The focus of my career has been on research, teaching, and clinical service in the area of psychotherapy approaches for treating suicidal behavior in adolescents, with some additional work on suicidal adults. I have been dedicated to the “scientist-practitioner” model, in which my research and clinical work reciprocally inform and enhance each other. I have been fortunate to have obtained a significant amount of both research and clinical experience with suicidal behavior, an understudied area in which relatively few people receive specialized training. Despite the fact that suicide is the third leading cause of death among 10-14 year-olds and the second leading cause of death among 15-24 year-olds (CDC, 2015), there is surprisingly little research on effective psychosocial treatments for these youth. It is my mission to continue to contribute to the research literature in this area, as well as to provide high quality, empirically informed training in suicide assessment and treatment to therapists in training and to mental health professionals in the community. Treating suicidal behavior is one of the most difficult challenges faced by clinicians and the loss of a young person by suicide is a devastating outcome. My goals for my research, teaching, and clinical service are to: a) have a broad impact on the field in terms of developing empirically-supported interventions for adolescent suicide attempters, b) disseminate these interventions into the community, c) increase the quality of service provided to suicidal patients by the mental health professionals I have trained (and indirectly, as those I have trained go on to train others), and ultimately, d) prevent adolescent suicide and suicide attempts.
- Dialectical Behavior Therapy
- Cognitive Behavioral Therapy
- Suicidal and Self-Harm Behavior
Assistant Professor - Med Center Line, Psychiatry and Behavioral Sciences - Child and Adolescent Psychiatry
PhD Training:New York University (2001) NY
Ph.D., New York University, Clinical Psychology (2001)
Fellowship:University of Pennsylvania, Psychopathology Research Center (2003) PA
Fellowship:Mount Sinai St. Luke's/Roosevelt Hospital (2001) NY
Internship:Mount Sinai St. Luke's/Roosevelt Hospital (2000) NY
Current Research and Scholarly Interests
The focus of my research is on adolescent suicidal and self-harm behavior. I am currently one of four Principal Investigators of a multisite NIMH-sponsored RCT of DBT for adolescents at high risk for suicide (NCT01528020: Collaborative Adolescent Research on Emotions and Suicide [CARES], PI: Linehan, McCauley, Berk, & Asarnow) aimed at evaluating the efficacy of DBT with adolescents compared to a combined individual and group supportive therapy control condition (IGST).
Collaborative Adolescent Research on Emotions and Suicide
Suicide is the third leading cause of death among adolescents in the US yet there is a paucity of research on effective treatments for this population. The primary aim of the research described in this application is to evaluate the efficacy of dialectical behavior therapy (DBT) for suicidal adolescents. DBT has an empirical track record with suicidal adults of reducing the incidence, frequency and medical risk of suicide attempts and non-suicidal self-injuries among individuals meeting criteria for borderline personality disorder (BPD). While DBT is widely used in the community with suicidal adolescents, particularly those with difficulties characteristic of BPD such as poor emotion regulation and impulse control, no randomized trial of DBT with suicidal adolescents has ever been conducted. And, while non-randomized trials indicate that the intervention is both safe and effective, without a randomized trial the investigators simply do not know whether DBT for suicidal adolescents is efficacious or not. Given the severity of the problem and the lack of alternative treatments for high risk adolescents, addressing this question is of great importance. The second aim of the research is to analyze mediators of reduced suicidal and self-injurious behaviors in adolescents. 170 adolescents at two sites (Seattle and Los Angeles) will be randomized to DBT or Individual and Supportive Group Therapy (IGST). Both treatments include 6 months of individual and group treatment and adolescents and a parent complete 5 assessments over a 1-year period.
Stanford is currently not accepting patients for this trial. For more information, please contact Spectrum Child Health, 650-724-1175.
- Parental Validation and Invalidation Predict Adolescent Self-Harm PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2018; 49 (4): 274–81
Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk of Suicide
View details for DOI 10.1001/jamapsychiatry.2018.1109
Emergency Department Youth Patients With Suicidal Ideation or Attempts: Predicting Suicide Attempts Through 18 Months of Follow-Up.
Suicide and life-threatening behavior
This prospective study of suicidal emergency department (ED) patients (ages 10-18) examined the timing, cumulative probability, and predictors of suicide attempts through 18 months of follow-up. The cumulative probability of attempts was as follows: .15 at 6 months, .22 at 1 year, and .24 by 18 months. One attempt was fatal, yielding a death rate of .006. Significant predictors of suicide attempt risk included a suicide attempt at ED presentation (vs. suicidal ideation only), nonsuicidal self-injurious behavior, and low levels of delinquent symptoms. Results underscore the importance of both prior suicide attempts and nonsuicidal self-harm as risk indicators for future and potentially lethal suicide attempts.
View details for DOI 10.1111/sltb.12309
View details for PubMedID 27813143
Assessment of suicidal youth in the emergency department.
Suicide and life-threatening behavior
2015; 45 (3): 345-359
Accurate evaluation of suicidal adolescents in the emergency department (ED) is critical for safety and linkage to follow-up care. We examined self-reports of 181 adolescents who presented to an ED with suicidal ideation (SI) or a suicide attempt (SA). Parents also completed self-reports. Results showed fair agreement between parents and youth on the reason for the ED visit (e.g., SI vs. SA) and greater agreement between independent judges and youths than between judges and parents. In accordance with accepted definitions of suicide attempts (e.g., Crosby, Ortega, & Melanson, 2011; O'Carroll, Berman, Maris, Moscicki, Tanney, & Silverman, 1996, p. 237; Posner, Oquendo, Gould, Stanley, & Davies, 2007, p. 1035; Silverman, Berman, Sanddal, O'Carroll, & Joiner, 2007, p. 248), most youth with SA as the reason for the ED visit reported some intent to die associated with the attempt. Finally, youth presenting to the ED with SA did not differ clinically from youth presenting with SI, and almost half of youths with SI reported past suicide attempts. These results highlight the need to emphasize adolescents' reports in clinical decision making, suggest adolescents' defined suicide attempts similarly to published definitions, and show that assessment of past SAs, as well as present suicidal thoughts and behaviors, is critical in determining future risk.
View details for DOI 10.1111/sltb.12133
View details for PubMedID 25327838
The SAFETY Program: a treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters.
Journal of clinical child and adolescent psychology
2015; 44 (1): 194-203
The purpose of this article is to describe feasibility, safety, and outcome results from a treatment development trial of the SAFETY Program, a brief intervention designed for integration with emergency services for suicide-attempting youths. Suicide-attempting youths, ages 11 to 18, were enrolled in a 12-week trial of the SAFETY Program, a cognitive-behavioral family intervention designed to increase safety and reduce suicide attempt (SA) risk (N = 35). Rooted in a social-ecological cognitive-behavioral model, treatment sessions included individual youth and parent session-components, with different therapists assigned to youths and parents, and family session-components to practice skills identified as critical in the pathway for preventing repeat SAs in individual youths. Outcomes were evaluated at baseline, 3-month, and 6-month follow-ups. At the 3-month posttreatment assessment, there were statistically significant improvements on measures of suicidal behavior, hopelessness, youth and parent depression, and youth social adjustment. There was one reported SA by 3 months and another by 6 months, yielding cumulative attempt rates of 3% and 6% at 3 and 6 months, respectively. Treatment satisfaction was high. Suicide-attempting youths are at high risk for repeat attempts and continuing mental health problems. Results support the value of a randomized controlled trial to further evaluate the SAFETY intervention. Extension of treatment effects to parent depression and youth social adjustment are consistent with our strong family focus and social-ecological model of behavior change.
View details for DOI 10.1080/15374416.2014.940624
View details for PubMedID 25255931
View details for PubMedCentralID PMC4289426
Conducting Research on Adolescent Suicide Attempters: Dilemmas and Decisions.
The Behavior therapist / AABT
2014; 37 (3): 65–69
Research on effective treatments for adolescent suicide attempters is urgently needed. However, there has been a lack of research in this area. This is likely a result of the multiple challenges faced by investigators working with individuals at high risk of suicide. Based on our experiences conducting a large, randomized clinical trial with adolescent suicide attempters, in this article, we review ways to address these challenges in order to facilitate needed research on suicide prevention in adolescents.
View details for PubMedID 24954969
View details for PubMedCentralID PMC4061763
Differential susceptibility in longitudinal models of gene-environment interaction for adolescent depression
DEVELOPMENT AND PSYCHOPATHOLOGY
2013; 25 (4): 991-1003
Although family support reliably predicts the development of adolescent depression and suicidal behaviors, relatively little is known about the interplay of family support with potential genetic factors. We tested the association of the 44 base pair polymorphism in the serotonin transporter linked promoter region gene (5-HTTLPR), family support (i.e., cohesion, communication, and warmth), and their interaction with self-reported depression symptoms and risk for suicide in 1,030 Caucasian adolescents and young adults from the National Longitudinal Study of Adolescent Health. High-quality family support predicted fewer symptoms of depression and reduced risk for suicidality. There was also a significant interaction between 5-HTTLPR and family support for boys and a marginally significant interaction for girls. Among boys with poor family support, youth with at least one short allele had more symptoms of depression and a higher risk for suicide attempts relative to boys homozygous for the long allele. However, in the presence of high family support, boys with the short allele had the fewest depression symptoms (but not suicide attempts). Results suggest that the short allele may increase reactivity to both negative and positive family influences in the development of depression. We discuss the potential role of interactive exchanges between family support and offspring genotype in the development of adolescent depression and suicidal behaviors.
View details for DOI 10.1017/S0954579413000321
View details for Web of Science ID 000330358700009
View details for PubMedID 24229544
- Dialectical Behavior Therapy and Suicidal Behavior in Adolescence: Linking Developmental Theory and Practice PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2013; 44 (4): 257-265
Suicide Attempt Risk in Youths: Utility of the Harkavy-Asnis Suicide Scale for Monitoring Risk Levels
SUICIDE AND LIFE-THREATENING BEHAVIOR
2012; 42 (6): 684-698
The Harkavy-Asnis Suicide Scale (HASS), one of the few self-report scales assessing suicidal behavior was evaluated and ideation, was evaluated and predictors of suicide attempts (SAs) were identified with the goal of developing a model that clinicians can use for monitoring SA risk. Participants were 131 pediatric emergency department (ED) patients with suicidal behavior. The HASS and Diagnostic Interview Schedule for Children (DISC-IV) were administered approximately 2 months after ED presentation. When compared with DISC-IV ratings, sensitivity of the HASS SA items was excellent (100%), and overall classification accuracy was 72%. SA planning was the strongest predictor of SAs.
View details for DOI 10.1111/j.1943-278X.2012.00122.x
View details for Web of Science ID 000312131900008
View details for PubMedID 23072257
View details for PubMedCentralID PMC4584212
An Emergency Department Intervention for Linking Pediatric Suicidal Patients to Follow-Up Mental Health Treatment
2011; 62 (11): 1303-1309
Suicide is the third leading cause of death among adolescents. Many suicidal youths treated in emergency departments do not receive follow-up treatment as advocated by the National Strategy for Suicide Prevention. Two strategies for improving rates of follow-up treatment were compared.In a randomized controlled trial, suicidal youths at two emergency departments (N=181; ages ten to 18) were individually assigned between April 2003 and August 2005 to one of two conditions: an enhanced mental health intervention involving a family-based cognitive-behavioral therapy session designed to increase motivation for follow-up treatment and safety, supplemented by care linkage telephone contacts after emergency department discharge, or usual emergency department care enhanced by provider education. Assessments were conducted at baseline and approximately two months after discharge from the emergency department or hospital. The primary outcome measure was rates of outpatient mental health treatment after discharge.Intervention patients were significantly more likely than usual care patients to attend outpatient treatment (92% versus 76%; p=.004). The intervention group also had significantly higher rates of psychotherapy (76% versus 49%; p=.001), combined psychotherapy and medication (58% versus 37%; p=.003), and psychotherapy visits (mean 5.3 versus 3.1; p=.003). Neither the emergency department intervention nor community outpatient treatment (in exploratory analyses) was significantly associated with improved clinical or functioning outcomes.Results support efficacy of the enhanced emergency department intervention for improving linkage to outpatient mental health treatment but underscore the need for improved community outpatient treatment to prevent suicide, suicide attempts, and poor clinical and functioning outcomes for suicidal youths treated in emergency departments.
View details for Web of Science ID 000296674000009
View details for PubMedID 22211209
View details for PubMedCentralID PMC3251923
Suicide Attempts and Nonsuicidal Self-Injury in the Treatment of Resistant Depression in Adolescents: Findings from the TORDIA Study
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2011; 50 (8): 772-781
To evaluate the clinical and prognostic significance of suicide attempts (SAs) and nonsuicidal self-injury (NSSI) in adolescents with treatment-resistant depression.Depressed adolescents who did not improve with an adequate SSRI trial (N = 334) were randomized to a medication switch (SSRI or venlafaxine), with or without cognitive-behavioral therapy. NSSI and SAs were assessed at baseline and throughout the 24-week treatment period.Of the youths, 47.4% reported a history of self-injurious behavior at baseline: 23.9% NSSI alone, 14% NSSI+SAs, and 9.5% SAs alone. The 24-week incidence rates of SAs and NSSI were 7% and 11%, respectively; these rates were highest among youths with NSSI+SAs at baseline. NSSI history predicted both incident SAs (hazard ratio [HR]= 5.28, 95% confidence interval [CI] = 1.80-15.47, z = 3.04, p = .002) and incident NSSI (HR = 7.31, z = 4.19, 95% CI = 2.88-18.54, p < .001) through week 24, and was a stronger predictor of future attempts than a history of SAs (HR = 1.92, 95% CI = 0.81-4.52, z = 2.29, p = .13). In the most parsimonious model predicting time to incident SAs, baseline NSSI history and hopelessness were significant predictors, adjusting for treatment effects. Parallel analyses predicting time to incident NSSI through week 24 identified baseline NSSI history and physical and/or sexual abuse history as significant predictors.NSSI is a common problem among youths with treatment-resistant depression and is a significant predictor of future SAs and NSSI, underscoring the critical need for strategies that target the prevention of both NSSI and suicidal behavior.Treatment of SSRI-Resistant Depression in Adolescents (TORDIA). URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00018902.
View details for DOI 10.1016/j.jaac.2011.04.003
View details for Web of Science ID 000293427800008
View details for PubMedID 21784297
View details for PubMedCentralID PMC3143365
Effective Components of TORDIA Cognitive-Behavioral Therapy for Adolescent Depression: Preliminary Findings
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2009; 77 (6): 1033-1041
In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.
View details for DOI 10.1037/a0017411
View details for Web of Science ID 000272404800003
View details for PubMedID 19968380
View details for PubMedCentralID PMC3705725
- Family Intervention for Suicide Prevention: A Specialized Emergency Department Intervention for Suicidal Youths PROFESSIONAL PSYCHOLOGY-RESEARCH AND PRACTICE 2009; 40 (2): 118-125
- The Sting of Lack of Affection: Chronic Goal Dissatisfaction in Transference SELF AND IDENTITY 2008; 7 (4): 393-412
Pediatric emergency department suicidal patients: Two-site evaluation of suicide ideators, single attempters, and repeat attempters
JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY
2008; 47 (8): 958-966
Reducing youth suicide and suicide attempts are national priorities. Suicidal youth emergency department (ED) patients are at high risk for repeat and fatal attempts, yet information is lacking to guide service delivery. In one of the largest clinical studies of youth ED patients presenting with suicidality, we examine ideators, single attempters, and repeat attempters with the aim of clarifying optimal strategies for ED management and risk assessment.Consecutively admitted suicidal youths (10-18 years) from two EDs (N = 210) completed a questionnaire assessing sociodemographic, clinical, service use, and environmental stress variables.Despite differences in background characteristics, high levels of depression, externalizing behavior, posttraumatic stress symptoms, substance use, and thought problems were observed across sites. Suicide attempt risk, defined along a continuum ranging from ideation to single attempts to repeat attempts, was predicted by higher levels of clinical symptoms, service use, and environmental stress. Specific stresses associated with increased suicide attempt risk were romantic breakups, exposure to suicide/suicide attempts, and pregnancy in self or partner. Significant predictors of attempt risk in the male-only subgroup were depression, thought problems, previous ED visits, and romantic breakups.Pediatric ED patients presenting with suicidal ideation, single attempts, and repeat attempts fall along a continuum of increasing risk. Suicide attempt risk in males is associated with high levels of depression, but not with increased treatment rates, suggesting undertreatment in males, a group with particularly high risk for death by suicide. Treatment barriers must be addressed to achieve our national goal of reducing suicide/suicide attempts in youths.
View details for DOI 10.1097/CHI.0b013e3181799ee8
View details for Web of Science ID 000258043800017
View details for PubMedID 18596552
Characteristics of recent suicide attempters with and without Borderline Personality Disorder.
Archives of suicide research
2007; 11 (1): 91-104
The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.
View details for PubMedID 17178645
A cognitive therapy intervention for suicide attempters: An overview of the treatment and case examples
COGNITIVE AND BEHAVIORAL PRACTICE
2004; 11 (3): 265-277
View details for Web of Science ID 000228417900001
History of multiple suicide attempts as a behavioral marker of severe psychopathology
AMERICAN JOURNAL OF PSYCHIATRY
2004; 161 (3): 437-443
Individuals with a differing number of past suicide attempts are generally considered a homogeneous group, despite emerging evidence to the contrary. The current study aimed to test the hypothesis that multiple suicide attempters would exhibit a more severe clinical profile than single suicide attempters.A series of self-report batteries and clinical interviews was administered to 39 single attempters and 114 multiple attempters who came to an urban hospital emergency room after a suicide attempt. The participants were predominantly poor and nonwhite.Multiple suicide attempters versus single attempters exhibited a greater degree of deleterious background characteristics (e.g., a history of childhood emotional abuse, a history of family suicide), increased psychopathology (e.g., depression, substance abuse), higher levels of suicidality (e.g., ideation), and poorer interpersonal functioning. Profile differences existed even after control for borderline personality disorder.Results indicate that multiple attempters display more severe psychopathology, suicidality, and interpersonal difficulties and are more likely to have histories of deleterious background characteristics than single attempters. Moreover, these differences cannot be explained by the diagnosis of borderline personality disorder. Results suggest that the identification of attempt status is a simple, yet powerful, means of gauging levels of risk and psychopathology.
View details for Web of Science ID 000221276000008
View details for PubMedID 14992968
The impact of past relationships on interpersonal behavior: Behavioral confirmation in the social-cognitive process of transference
JOURNAL OF PERSONALITY AND SOCIAL PSYCHOLOGY
2000; 79 (4): 546-562
This study extended research on transference in social perception (e.g., S. M. Andersen, I. Reznik, & L. M. Manzella, 1996) into the realm of social behavior by examining behavioral confirmation (e.g., M. Snyder, 1992) in transference. Each perceiver participated in a brief conversation with a naive target participant, who either did or did not appear to resemble the perceiver's own positively or negatively regarded significant other. Trained judges rated positive affect expressed in targets' behavior. As predicted, targets expressed more positive affect in their behavior when they allegedly resembled the perceiver's own positively versus negatively toned significant other, an effect not found in the control condition. This evidence demonstrates behavioral confirmation in transference, suggesting a means by which present relationships may resemble past ones.
View details for DOI 10.1037//0022-3522.214.171.1246
View details for Web of Science ID 000089712600005
View details for PubMedID 11045738