Brief Dialectical Behavior Therapy for a Suicidal Ideation Case: A

Literature Review

Retno Ayu Astrini and Ike Herdiana

Faculty of Psychology, University of Airlangga, Surabaya, Indonesia

Keywords: Brief dialectical behavior therapy, psychological distress, suicidal behavior, coping skills

Abstract: The current review presents a theory-guided review of existing brief Dialectical Behavior Therapy (Brief

DBT) interventions for suicidal ideation cases. The purpose of this review is to clarify suicidal problems by

synthesizing and assessing empirical literature on brief DBT for suicidal ideation cases. Across the four

studies that are investigated within this study, a reduction was shown in people with suicidal ideation.

Suicidal ideation is the desire to commit suicide, which arises in the minds of individuals. Attempts at past

suicides have allowed individuals to continue to generate suicidal ideation. Brief DBT or DBT with shorter

sessions and durations, indicates a greater symptom reduction in clients with suicidal problems. The

investigation was conducted through an electronic database search using Google Scholar, SagePub, Science

Direct, Proquest, Springer Link, and Ebsco. Results indicated an effect from brief DBT participants across

the studies. Brief DBT participants showed great improvement in psychological distress, measurements of

anger, distress tolerance, mindfulness, emotion regulation, and the improvement of coping skills. Directions

for future research and recommendations for clinicians are provided in an attempt to further develop the

existing brief Dialectical Behavior Therapy (brief DBT) clinical research evidence base.

1 INTRODUCTION

Suicide is a phenomenon that has become a

worldwide public problem. Each year, an estimated

800,000 people died due to suicide; this figure

excludes suicide attempts (WHO, 2014, in

Batterham et al., 2016). The thought of suicide,

commonly referred to as suicidal ideation and

suicidal behavior are complex phenomena

influenced by various related factors, including

personal, social, psychological, cultural, biological,

and environmental personal problems (Goldston et

al, 2009, in Batterham et al., 2016).

Suicide and its prevention is a public health

concern that needs attention (World Health

Organization, WHO 2014, in Kavalidou et al, 2016).

According to the World Suicide Report from the

WHO, the global standard suicide rate for 2012 is

11.4% per 100,000 people in the population, which

translates to 804,000 suicide deaths annually

worldwide (WHO, 2014, in Kavalidou et al., 2016).

Kavalidou and his colleagues (2016) identified high-

risk populations of suicide among other clinical

populations who suffer from mental illness,

individual groups with violence issues, groups with

problem families, homeless populations, and general

social populations experiencing social stress and

adverse life events.

The purpose of this review is to clarify suicidal

issues by synthesizing and assessing the brief

empirical literature on DBT for cases of suicidal

ideas. The main goal is to test whether brief DBT

produces clinically significant results as predicted by

cases of suicidal ideas and brief DBT theories. The

review began with a review of the DBT theoretical

review of suicidal ideas. The theories relevant to the

etiology of suicide ideas were presented. The

existing literature on short DBT for cases of suicidal

ideas was reviewed, and concept gaps and

inconsistencies as well as methodological and

statistical problems in the literature were

highlighted.

1.1 Brief Dialectical Behavior Therapy

(Brief DBT)

Dialectical Behavior Therapy (DBT) was first

developed by Marsha M. Linehan in 1993 (Linehan,

2015). The original manual training of the DBT

module was used for individuals with a high risk of

Astrini, R. and Herdiana, I.

Brief Dialectical Behavior Therapy for a Suicidal Ideation Case: A Literature Review.

DOI: 10.5220/0008587902530260

In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in

Global Community, pages 253-260

ISBN: 978-989-758-435-0

253

personality disorders. Skills training with DBT are

effective to reduce the need for clients, as well as for

handling personal problems, regulatory issues, and

interpersonal issues (Linehan, 2015).

DBT skills from Linehan (2015) are widely used

in mental health programs for communities,

individuals living in shelters, acute care, prisons, and

many other conditions. There is a wealth of data and

clinical experience that show that DBT skills are

effective in a variety of clinical and nonclinical

populations in various places. McCay and his

colleagues (2016) explain that DBT interventions

are effective in reducing stress and strengthening

resilience in individuals living in shelter homes.

DBT and brief DBT are empirically designed to deal

with serious mental health problems, such as suicide,

self-harming behavior, addictive behaviors, and

issues related to emotional regulation.

The main component of DBT is the theory of

disorders based on a biosocial perspective. The

theory suggests that: (1) problematic or irregular

behavior, especially highly dysfunctional behaviors,

may be a consequence of emotional dysregulation or

attempts to reorganize emotions; (2) failure to adapt

to playing a role in causing difficulties in regulating

emotions; and (3) the general pattern, which

develops as one struggles to regulate emotion; this

pattern becomes an issue that must be treated.

Therefore, the overall basis of DBT treatment is to

teach and support emotional regulation and restore

the function of organized emotions naturally

(Linehan, 2015).

Linehan (2015) explains that the skills listed in

the DBT module can be used according to the

client's needs, considering the circumstances of the

client, not required to use the overall skill in the

DBT intervention manual. Differences in culture,

ethnicity, nationality, socioeconomic status, and the

age of clients are some of the important aspects and

require a different set of skills in the application of

DBT interventions.

1.2 Theoretical Overview of Suicidal

Ideation

Beck et al. (1979, in Zhang et al., 2017) define

suicidal ideation as an individual’s desire to die and

commit suicide. Osman and his colleagues (2014, in

Zhang, 2017) explain that the shape of suicidal ideas

can vary, ranging from quick thoughts to planning

suicide attempts, and from attempting role play to

failed suicide attempts.

People with suicidal ideation are individuals who

currently have a plan to and want to commit suicide,

but have not yet committed significant or open

suicide attempts. The idea of suicide logically

precedes attempting suicide or realizing suicide

itself. It, therefore, seems appropriate to focus on the

intensity and characteristics of the idea and desire to

measure suicidal intentions at this time and to

predict a person's risk of suicide in the future. The

idea of suicide also includes suicidal threats that

have been expressed in open behavior or verbally

expressed to others (Beck et al., 1979, in Jacobs et

al., 2010).

Suicide includes all behaviors that seek solutions

to an existential problem by experimenting on the

subject's life. Corr and Nabe (2003, in Hawton &

Heeringen, 2008) explain that for a death to be

defined as suicide, it must be accompanied by the

intention to die. Nevertheless, intentions are not easy

to determine, because the intentions are very varied

and can precede, for example, to get attention, take

revenge, end something perceived as suffering, or

end life (Hawton & Heeringen, 2008).

Successful suicide and suicide attempts have

complex relationships (Maris et al., 2000, in Jacobs

et al, 2010). This is due to the interaction and

comorbidity between the etiologies of both

behaviors. In addition, most suicidal individuals

make several suicide attempts before finally

succeeding. Beck (in Rossom et al., 2017) defines a

suicide attempt as a situation in which a person has

committed an actual or seemingly life-threatening

behavior with the intention of killing him/herself, or

showing such intentions, but has not resulted in

death.

Suicidal ideation is part of suicidal behavior.

Suicidal ideation refers to the view of the experience

that life is worthless, from a fleeting thought to a

real thought, or a thought about self-destruction.

Suicidal ideation logically arises first from suicide

attempts or completed suicide, so suicidal ideation is

the right construct to focus on the intensity, spread,

and characteristics of suicidal behavior and can later

measure suicidal ideation as a predictor of a

potential risk of suicide. Individuals with suicidal

ideation are individuals who currently have plans

and suicidal desires but have not clearly committed

suicide in recent times (Kavalidou et al., 2017).

People with suicidal ideation find it very easy to

think about death. The thought of dying and suicide

is very attractive to people with suicidal ideas.

Unconsciously, considering suicide is a torturous

thought. Many sufferers do not realize that the idea

of suicide is something that needs to be overcome;

the longer it takes to overcome, the more likely it

can develop into real suicide action. Suicidal

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

254

ideation can be stored for years by the sufferer, but

there are also direct suicide attempts. Suicidal

ideation often appears in the mind of the sufferer

(Baller & Richardson, 2009).

Some literature describes risk factors for

behavior related to suicide. Risk factors for suicidal

ideas fall into three broad categories as follows:

biological and genetic factors, psychological factors,

and psychosocial factors. Individuals who have

suicidal ideas often have a strong family history of

suicide or serious mental illness and are more likely

to show changes in brain structure and function,

such as low serotonin levels and enlarged amygdala

(Desai et al., 2013).

Psychiatric history, including serious mental

illness, suicide attempts, suicidal ideas, and

substance abuse are strong predictors of suicide

attempts and the desire to die. Finally, although the

mechanism is more varied, psychosocial factors and

demographics such as gender, age, race, social

support, and life-threatening events are also

associated with the risk of suicide (Desai et al.,

2013).

Research conducted by Zhang and colleagues

(2010) in China, explains that the collective culture

of Asian society has an influence on the risk of one's

own idea of suicide, especially in women.

Traditional culture and values still play a major role

in providing normative standards and regulating

social interaction. Women consciously or

unconsciously must accept what is said to be

"appropriate behavior for women" according to the

norms of society. These gender issues have an

impact on women's lives, including the idea of

suicide (Zhang et al., 2010).

Research conducted by Griffin and Williams

(2006, in Zhang et al., 2010) found that although

men are more likely to actually commit suicide,

women are more likely to have suicidal ideation.

Watt and Sharp (2001, in Zhang et al, 2010) explain

that the cause of men and women wanting to commit

suicide is different. The study further explained that

men want to commit suicide on the grounds of

financial problems, while women feel the need to

commit suicide due to social factor issues.

There are differences in patterns and suicidal

tendencies between countries in the Asian region

and Western countries. The sex ratio for suicides in

Asia is smaller than in the West, where women tend

to be more vulnerable to suicide-related behaviors.

The occurrence of suicide in Asia tends to increase

with age and adults are more susceptible to suicide.

Unlike Western countries, the population of youth

groups shows an increase in suicide (Hawton &

Heeringen, 2008).

There is evidence to suggest that mental illness,

particularly depressive disorders and substance

abuse, is a strong risk factor for suicide in both

Eastern and Western countries. Social problems may

be a stronger correlation to suicide-related behavior

in some Asian countries. Very low suicide rates are

found in Islamic countries. The prevalent view of

suicide evident in Asia shows that they are very

much dependent on people's views or community

norms (Hawton & Heeringen, 2008).

1.3 Brief DBT for Suicidal Ideation

Cases

Davidson and colleagues (2006, in Stanley et al.,

2014) recommend fewer and shorter sessions for

DBT intervention if the psychological problem of

therapeutic focus is a suicidal problem. Handling of

DBT therapy with shorter durations and sessions

allows clients and therapists to focus more on the

issues experienced by clients, while also minimizing

the possibility of loss of commitment or therapeutic

relationships between clients and therapists (Stanley

et al., 2014).

Brief DBT therapy also minimizes the chaos and

tension in therapeutic relationships between the

client and the therapist, while the client focuses

more quickly on acquiring and developing the skills

gained from the therapeutic process. Therapy with

short duration and sessions will make clients more

likely to survive in a series of therapeutic processes

and be more motivated and committed to achieving

the benefits of the therapeutic process. Clients can

complete recommended therapies that increase

expectations for those who have had many stop

experiences or premature termination of the

treatment process (Stanley et al., 2014).

Research conducted by Ciesielski (2013)

suggests that DBT or brief DBT therapy with short

sessions and durations, indicates a greater symptom

reduction in clients with suicidal problems,

especially for those who are in shelters. This is

partly because the short therapy suppresses a client’s

possible lack of commitment to the therapeutic

process and has a direct impact on the idea of

suicide (Ciesielski, 2013).

Carter et al. (2010, in Steffel, 2014) explains that

some studies suggest brief DBT interventions with

short sessions and durations are more effective in

dealing with problems resulting from emotional

dysregulation. Several studies using brief DBT

intervention show clinical improvement in dealing

Brief Dialectical Behavior Therapy for a Suicidal Ideation Case: A Literature Review

255

with suicide, depression, dissociation, anxiety,

identity problems, impulsivity problems, emotional

stability, and interpersonal problems (Rathus &

Miller 2002; Christensen, 2013).

Linehan (2015) divides the taught DBT skills

into two: (1) acceptance skills, which include

distress tolerance and mindfulness; and (2) change

skills, which include emotion regulation and

interpersonal effectiveness. The first skill given to

this brief DBT intervention is distress tolerance.

Distress tolerance skills are like refueling a vehicle,

to keep it, or themselves, going. Distress tolerance

includes the ability to calm down and is meant to

provide a sense of peace and relief from the pain

experienced so that the individual can consider what

to do next. Distress tolerance skills are acquired so

that individuals can divert, relax, and solve

problems. Deep relaxation is the key to distress

tolerance (McKay et al., 2007).

Activities for distress tolerance skills help the

individual to calm down, accept his/her situation, to

regain his/her inner strength and then solve problems

in challenging situations. This is needed before the

individual can overcome any further problems with

mindfulness, emotion regulation, or interpersonal

effectiveness skills. The given distress tolerance skill

will help the client to self-divert from situations that

cause emotional pain. This skill is important because

it can stop clients from thinking about the pain they

are experiencing, and can ultimately provide an

opportunity for them to find appropriate coping

strategy responses.

The next skill is mindfulness, which is the ability

to be aware of the mind, emotion, physical

sensation, and action at that moment (in the present

moment), regardless of self-criticism or experience

(McKay et al., 2007). Feigenbaum (2008) explains

that mindfulness is a core skill in DBT. Mindfulness

is related to the ability to consciously experience and

observe oneself and events with curiosity and

without judgment, to see and understand reality as it

really is, and to participate effectively in the current

stream of life. Mindfulness skills are at the core of

all skills in DBT. Mindfulness skills help the client

to focus on the present situation (Linehan, 2015).

Various problems and disorders in an individual,

including suicidal ideation, generally arise due to

difficulties in regulating emotions. These difficulties

include problems in recognizing emotions,

describing and labeling emotions, emotional

avoidance, and by knowing what to do when feeling

certain emotions. Therefore emotion regulation

skills are taught to clients. Individuals who have

problems or disorders need others beside them as a

form of safe and protective behavior. By contrast,

individuals with suicide-related problems generally

have difficulty in engaging in relationships or

engaging in relationships with others. Hence the

interpersonal effectiveness skill is taught to the

client (Linehan, 2015).

2 METHOD

This article is based on four reviews of literature and

journals obtained from various sources. The study

was identified by the following procedure. First,

searching for electronic databases using Google

Scholar, SagePub, Science Direct, Proquest,

Springer Link, and Ebsco. Search terms included:

(1) all possible permutations (for example, suicides,

suicide ideas, suicide attempts, committing suicide);

(2) all possible permutations from the target sample;

and (3) all possible permutations of target treatment

(for example, intervention, treatment, training,

therapy, Dialectical Behavior Therapy, brief DBT).

Furthermore, the articles obtained were reviewed

and the reference list was examined again to identify

any articles that were not captured by the literature

search. Based on the selection of references that

have been made, the researcher acquired four

references that discussed brief DBT for cases of

suicidal ideation.

3 RESULTS

3.1 Study Characteristics

Articles that met the study inclusion criteria were all

published between 2013 and 2016. Studies ranged in

sample size from 18 to 42 participants. All

interventions were delivered in a different setting.

3.2 Group Brief DBT for Suicidal

Cases

Stanley et al. (2014) conducted an open clinical trial

of the group's brief DBT intervention. Participants

from major metropolitan areas that were part of a

larger research project investigating biological and

clinical factors associated with suicidal behavior

were offered open care. All participants were

outpatients and had active suicide ideation at the

start. The exclusion criteria were psychotic

disorders, mental retardation, a history of severe

head trauma, or other cognitive disorders that might

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

256

interfere with the accuracy of assessment or

competence to give informed consent.

Analysis examined the effectiveness of brief,

targeted DBT intervention for individuals with

suicidal ideation. Stanley et al. (2014) found that a

six-month intervention leads to significant

reductions in subjective distress, self-rated

depression, urges to self-injure, Non Suicidal Self

Injury (NSSI), suicide ideation, and hopelessness.

McMain et al. (2016) conducted a study with a

total of 140 prospective subjects who were screened,

and 84 eligible participants who were randomly

assigned to DBT skills training. The curve analysis

of the effects of mixed linear growth from

measurements of coping skills (tolerance distress,

regulation of emotion) revealed far greater

improvements in the DBT group compared to other

groups regarding distress tolerance and emotion

regulation, at all time points. At full awareness, there

was no difference between the groups at any point in

time. The DBT group showed a much greater

increase in social adjustment and symptomatic

symptoms over 20 weeks; However, this group

difference was not maintained at 32 weeks. There

was no significant group difference in impulsivity at

any point in time.

Moore et al. (2016) conducted a study in prison

of 16 participants who had completed the self-

reported post-test assessment and had attended at

least six of the eight sessions with the abbreviated

DBT skill group. In general, participants gave

positive feedback about the group. The participants

reported that the group was very helpful in teaching

skills to maintain suicidal desires.

The participants mentioned a number of things

they would change about the group, which

unfortunately were not all feasible in correctional

settings. They expressed a desire to: (1) have classes

twice a week to keep information about skills fresh

in their minds; (2) have a longer class (1.5 hours

compared to 1.25 hours) so that there is more time

for discussion; and (3) for group leaders to write

individual reports for each participant as a concrete

way to show their progress across groups (Moore et

al., 2016).

3.3 Combined Group and Individual

Brief DBT for Suicidal Case

Ciesielski (2013) conducted open clinical trials on

group combinations and individual short DBT

interventions. Participants included those who had

experienced the idea of suicide at the time of

telephone screening, as evidenced by a score of 10

or higher on the Beck Scale for Suicide Ideas.

Additional inclusion criteria were 18 years or older,

within commuter distance to the University of

Washington research office, and a willingness to

agree to recording and assessment. Individuals were

excluded if they were younger than 18 years and did

not speak English. Individuals seeking treatment

were defined as those who currently receive

outpatient mental healthcare (psychotherapy or

drugs) and those seeking mental healthcare (whether

they are currently involved in it or not), while

individuals seeking treatment are those currently

under care and are not interested in participating in

mental healthcare during the telephone screening.

Participants were presented with five previously

selected DBT skills (Linehan, 2015) –mindfulness,

two emotion regulation skills, and two distress

tolerance skills. Awareness and emotion

management skills were selected based on the DBT-

BASICS intervention (Whiteside, 2011 in Ciesielski,

2013) and were identical to those used in the DBT-

BASICS curriculum. Two danger tolerance skills

were added to anticipate target population deficits in

tolerating and managing extreme emotions and

crises.

Fourteen participants gave feedback about their

experiences as part of the study after completing the

intervention. There were no significant differences

in feedback provided by treatment seekers compared

to non-treatment seekers. Eleven participants

reported feeling better at the end of the intervention,

although only two participants reported that they

were expected to feel better after their participation.

In fact, three participants were expected to feel

worse, while seven people were thought to feel no

different as a result of their participation. Nine

participants reported that the assessment was very

helpful, three of them said it was quite helpful, and

two of them reported that it was not helpful at all. In

addition, twelve participants reported that skills

training was very helpful and two reported that the

training was rather helpful. These reports indicate

that participants, seeking treatment or not, find value

in short interventions (Ciesielski, 2013).

3.4 Effectiveness of Brief DBT for

Suicidal Case

Based on the literature study, there are several

studies that have been conducted to measure the

effectiveness of the brief DBT intervention in

reducing suicidal ideation (suicidal ideation). A

study by Stanley et al. (2014) suggests that brief

DBT intervention is significantly effective in

Brief Dialectical Behavior Therapy for a Suicidal Ideation Case: A Literature Review

257

treating patients with first-time suicide attempts.

brief DBT intervention conducted by Stanley et al.

(2014) was given to patients with a diagnosis of

Borderline Personality Disorder (BPD), who were at

risk of suicidal behavior. The results of the study

explain that giving brief DBT intervention to BPD

patients effectively reduces suicidal behavior.

Research conducted by Ciesielski (2013)

suggests that DBT or brief DBT therapy with short

sessions and durations, indicates a greater reduction

in clients with suicidal problems, especially for

clients who are in care or shelters. This is partly

because short therapy suppresses the possibility of a

lack of commitment by the client to the therapeutic

process and has a direct impact on the idea of

suicide (Ciesielski, 2013).

Ciesielski (2013) conducted a study of suicidal

populations and suicide-related behaviors. The

research was conducted using an experimental

method, which divided the population into an

experimental group and a control group. The brief

DBT intervention given to the population with these

suicidal characteristics suggested that suicidal

ideation experienced by the subject, significantly

decreased within one month. The study resulted in

the conclusion that the brief DBT intervention is

effective in reducing suicidal ideation experienced

by individuals with suicidal problems (Ciesielski,

2013). Carter et al. (2010, in Steffel, 2014) explain

that some studies suggest brief DBT interventions

with short sessions and durations are more effective

in dealing with problems resulting from emotional

dysregulation. Several studies using brief DBT

intervention show clinical improvement in dealing

with suicide, depression, dissociation, anxiety,

identity problems, impulsivity, emotional stability,

and interpersonal problems (Rathus & Miller 2002,

Christensen et al., 2013) Research conducted by

McMain et al. (2016) states that standard DBT

interventions cost and sacrifice a lot and are more

complex to provide for clients who need it. Brief

DBT interventions are more effective due to

efficiency factors and easier therapeutic processes

for clients (McMain et al, 2016).

McMain and his colleagues (2016) provided

brief DBT intervention to suicidal patients with a

diagnosis of borderline disorder. The results showed

that participants in the study demonstrate a

significant reduction in suicidal ideation.

Participants also showed improvement in controlling

anger, distress tolerance, and emotional regulation

(McMain et al., 2016).

Research conducted by Moore et al. (2016)

provided brief DBT intervention to prison inmates

with suicidal ideation. This group intervention

provided demonstrated that brief DBT intervention

is appropriate for prison settings or places that

restrict a person's freedom. The result of the research

was that brief DBT intervention improved coping

skills in participants who are prisoners (Moore et al.,

2016).

Based on the literature study above, brief DBT

intervention is effective in dealing with clients with

suicidal problems. Brief DBT intervention with short

sessions and duration is more effective in dealing

with problems resulting from emotional

dysregulation. Several studies using brief DBT

intervention have shown clinical improvement in

dealing with suicide problems, depression,

dissociation, anxiety, identity problems, impulsivity,

emotional stability, and interpersonal problems.

Statistically and clinically, participants also

Table 1: Review of the researches based on key finding.

No.

Title/Researcher

Key Findings

Brief Dialectical Behavior Therapy

(DBT-B) for Suicidal Behavior and Non-

Suicidal Self Injury. Stanley et al., 2014

Significant decreases in subjective distress, self-rated

depression, urges to self injure, Non Suicidal Self Injury

(NSSI), suicide ideation, and hopelessness.

An Open Pilot Feasibility Study of a

Brief Dialectical Behavior Therapy

Skills-Based Intervention for Suicidal

Individuals. Ciesielski, 2013

Effective in reducing suicidal ideation symptom or suicidal

ideation experienced by individuals with suicidal problems.

A Randomized Trial of Brief Dialectical

Behaviour Therapy Skills Training in

Suicidal Patients Suffering From

Borderline Disorder. McMain et al.,

2016

Improvement in controlling anger, distress tolerance, and

emotional regulation

Pilot Study of a Brief Dialectical

Behavior Therapy Skills Group for Jail

Inmates. Moore et al., 2016

Improving coping skills to participants who are prisoners; very

helpful in teaching skills for maintaining suicidal ideation.

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

258

experienced improvements in brief DBT

intervention aspects, namely psychological distress,

mindfulness, and distress tolerance. Participants also

showed improvements in controlling anger, distress

tolerance, and emotional regulation. The brief DBT

intervention provided improved coping skills for

participants. Brief DBT interventions are more

effective because the efficiency and therapeutic

processes are easier to administer to clients,

compared to conventional DBT interventions.

4 DISCUSSION AND FUTURE

DIRECTIONS

4.1 Overall Discussion

This open feasibility trial has provided valuable

information about the possibility of registering

suicidal individuals who are not interested in mental

healthcare or the acceptance of participation in short

interventions. Stanley et al. (2014) suggest that short

interventions cause a significant reduction in

subjective pressure, self-depressed depression,

urgency for self-injury, non-suicidal self-injury

(NSSI), suicidal ideas, and despair.

Brief Dialectical Behavior Therapy is

significantly more effective than community care by

expert doctors, over a two-year period (one year of

treatment, one year of follow-up). This study shows

that, among participants who received DBT, most

suicide attempts occurred during the first six months

of treatment. Similarly, in the initial DBT study by

Linehan, Armstrong, Suarez et al. (1991, in Linehan,

2015), a significant reduction in suicide attempts and

NSSI occurred during the first four months of

treatment, which did not decrease in the following

eight months. The reason for additional months of

treatment was for the 'consolidation of profits'

(Linehan, 2015). While it can be argued that

recurrence may be greater without longer treatment

times, this is an untested hypothesis.

The research findings support the theory that

developing coping skills can be an important

ingredient in DBT that contributes to improvements

in outcomes, an idea supported by a DBT study,

which found that coping skills mediated results.

DBT skills training is enough to stabilize high-risk

behavior and reduce the use of expensive crisis

services. As a result, when long-term comprehensive

treatment is not accessible, short DBT skills training

can be a reasonable intervention to be recommended

as a first step, although not as a substitute for

comprehensive care.

It is possible that a shorter duration of treatment

allows both patients and therapists to focus on

behavioral problems and skill deficits and they are

less afraid of losing relationships because both

parties know in advance that treatment will end in

six months. In other words, therapeutic relationships

may be less frenzied, and tense and patients focus

more quickly on skill acquisition and development.

Perhaps, due to the short duration of treatment,

patients will be more likely to remain in treatment

for a period of time and be more motivated to

achieve real initial benefits.

Being able to complete recommended therapy

increases expectations for patients who have a lot of

experience dropping out of school or discontinued

treatment. Patients can continue treatment if desired,

based on an agreement with patients and therapists

(Stanley et al., 2014).

This finding is very important, because it may

mean that the period of consolidation of subsequent

treatment is less necessary than previously believed

if the main treatment goals reduce encouragement

and suicidal and non-suicidal behavior. Overall,

these results support the notion that DBT may be

effective in a short format, which is usually

recommended and used in clinical trials.

4.2 Future Directions

Researchers must continue to develop and evaluate

new methods for outreach and retention, and short

interventions should be a priority as a way to enable

valuable services, even if people have no interest in

participating in long-term treatment.

These initial findings are limited because they do

not include follow-up or comparison groups. It is

also important to note that the target behavior of this

analysis, while important, is narrow in focus and is

not designed to overcome emotional disturbances.

Subsequent research must determine whether the

objectives achieved during this time span can be

maintained without further treatment for this

behavior, with a limited boost session approach, or

whether maintenance is required for at least a year.

Randomized controlled trials are required to make

this determination.

Because variability in response is unavoidable,

research is also needed to identify factors that

moderate, mediate and predict different treatment

outcomes. However, these findings indicate that

brief DBT skills training has benefits and is not

harmful to suicidal individuals. These treatment

Brief Dialectical Behavior Therapy for a Suicidal Ideation Case: A Literature Review

259

options must be considered for this high-risk

population, especially for those who cannot access a

long comprehensive specialist program.

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