Suicidal ideation, an obsessive thought process about death and suicide, is an important health concern that warrants a holistic therapeutic approach to address the complex nature of the problem. Dialectic Behavioural Therapy has emerged as a promising treatment for this condition due to its focus on a holistic preventative method of tackling emotional regulation.

Understanding suicidal ideation

Suicidal ideation or suicidal thoughts, is a condition involving a preoccupation with death or suicide including thoughts of harming oneself. These thoughts can be fleeting in nature or elaborate plans, necessitating early recognition of the disorder, understanding the warning signs, mapping out the risk factors and effective interventions.¹ The prevalence of suicide, a preventable event, is rising; especially post the COVID-19 pandemic affecting individuals and their social support networks.² Suicidal ideation is a complex disorder to diagnose and treat; existing management includes a mixture of psychotherapeutic approaches and medications.¹ Dialectical behavioural therapy, aimed at improving mental resilience, is emerging as an effective intervention for the condition.

Overview of dialectical behavioural therapy (DBT)

Conceptualised by Dr Marsha Lineham, DBT for suicidal ideation is an evidence-based suicide prevention therapy rooted in cognitive-behavioural principles. It aims to inculcate emotion regulation skills and improve interpersonal effectiveness in therapy.³ 

At its core, DBT integrates four key modules: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Mindfulness is the first step, involving self-awareness of an individual’s thoughts and emotions in a safe space. Then comes distress tolerance, equipping individuals with crisis management skills during emotionally overwhelming episodes. Tackling emotional dysregulation is the next step, giving the person cognisance of their maladaptive emotional responses and the behaviours accompanying them to foster a deeper understanding of their thought patterns. Lastly, interpersonal communication skills empower the individual to navigate their social relationships and create a healthy social support system.⁴

The evidence of DBT as an effective treatment strategy is validated by numerous studies in the past decade. Proven to be effective for borderline personality disorder in the past, the therapy’s focus on teaching coping skills and mindfulness facilitates effective emotional regulation and promotes mental resilience. Additionally, a mixture of individual and group therapy sessions ensures that peer support networks and interpersonal skill reinforcement supplement personalised therapy. Individuals receive continued support through phone consultations in case of future crises.⁴

Application of DBT for suicidal ideation

The application of DBT involves targeting emotional dysregulation, a key component linked to suicidal ideation as well as equipping individuals with suicide coping skills. It encourages individuals to challenge their thought patterns in a non-judgemental way and gain a deeper understanding of their own psyche.

Mindfulness techniques

Identifying specific patterns of emotions and articulating those feelings is the first step to acceptance. Once identified, grounding exercises help individuals stay present during emotionally charged episodes and acknowledge them in a non-judgmental manner.

Distress tolerance skills

Radical acceptance of their challenging thought processes and emotions helps foster a resilient approach to emotionally overwhelming times. The key is to create a safe space for oneself during times of distress.

Emotion regulation strategies

These provide a blueprint for the individual’s maladaptive emotional responses and how they can be managed. The focus is on creating a positive and healthier emotional response by building positive experiences.

Interpersonal effectiveness

This aspect focuses on building positive social support networks by inculcation healthier relationships and communication skills as well as addressing the social aspects of suicidal ideation. It also emphasises the creation of healthy boundaries especially due to the sensitive nature of this topic with loved ones.^3,4

Therapeutic process in DBT: what to expect in DBT sessions

Individual therapy sessions

One-on-one sessions allow the therapist to help the individual explore their emotions, behaviours and thought patterns around suicide in depth. They can collaboratively build a management plan including setting goals, tracking progress and navigating their unique experiences in life in a positive way. 

Group skills training

Group sessions are important as they contribute to a sense of belongingness and shared learning. They offer a safe non-judgmental space for individuals to explore their experience as well as their peers, build a social network as well as practice suicide coping skills.

Phone coaching for crisis situations

DBT recognises that distressing situations may arise between sessions. Phone consultations allow individuals to reach out to their therapists during challenging moments creating a safety net during their healing journeys.⁵

Consultation team for therapists

A collaborative approach is the cornerstone of DBT. Therapists often participate in team sessions with other therapists to improve their practice. This encourages discussion of cases and an improved understanding of the nuances of suicidal ideation.^3,4,6

Challenges and considerations

Commitment and consistency in therapy

One of the challenges of DBT lies in commitment and consistency in attending therapy sessions. One of the symptoms of suicidal ideation involves periods of social withdrawal and lack of motivation to do simple tasks, which can make the activities challenging. Therapists play an important role in supporting individuals through these periods of emotional fluctuations.

Addressing co-occurring disorders

Suicidal ideation often co-occurs with other mental health disorders such as anxiety, depression, substance abuse and BPD. The therapeutic approach has to be tailored to manage these conditions as well, necessitating an integrated approach which may involve medications.

Tailoring DBT to individual needs

Every individual has their own complex trauma and a combination of physical, biological and social factors that have contributed to the disorder. This means that therapists adapt the principles of DBT according to the person's experiences, challenges and personalised experiences.

Application of the skills

Learning skills that were taught in a controlled therapeutic environment can be difficult to implement in real life. Encouraging and reinforcing the practical applications of mindfulness, emotional regulation, and interpersonal effectiveness skills is an ongoing process.

Managing relapses

Relapses are painful and pose a significant challenge in the healing journey. Establishing a strategy to manage relapses, including ongoing crisis support, resuming therapy sessions for emotional regulation and reassessment of coping strategies is an important part of the treatment plans.⁶

The relationship with the therapist is one of the most important ones in managing suicidal ideation. Open communication, commitment to the therapeutic process and engaging with the coping activities are vital to the healing process.

Effectiveness of DBT

Research studies affirm the benefits of DBT in tackling suicidal ideation, especially in individuals with co-occurring mental health conditions and high suicide risk. DBT has a proven track record of reducing suicidal thoughts in subsequent episodes of overwhelm due to its emphasis on building a positive relationship with one's emotions. Personal accounts report a reduction in depressive symptoms; self-harm episodes and an improved relationship with their social networks. By building emotional resilience and providing practical tools for managing challenges, DBT empowers individuals to take charge of their emotions and heal themselves in the long term.⁷

Summary

Suicidal ideation is a complex mental health condition that affects an individual's ability to regulate emotions and crises leading to recurring thoughts about suicide and death. Dialectic Behavioural therapy is an effective way to treat this condition as it focuses on empowering the individual to assess and change their maladaptive thought, emotional and behavioural patterns and handling distressing situations with suicide prevention strategies, emotion regulation skills, mindfulness techniques, distress tolerance, and interpersonal effectiveness in therapy. Commitment to the personalised therapeutic program along with integrated therapies to address co-occurring illnesses has proven to alleviate the condition significantly.