– Children who are suicidal and victims of trauma, especially those with PTSD, pose an especially difficult challenge for psychiatrists. Trauma, suicidality, and self-harm often present together, and they might heighten the risk of treatment.

“It becomes a dilemma to know in what order to treat those symptoms, because sometimes it feels like one will not get better without treating the other,” said Michele Berk, PhD. “But there’s also some question around when it’s safe to do exposure-based treatments – which are the key ingredient to resolving PTSD symptoms,” Dr. Berk said during a session focused on trauma and suicidality in youth at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dialectical behavior therapy, or DBT, is an option. DBT was developed by Marsha M. Linehan, PhD, to treat chronic suicidality comorbid with borderline personality disorder. In addition to PTSD, newer work has shown DBT as efficacious for treating substance use disorders, depression, and eating disorders.

DBT is based on the idea that self-harm occurs, at least in some cases, because the patient is predisposed to experiencing heightened emotional reactions. When the patient is exposed to an invalidating environment, such as when a parent or caregiver tells them to “just get over it; you’re overreacting,” this can lead patients to question their emotions. Most importantly, patients never learn effective strategies to that manage their emotions, according to Dr. Berk, assistant professor of psychiatry and behavioral sciences at Stanford (Calif.) University.

In addition, Dr. Berk said, traumatized youth sometimes present with the most extreme form of invalidation, in which the patient’s entire being is violated through physical violence.

“So you have people who have these really intense negative emotions but don’t know how to help themselves manage them, and that is where DBT believes suicidal and self-harm behavior comes in,” Dr. Berk said. “We know that self-harm, though not suicidal self-injury, does in fact reduce emotion.”

DBT aims to counter suicidality by assisting the patient to build a life worth living. It encompasses five modes, including skills training, individual psychotherapy, in-the-moment coaching, case management, and a DBT consultation team to support the therapist.

The program prioritizes life-threatening behaviors in stage I and saving any exposure or PTSD therapy for stage II, which might begin up to 12 months later.

Also in stage I, after life-threatening behaviors have been resolved, the therapist addresses symptoms or factors that potentially interfere with further therapy. That’s important, because patients usually have comorbid symptoms and might be acutely distressed. “DBT has developed a clear hierarchy of how to target those things so that the sessions don’t get chaotic or off track,” Dr. Berk said.

Trauma symptoms might be tackled in stage I if they’re directly linked to suicidality or interfere with treatment, through reluctance to share information or because they might lead to dissociation during a session. After that, the program addresses quality of life, since its goal is to help patients create lives they deem worth living.

The skills training component of DBT includes mindfulness to help ground patients in the present moment. It also fosters skills that can be used to address trauma, including distress tolerance. Distress tolerance incorporates actions such as distraction and self-soothing. Emotional regulation seeks to help patients alter their emotions when possible. Interpersonal relationship skills help the patients ask for what they want and how to say “no” effectively.

Exposure therapy does not begin until patients have gone at least 2 months without any self-harming behavior, and it is interrupted if the patients exhibit self-harming behavior after it starts.

DBT remains a subject of continuing research. One avenue would be to more directly integrate exposure therapy with DBT in adolescents, but a protocol has not yet been developed. Prolonged exposure is typically used in adult PTSD patients, but trauma-focused cognitive-behavioral therapy more often is the choice for adolescents.

Whatever the choice, involvement of caring adults would be key. “In adolescents, there’s a need to involve parents and caregivers in whatever the trauma treatment is going to be,” Dr. Berk said.

Dr. Berk disclosed no conflicts of interest.