What Type of Outpatient Treatment Works Best?

In 2014, the Centers for Disease Control (CDC) released an astonishing report. That year, suicide became the second leading cause of death for people ages 10-24. Then, in 2017, they revised that finding to define adolescent suicide as the second leading cause of death for ages 15-19. For those teens, suicide is second only to death by accidents in general. However, though more teens die by accidents each year than suicide, more teens suicide each year than by car accidents.

That’s more than astonishing.

It’s alarming.

And it’s getting worse, exacerbated by the secondary effects of the coronavirus pandemic.

That’s not the only astonishing and alarming trend observed in teens in recent years. Experts also indicate that rates of non-suicidal self-injury (NSSI) – a.k.a. self-harm or self-injury – are higher now than ever before. For parents unfamiliar with the phenomenon of self-harm, here’s a basic definition:

“The condition – clinically known as non-suicidal self-injury or NSSI — is characterized by deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm…engage in myriad other behaviors that are intended to cause themselves pain but not end their lives.”

We include this definition to help parents understand the precarious position our teens occupy in the immediate post-pandemic era. The rates of adolescent suicide and self-injury reflect the upward trend in mental health disorders among teens over the past fifteen years. These increases prompted the Surgeon General of the United States to publish what’s called a Surgeon General’s Advisory (SGA) on teen mental health in 2021.

We encourage parents to read our summary of that advisory here:

Surgeon General’s Advisory: Youth Mental Health in 2021

This article will use that data from the SGA and additional peer-reviewed journal publications to discuss the most effective outpatient treatments for teens who self-harm and/or are at risk of suicide, and offer information on evidence-based outpatient treatment for preventing adolescent suicide/self-harm.

First, though, we need to bring parents up to date with the latest statistics on suicide and self-harm among adolescent in the U.S.

Adolescent Suicide and Self-Harm: Facts and Figures

Here’s data from the SGA on long-term trends in teen suicide:

• Between 2007 and 2018, rates of suicide increased 57% for people ages 10-24
• From 2009 and 2019, the percentage of high school students seriously considering suicide increased by 36%
• Between 2009 and 2019, the percentage of high school students who had a suicide plan increased by 44%

Now let’s look at the data for 2019:

• 8.9% of high school students said they’d attempted suicide attempt in the previous year
• 18.8% said they’d seriously considered suicide in the previous year

Before we share the statistic on NSSI among teens, let’s put real numbers to those percentages. Based on reliable population data, there were 15.1 million high school students in 2019. That means close to 1.5 million teens attempted suicide that year, and close to three million teens seriously considered suicide that year.

That’s why parents need to know about any therapeutic options available. These include, among others, outpatient treatment for teens and virtual therapy for teens.

Now let’s examine the NSSI statistics in the U.S.:

• 17% of adolescents report NSSI at least once
• The first incident of NSSI typically occurs around age 14
• 74% of teens engage in NSSI to escape disruptive/painful/negative emotions
• 46% of teens engage in NSSI to communicate the presence of disruptive/painful/negative emotions to family, friends, or other important people in their lives

Based on a population of about twenty-five million teens in the U.S., those statistics tell us that 4.2 million teens intentionally harm themselves at least once in their lives. Here’s an element of the data we don’t include above: teenage girls attempt suicide and engage in NSSI at roughly twice the rate of teenage boys.

Therefore, parents of teenage girls should understand the warning signs and risk factors for both suicide and NSSI.

Suicide and Non-Suicidal Self-Injury Among Teens: Risk Factors

We’ll start with the known risk factors for suicide. In the study Five Profiles of Adolescents at Elevated Risk for Suicide Attempts, researchers identified the following risk factors for suicide:

• Presence of mental health disorders:
  • Mental health disorders associate with suicide attempts include depression, anxiety, alcohol use disorder (AUD), and substance use disorder (SUD)
• Identification as LGBTQ+
  • For LGBTQ+ individuals age 10-24, suicide is a leading cause of death
  • LGBTQI youth engage in suicidal ideation or attempt suicide at three times the rate of non-LGBTQI youth
• Previous suicide attempts
• Past trauma
• Past abuse, whether emotional, physical, or sexual
• Significant loss/grief Social isolation

To clarify, what that list means is that an adolescent who has those characteristics or experiences is at increased risk of attempting suicide, compared an adolescent who does not. Presence of those factors increase risk: they do not mean a teen with those characteristics will attempt suicide.

For a comprehensive list of warning signs for teen suicide, please read our article here:

Treatment for a Suicidal Teenager: Understanding the Line between Passive Suicidal Thoughts and Active Intentions

Next, we’ll look at the risk factors associated with adolescent NSSI.

New evidence indicates the following groups are at increased risk of NSSI:

• Adolescents between age 12-17
• Young people between age 18-24
• Females
• Adolescents with peers who engage in NSSI
• Adolescents who encounter NSSI on social media, television, or online
• Young adults or teens with a history of adverse childhood experiences (ACEs)

Additional evidence associates the following factors with increased risk of NSSI:

• Presence of clinically diagnosed mental health disorder
• History of suicide attempt
• Previous NSSI
• Presence of suicidal ideation, i.e. thinking or talking about suicide
• NSSI or suicidality among family members
• Experiencing online bullying or in-person bullying
• Being a member of the LGBTQ+ community

For a comprehensive list of warning signs for teen NSSI, please read our article here:

Self-Injury Treatment Programs for Non-Suicidal Teens

Parents who think their teen is at risk of attempting suicide or engaging in NSSI should read and understand all of the above. That’s critical: knowing and understanding that information is the first step toward preventing teen suicide or self-harm.

Adolescent Suicide and Self-Harm: Initial Steps for Parents

Next, we’ll talk about the most effective known outpatient treatments for self-harm. First, though, parents of at-risk teens should know three things:

1. Never ignore suicidal ideation. Parents who think their teen is at imminent risk of harming themselves should call 911 or take their teen to an emergency room or a mental health hospital for adolescents.
2. We encourage parents who think their teen may be at risk of engaging in self-harm to arrange for a full biopsychosocial evaluation with a qualified mental health professional. If they diagnose self-harm or elevated risk of NSSI – and the teen is not in crisis or imminent risk of harming themselves – the evaluating professional will most likely recommend outpatient treatment or intensive outpatient treatment (IOP).
3. Outpatient treatment can be effective. Evidence-based treatment for teens at-risk of suicide or self-harm are available, and can help prevent teen suicide and teen self-harm.

Those three points are very important, and can help parents get a handle on a situation with their teen that may be both overwhelming and frightening. We’ll spend the rest of this article on the last point: outpatient for teen suicide or self-harm.

Dialectical Behavior Therapy (DBT): Evidence-Based Support for Adolescent Suicide/Self-Harm

There’s one more factor we need to discuss before we talk about the gold-standard treatment for teens at risk of self-harm and suicidal ideation: for teens to benefit from treatment, they need to stay in treatment and go to their appointments. One of the first studies on the subject, “Are Adolescent Suicide Attempters Noncompliant with Outpatient Care?,” published close to thirty years ago, indicates that among teens in outpatient treatment for teens who attempt suicide, those who skip appointments are more likely to  attempt suicide than those who do not.

That’s a disclaimer: for treatment to work, teens need to adhere to the treatment plan and go to therapy when scheduled. We understand, of course, that sometimes things come up that prevent perfect attendance. However, we encourage parents who seek treatment for their teens to commit one hundred percent and do everything they can to get their teen to all their appointments.

The data shows it makes a difference.

Now let’s discuss DBT.

What is DBT and Why Does it Help Teens?

DBT was developed by Dr. Marsha Linehan in order to support adult women with severe mental health disorders manage self-harming behaviors and suicidal ideation. DBT is based on cognitive behavioral therapy (CBT), which is a well-known, time-tested, evidence-based treatment approach that’s an effective treatment for mental health disorders such as depression and anxiety. In some cases, though, Dr. Linehan noticed that CBT didn’t work – especially for patients with high emotional reactivity.

Whereas CBT focuses on the relationship between thoughts and behaviors, DBT adds a critical component: the role of emotion. CBT explores the thought-behavior relationship, while DBT explores the thought-emotion-behavior relationship through five core modules:

1. Mindfulness
2. Emotion Regulation
3. Interpersonal Effectiveness
4. Distress Tolerance
5. Walking the Middle Path

Dr. Linehan added the fifth core module specifically for adolescents, because she found it necessary to help adolescents learn to find balance and avoid the extremes of thinking that often lead to both self-harm and suicide attempts. The Middle Path module teaches teens there are alternatives to polarized thinking. Events in life often occur in the areas that are neither all one thing or all another thing. For example, there’s a middle ground between everything is terrible and everything is great or I know everything and my parents know nothing. It also helps teens deal with thoughts like everything I try to do is so hard and everything my friends do is so easy for them.

CBT helps patients avoid black-and-white thinking as well. But in DBT, the addition of emotion regulation, distress tolerance, and balanced thinking makes a difference for a teen, whose developmental stage – i.e. the in-progress nature of the executive function and impulse control systems in their brain – makes untangling the relationship between emotion and behavior a legitimate challenge.

The Data on DBT: Reducing Teen Suicide and Self-Harm

A meta-analysis published in 2021 examined the outcomes of outpatient DBT-A programs on teen self-harm and teen suicidal ideation.

A quick aside: meta-analysis means researchers examined data from all high-quality studies they could find on DBT-A for suicidal ideation/self-harming behavior, and the acronym DBT-A means DBT programs designed for adolescents.

In that meta-analysis, researchers found that outpatient DBT-A is effective in reducing both suicidal ideation and self-harm in teens. This approach helps teens by teaching them coping mechanisms and self-management skills that allow them to identify life-interrupting patterns of thought and emotion that lead to life-interrupting patterns of behavior. Once they identify those patterns of thought and emotion, they can change their patterns of behavior and achieve goals they set for themselves – which is one of the primary objectives of any type of mental health treatment.

Another quick aside: clinicians use CBT and DBT in outpatient programs, intensive outpatient programs (IOP), and residential programs (RTC) for teens. To learn more about these levels of care in mental health treatment for teens, click here.

Now, back to the study. Lets’ take a look at what the researchers found:

• DBT-A showed moderate reductions in suicidal ideation and self-harming behavior in teens all clinical studies that monitored teens throughout the trial, compared with a control group
• DBT-A showed large reductions in suicidal ideation and self-harming behavior in all clinical studies that administered pre/post treatment assessments, compared with a control group

Those two simple bullet points contain good news for parents and families of teens at risk of suicidal ideation and/or self-harming behavior. First, they give hope: there are effective treatments available for preventing and/or reducing teen suicide and self-harm. Second, these are outpatient programs, which means that in some cases, teens can learn to manage the emotions related to suicide and self-harm while living at home and going to school. However, with that said, we advise all parents to pursue the level of care recommended by their teen’s assessing psychiatrist or therapist.

The Importance of Family in Treatment

There’s an element of the study above we’d like to point out before we close this article: DBT-A stresses family involvement. All the studies that showed reductions in suicide and self-harm involved programs that required family members to participate in the treatment process. That’s important, because it confirms the validity of an integrated, comprehensive approach to mental health treatment. The comprehensive approach to treatment considers all aspects of a teen’s life: family, peers, school, activities, diet, exercise – everything counts. What therapists have learned over decades is that when the family understands the diagnosis and the treatment, they can support the family member in treatment more effectively and help improve the outcome.

With regard to teen suicide and self-harm, an improved outcome can be life-changing, and in some cases, life-saving.

Suicide and Self-Harm Hotlines

Teens who need help can call or text the following numbers:

• The National Suicide Prevention Lifeline (24/7/365): 1-800-273-8255
• The Trevor Project Phone (24/7/365): 1-866-488-7386
  • Note: The Trevor Project was originally created to support LGBTQI+ teens in crisis. However, they will help anyone who calls.
• The Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
• The Trevor Project Chat: CLICK HERE
• The Crisis Text Line (24/7/365): Text CONNECT to 741741
• The Youth Yellow Pages TEEN LINE (6pm-10pm PT) 310-855-4673
• The Youth Yellow Pages TEXT: Text TEEN to 839863