(PS8-31) Dialectical Behavior Therapy Program Outcomes for Suicidal Individuals: Examining the Moderating Role of Internalizing and Externalizing Symptoms

Youth with internalizing (e.g., depression) and externalizing symptoms (e.g., aggression) have an elevated risk of engaging in suicidal behaviors (Piqueras et al., 2019). Thus, researchers have sought to better understand the process of how the gold standard treatment for suicide, Dialectical Behavior Therapy (DBT; Linehan, 1993), can target youth internalizing (McCredie et al., 2017) and externalizing (Jakubovic & Drabick, 2023) symptoms. Yet, no study to date has examined DBT outcomes in patients with suicidality, internalizing, and externalizing symptoms. Distinguishing how DBT target outcomes among suicidal patients are affected by different levels of internalizing or externalizing symptoms is needed to better understand how specific DBT skills can help increase coping in individuals at risk of suicide. Our study aimed to 1) explore the potential effectiveness of a DBT partial hospital program (PHP) in youth and young adults by assessing their DBT outcomes pre and post treatment, and 2) investigate the moderating role of internalizing and externalizing symptoms on suicidal behaviors and DBT outcomes.

Data come from 117 adolescents and young adults (Mage = 17.82; 66% Cisgender female; 83% White). Youth self-reported suicidal thoughts and behaviors (SBQ), internalizing and externalizing symptoms (YSR for adolescents; ASR for adults; t-scores >60 and >70 represent at-risk and clinically significant symptoms, respectively), and mindfulness (FFMQ), emotion regulation (DERS), distress tolerance (DBT-WCCL general dysfunctional coping scale), interpersonal effectiveness (AICQ), and DBT skills use (DBT-WCCL skills use scale). Regression-based moderation analyses with simple slopes were conducted to explore the associations between suicidal behaviors and DBT outcomes. Internalizing and externalizing symptoms were considered as potential moderators.

When comparing pre-post DBT outcomes, there were decreases in emotion dysregulation and distress tolerance difficulties and increases in mindfulness, interpersonal competence, and DBT skills use for patients with internalizing and externalizing behaviors. Externalizing symptoms moderated emotion dysregulation outcomes for individuals with suicidal behaviors, where at-risk (b = 3.17, p = 0.01) and clinically significant (b = 4.97, p = 0.001) levels of externalizing symptoms were associated with higher emotion dysregulation post treatment. Internalizing symptoms showed omnibus moderation of the link between suicidality and distress tolerance (b = 0.01, p = 0.04), but simple slopes tests for all prior points of interest were non-significant (t-scores of 50, 60, and 70 which correspond to normal, at-risk, and clinically elevated levels of symptoms, respectively).

Higher levels of externalizing symptoms were associated with worse emotion regulation outcomes. These findings stand in the broader context of DBT PHP showing an average decrease overall for all DBT target outcomes. Findings can help identify and guide the specific DBT skills targeted during sessions (e.g., additional clinical attention to emotion regulation for those with high levels of externalizing symptoms).