In Making Sense of Suicide: Part 2 Theory, I introduced Joiner’s Interpersonal Theory of Suicide and Jobes’ Collaborative Assessment and Management of Suicide. In this blog, I’ll round out my discussion on theory by reviewing Marsha Linehan’s Dialectical Behavior Therapy (DBT). There is much to be said about this encompassing therapy which can be applied to a wide range of clinical presentations and needs.
To stay within the realm of theory and suicide, I’ll be limiting my review to the core principles that everything is caused, and validation and change. I will also be providing a brief introduction to borderline personality disorder (BPD). DBT was developed for BPD, a diagnosis that has been severely stigmatized and misunderstood.
Shame and Blame and BPD
A diagnostic marker of BPD is persistent and chronic suicidal ideations and related behaviors, including suicidal attempts and non-suicidal self-directed violence (aka self-harm). It is unfortunately still quite common to hear providers call those with BPD as “attention seeking” after a suicidal behavior, further claiming that, if “they really wanted to kill themselves they would have by now.”
Such disparaging comments are demeaning and dehumanizing. And they miss the mark on the function of these behaviors and in turn, what is needed for meaningful, long-lasting change. And let me tell you, it’s not likely a three-day psychiatric hospitalization or a med change (though there is a time and place for both).
What’s the function?
For real meaningful change, identifying the function of the behavior is essential. In this case, suicide and self-harm, broadly speaking, are functioning as coping mechanisms. Self-harm can jar you into a different emotional state. Planning for suicide can help you feel empowered that you have a way out of your suffering. Either behavior can demand that others see you and attend to your distress. Also, what is reinforced through this form of coping, is a sense of agency and control. I may not be able to stop the chaos around me AND this is in my control (even when the actions themselves may feel out of your control).
In these instances, the goal of suicidal thinking, communications, and behaviors is not actually death. This is why it is imperative to clarify, for the individual sitting in front of you, what their suicidal experience was about. Keep in mind, most folks don’t have conscious awareness of what is driving and reinforcing their behaviors. When they say they “don’t know” why they cut themselves, they aren’t necessarily being willful or avoidant. They may genuinely not know. This is how we use the principle that everything is caused to start making sense of it all.
Everything is Caused
DBT recognizes that thoughts, bodily sensation, feeling, and actions don’t “just happen,” even when that’s what it feels like. It postulates (from Zen Buddhism influences) that there were dozens of moments leading up to and influencing that “just happened” moment, much like dominoes in a row. And that moment will lead to another set of moments. Suicide and self-harm function as a response to those moments and as a way of impacting the moments to come. So how do we uncover this at a more specific and personal level to our client?
DBT strives to understand function on two levels. The first is more globally, looking at someone’s overall patterns of functioning via the biopsychosocial model. Second, it uses chain analyses to unpack individual moments.
The Biopsychosocial Model
The biopsychosocial model posits that the unique presentation of BDP is the cumulative effects of a child, with baseline high emotional sensitivity or temperament, experiencing neglect, trauma, or abuse in an overarchingly invalidating environment . This model can help clinicians make sense of how and why patterns of coping developed and are maintained. And that we are all just doing the best we can with the hand we were dealt.
Chain Analyses
A chain analysis zooms in on a singular moment in time when suicidal behaviors occurred. The clinician guides the client to identify their thoughts, feelings, behaviors, body sensations, and actions, as well as what was occurring around them, in a step-by-step fashion. Doing so clarifies the links between these elements to illuminate how and why the suicidal behavior occurred and how it was functioning.
Validation and Change
It is the making-sense that makes all the difference. A lot of clinicians and clients alike aren’t huge fans of traditional cognitive behavior therapy because of how change is talked about. It is made to seem easy – you just have to catch it, check it and change it! And the idea is that by reworking thoughts, the rest will follow. What I find is missing in this model, is the role of validation.
Change is HARD. If it wasn’t, the field of mental health wouldn’t exist. And it’s hard because it means letting go of something that is working. As awful as having thoughts of suicide can be, it may be “working” because it is reinforcing that sense of agency and control. That’s where the making sense, and validation components of DBT come in. We first make sense, then validate, then change with the use of new skills (including distress tolerance , mindfulness, and emotion regulation). Then we make sense and validate again when the change is slow and imperfect.
MOST IMPORTANTLY
DBT prioritizes understanding and changing suicide and self-harm and as such they are kept at the forefront of treatment. Recognizing that work, relationships, hobbies, etc. don’t really amount to much if you’re dead. This can sound harsh. It is not meant to be delivered in a shame and blaming way. Rather, it can be said as a grounding, validating, and most importantly, empowering way. It is ALWAYS the client’s right to choose whether or not to do DBT and seek a life worth living. What we are striving for is to inspire hope that the essential need for agency and control can be found outside of self-harm and suicide.
To Learn More:
- Check out Linehan’s Behavioral Health Institute
Theory Wrap-Up
We’ve officially reviewed Interpersonal Theory of Suicide, the Collaborative Assessment and Management of Suicide (CAMS), and Dialectical Behavior Therapy (DBT), the three frameworks I use most for making sense of suicide. Each has a slightly different flavor, emphasis and goal.
What do they all have in common?
All three of these theories put suicide first. Also, suicide is conceptualized as an experience unto itself, not as a symptom of another diagnosis. Furthermore, they all validate suicide as an understandable response to unbearable suffering. And, they all believe it can be treated.
This does not mean everyone can be saved and all suicides are preventable. Another thing these theories have in common is the awareness that it is ultimately the individual’s choice to choose to live. This can be difficult to hear for clinicians, survivors of those lost to suicide, survivors of suicide attempts, family members and friends of those currently suffering, because it takes away our sense of control. Our desire to be able to fix, to heal, to have been able to make things happen differently. Hold this awareness gently and with kindness.
For Clinicians: I hope this gives you a new framework for conceptualizing clients struggling with chronic suicidal ideation that supports the compassion and perseverance needed for sustainability working with such presentations.
For Those Seeking Healing: As I said in my last suicide post, I hope this material helps you feel seen and understood and gives you hope that healing is possible. Again, these posts, and any recommended resources, do not equate to emergency interventions or therapy. Please call 9-8-8 or go to your local emergency room if you are in crisis.
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