomes, Linehan stayed the course, improvising within the rules. She modified her use of CBT strategies to fit the individuals and the moment. She eliminated strategies that didn’t seem to work. She experimented with interventions from other individual and family psychotherapy models, self-help programs, and spiritual practices, preserving those that met with success. Developed first from a straight, then slightly modified, behavioral model, DBT arrived on the scene as a synthesis of three paradigms: behaviorism as a means of changing behavior; mindfulness as a means of fostering awareness, acceptance, and compassion; and dialectics as a means of finding fluidity and balancing acceptance and change in the face of rigidity and impasse. The first draft of the treatment manual was completed in 1984 and tested in a randomized controlled trial that was published in the Archives of General Psychiatry in 1991. The psychotherapy manual and the skills training manual were both published in 1993. In the past 13 years DBT has been subjected to dozens of research trials, including eight published randomized controlled trials essentially confirming the initial findings.
Well acquainted from having been psychology interns together at Montefiore Medical Center several years earlier, Alec Miller and Jill Rathus found themselves working together again in 1995 at Montefiore’s Adolescent Depression and Suicide Program, where Miller was appointed director of the program and Rathus director of research. Miller and Rathus began a search for empirically validated treatment approaches to depressed and suicidal adolescents. The very first time I met them was when they came to the New York Hospital–Cornell Medical Center in White Plains, New York, to learn first hand about my inpatient adaptation of DBT for individuals diagnosed with borderline personality disorder. Encouraged by what they saw, they wondered whether they could similarly adapt DBT to the treatment of suicidal youth. I urged them to try it. Even though at the time there were limited research data to support using a diagnosis of borderline personality disorder in patients younger than 18 years of age, the chronic dysfunctional behavioral patterns and skills deficits showed obvious overlap with those of our patients.
Having come up empty-handed in their search for an evidence-based treatment specifically developed for suicidal teens, they turned to the project of modifying DBT for their patients. But what would they need to change about DBT to fit it to teenagers and families? And how could they know which features of DBT to preserve; that is, which features were essential to the documented positive outcomes? There was simply no way to answer these questions, questions that arise every time someone adapts an evidence-based treatment to a new population or setting. The strategy chosen by Miller and Rathus was to do DBT “by the book” with their population, modifying it only when needed. Through a trial-and-error strategy similar to Linehan’s on the road from CBT to DBT, they eventually developed their own treatment manual and subjected it to a pilot research trial. The results gleaned from this quasi-experimental design were impressive and have by now already had a far-reaching impact.
They wisely held tight to the strategy of adhering to the highest degree possible to standard DBT. But the modifications that eventually took hold and that appear in this book are terribly imaginative and will intuitively make sense to any clinician familiar with teens and families. Let me give you a small taste. To adjust to the adolescent’s shorter time perspective (a 1-year commitment to treatment could seem a lifetime), Miller and Rathus shortened the duration of treatment to 16 weeks. To adjust to the shorter duration, they reduced the number of skills taught in the four standard skills training modules. After several rounds involving family members in DBT skills training, they designed a fifth module for patients and families called “Walking the Middle Path.” To bring the skills package to both patients and families, they arrived at a multiple family skills group format followed by a graduate group for the teenagers without the families. Synthesizing principles of family therapy with principles and strategies of DBT, they developed a DBT family therapy approach that could be offered when individual family therapy seemed indicated. As they grew familiar with the typical transactional patterns among patients, families, and therapists that interfered with treatment progress, they described a set of dialectical dilemmas, thereby sharpening case formulations and treatment interventions. This book finally presents the comprehensive treatment package developed by Miller and Rathus, along with variations arrived at by others in adapting DBT to this population (e.g., some have not found it necessary to shorten the 1-year treatment duration in their adaptations for teens and families).
Adapting DBT for multiproblem suicidal adolescents and their families has been an enormous undertaking. For mental health practitioners now to learn, implement, practice, and research this treatment will require a significant, sustained effort by program administrators, clinicians, researchers, families, and patients. How can we justify a commitment of this magnitude? At the very least we need to consider the scope of the problem as documented in statistics and the unmistakable suffering and disruption that clinicians routinely see, alongside the absence of any treatment with demonstrated efficacy.
The scope of the problem of the suicidal teenager is substantial and has been increasing. As the authors note in the first chapter, suicide is the third leading cause of death in the United States in the age group from 10 to 19 years. For each completed suicide there are 100–200 suicide attempts; 16- to 18-year-olds make more suicide attempts than any other age group across the life span. In an average U.S. high school classroom, one boy and two girls have made suicide attempts in the previous year. The incidence of nonsuicidal self-injurious behavior in teens appears to be increasing. The more problem behaviors a teenager engages in (e.g., binge drinking, unsafe sex, cigarette smoking, violence, and disturbed eating behaviors), the more likely he or she is to make suicide attempts.
On a daily basis clinicians come face to face with chaos and hopelessness in the lives of multiproblem suicidal teens and their families. While the teenage patient spirals toward higher risk behaviors, the parents alternate between tightening their grasp, searching for help, and throwing up their hands. As exhaustion grows for those in the family and treatment systems, hospital admission looms again and again as the only relief in the moment. Suicide is in the air. Clinicians and some family members become painfully aware that they have no evidence-based (or even consensus) treatment to which to turn, a fact that itself heightens despair.
This picture is painfully familiar to me in private practice and in consultations to families, mental health programs, and schools. I have heard hundreds of variations on the same story for years in workshops across the United States, in Canada, and in Europe. If I had a dollar for each time a hopeful mental health practitioner asked me, with anticipatory excitement (and impatience), when the adolescent DBT book would be out, I could contribute a tidy sum toward a randomized controlled trial. And that is what we need next. This book lays the groundwork for that.
I applaud the authors for sticking to fundamentals, for improvising daringly within the rules, for finding synthesis and balance among differing perspectives, and for their painstaking insistence on getting it right in spite of growing pressures to get it done faster. Good jazz is not easy to come by.
CHARLES R. SWENSON, M D
University of Massachusetts School of Medicine, Worcester; private practice, Northampton, Massachusetts