Dialectical Behavior Therapy for Adolescent Suicide Attempters with Borderline Personality Disorder

suicide attempt

Adolescents with BPD who Attempt Suicide

Borderline Personality Disorder (BPD) is thought by many clinicians to be one of the most difficult psychiatric illnesses to treat, and is observed in both adult and adolescent populations.  Dialectical Behavior Therapy (DBT) was developed by Marsha Linehan as a treatment for patients with BPD, an illness that is often co-morbid with others, such as anxiety, depression, and suicidal and non-suicidal injurious thoughts and behaviors (Linehan et al., 1991).  Fleischaker, Bohme, Bruch, Schneider, & Schulz (2011) cite research among adolescent populations that indicates 10-50% of adolescents with a history of attempted suicide will make another attempt in the future. 11% of these will die as a result of suicide. Recurrent suicidal and self-injurious behaviors characterize the experience of many adolescents with BPD traits and diagnoses.  The researchers, therefore, seek to better understand treatment effects and address the 77% of adolescent suicide attempters who never seek or prematurely terminate outpatient treatment (Fleischaker et al., 2011).


DBT-A Explained

To tailor treatment to adolescent populations presenting with traits of borderline personality disorder and self-injurious behaviors, Rathus & Miller (2002) adapted Linehan’s model of DBT (DBT-A). The more recent study using DBT-A featured a 16-week behavioral treatment program that included weekly individual therapy, family therapy as necessary, and multifamily skills training for outpatient groups. Goals of therapy were for the participants to understand and implement skills that focus on mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation, family, and ‘walking the middle path’ (Fleischaker, Bohme, Bruch, Schneider, & Schulz, 2011, p. 2). 


Types of Support Provided

Fleischaker et al. (2011) used a German-translated DBT-A program on a sample of female adolescents exhibiting non-suicidal self-injurious and suicidal behaviors. Treatment was conducted at an outpatient clinic in Germany over a period of 16-24 weeks, and varied slightly over the holiday schedule. Treatment consisted of the aforementioned protocol and included frequent phone calls between client and therapist to ensure adequate support is provided. Participants were administered several assessments, both self-reported and through diagnostic interviewing, before treatment began, four weeks post treatment, and again one year post treatment.


Preventing Patient Drop Out

The results of Fleischaker’s et al. (2011) study demonstrate, “a stable reduction of suicidal and non-suicidal self-injurious behavior over the course of one year” (p. 8). This reduction is the primary target of DBT. The second goal in the hierarchy of DBT is to keep patients enrolled in therapy for the duration of planned treatment. In the researcher’s study, the drop-out rate was 25% (Fleischaker et al., 2011), as compared to 60% for the control group receiving the usual treatment in Rathus & Miller’s (2002) study. 


Benefits of the DPT-A Program

A significant reduction in symptoms also occurred for participants, resulting in only one patient meeting the diagnostic criteria for BPD one year after therapy. Fleischaker et al. (2011) note the adolescents made clear progress in diagnostic categories: “unstable and intense interpersonal relationships, identity disturbance, and impulsivity” (p. 8). Parents also reported consistent improvement in quality of life both during therapy and after one year.






Fleischaker, C., Bohme, R., Sixt, B., Bruck, C., Schneider, C., & Schulz, E. (2011). Dialectical behavioral therapy for adolescents (DBT-A): A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one year follow up. Child & Adolescent Psychiatry & Mental Health, 5(3), 1-10.


Linehan, M, Armstrong, H., Suarez, A., Allmon, D., & Heard, H. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48: 1060-1064.


Rathus, J., & Miller, A. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide & Life Threatening Behavior, 32(2), 146-157.


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