Specific psychotherapies

Working with suicidal children and adolescents is best done by a clinician who is available, has skill and training in managing suicidal crises, relates to the patient in an honest and consistent way, and can convey a sense of optimism and activity. Given these personal attributes, the therapist may use various models of psychotherapy, although relatively few empirical studies have evaluated their efficacy.

Cognitive-behavioural therapy

Cognitive-behavioural therapy is effective in depressed teenagers,(39) but its value for suicidal adolescents has not been demonstrated.(23) Brent et al/23> modified the approach for depressed adolescents. The treatment comprised 12 to 16 once-weekly sessions, followed by a 6-month booster phase of monthly or bimonthly sessions. It included a psychoeducational manual about mood disorders, training to monitor and modify automatic thoughts, assumptions, and beliefs, training in more assertive and direct methods of communicating, and help in conceptualizing alternative solutions to problems. Meetings with parents were sometimes held to augment the treatment, and psychopharmacology was used adjunctively if depressed adolescents had not improved after 4 to 6 weeks of pharmacotherapy.

Brent's study provides no evidence of the efficacy of cognitive- behavioural therapy for teenagers who had made a suicide attempt who were not included in this study.

Dialectical behavioural therapy

Dialectical behavioural therapy (DBT) is the only form of psychotherapy that has been shown in a randomized control trial to reduce suicidality in adults with borderline personality disorder. (49 This treatment is based on a biosocial theory in which suicidal behaviours are considered to be maladaptive solutions to painful negative emotions that also have affect-regulating qualities and elicit help from others. (S

The treatment involves developing problem-oriented strategies to increase distress tolerance, emotion regulation, interpersonal effectiveness, and the use of both rational and emotional input to make more balanced decisions. It usually involves individual and group sessions over the course of a year, although an untested modification for adolescents (DBT-A) is designed to take 12 weeks.(41 It involves the participation of a relative who is charged to improve the home environment and to teach other relatives how to model and reinforce adaptive behaviours for the adolescents.

Family therapy

As indicated above, family discord, poor communication, disagreements, lack of cohesive values and goals, and irregular routines and activities are common in suicidal children and adolescents who often feel isolated within the family. Family intervention aims to decrease such problems, improve family problem-solving and conflict resolution, and reduce blame directed at the suicidal child or adolescent. Family-based cognitive therapy aims to reframe the family's understanding of their problems, to alter the family's maladaptive problem-solving techniques, and to encourage positive family interactions. Psychoeducational approaches can help parents clarify their understanding of childhood and adolescent suicidal behaviour, identify changes in mental state that may herald a repetition, and reduce the extent of expressed emotion or anger.(39

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