Dynamic Deconstructive Psychotherapy Found Effective for Suicidal Adolescents

Developed by Robert Gregory, M.D., professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, DDP focuses on “deconstructing” the negative self-image and maladaptive patterns of responding to charged experiences that patients bring to therapy. Drawing on translational neuroscience and object relations theory, the therapy does not emphasize “crisis management,” but instead works to make fundamental changes in neural pathways that underlie suicidal responses to stress.

DDP is a key service of the Psychiatry High Risk Program (PHRP) at SUNY Upstate. This recovery-based outpatient treatment program for suicidal youth and young adults won the 2023 Silver Psychiatric Services Award for innovative and effective treatment.

“When we do research on different treatment modalities, ultimately what we want to know is whether a given treatment can still be effective outside of a laboratory and in a real-world setting,” Gregory told Psychiatric News. “The important aspect of our [quality assurance] study is that we show that in a real-world outpatient program, DDP can be highly effective for even the most severely suicidal adolescents.”

Gregory said that within DDP theory, “thoughts of suicide emerge when people are feeling stuck alone with overwhelming pain.”

A total of 65 adolescents, ages 13 to 17, who had been admitted to the PHRP between June 2020 and July 2023 were enrolled in the study; all had evidence of active suicide ideation as indicated by a score of two or greater on the Suicide Ideation Subscale of the Columbia Suicide Severity Scale (C-SSRS). Weekly individual psychotherapy with DDP was provided by 10 licensed providers, including five clinical social workers, three attending-level child and adolescent psychiatrists, an attending-level general psychiatrist, and a child psychologist.

Among 42 (65%) adolescents who completed at least six months of treatment, average suicide attempts decreased by 84% from baseline, a statistically significant improvement. Twenty-three of these adolescents achieved a clinical response, defined as a 50% or greater decrease in the C-SSRS suicide ideation score. The adolescents also showed statistically significant improvements between baseline and six months for several other outcomes, including depression, anxiety, self-harm, and self-compassion.

Forty of the adolescents had visited the emergency department for psychiatric issues in the three months preceding admission to the PHRP, but only 15 adolescents did so in the first three months following PHRP admission. Twenty-five adolescents were psychiatrically hospitalized in the three months before admission to the PHRP, but only five were re-hospitalized in the first three months following admission.

Rebecca Shields, D.O., lead author of the journal study and director of the adolescent PHRP, said DDP does not avoid crisis management, but also does not emphasize it. “We try not to spend most of the sessions doing crisis management, because that takes away from treatment time needed to address core vulnerabilities,” said Shields, whose co-authors were Gregory and Jessica Helfrich, the PHRP’s testing and research coordinator. “Typically developing teenagers struggle with forming meaningful relationships, managing their emotions, and developing their own sense of autonomy. DDP is naturally suited in some ways for addressing these issues as they come up.”

Shields added that while family involvement is encouraged, the therapy strives to create a patient-centered “safe space” for teenagers. “We inject hope by helping patients to identify their own treatment goals, by providing them with a formulation, and by laying out a clear path of recovery,” she said.

Gregory described DDP as a lower-intensity alternative to dialectical behavior therapy for adolescents (DBT-A), which has the been the gold standard treatment for suicidal adolescents. “It’s surprisingly unusual to have a dedicated outpatient program for suicidal adolescents or young adults that is not an intensive outpatient program or partial hospitalization,” he told Psychiatric News. “The downside of DBT-A is that it’s very intensive and difficult to adequately reimburse in private outpatient settings, which makes it hard to find outside of [intensive outpatient] or partial hospitalization programs, and many adolescents and families don’t want that level of involvement.”

Gregory added, “The program is not hospital-based or government-based, but is almost entirely self-supporting, covering its own costs. Given the dramatic reductions in inpatient utilization that our patients experience, this kind of program should be a no-brainer for health care systems, insurers, or government agencies looking for cost-effective solutions. We are showing that it’s possible to both save lives and save money.”

This study was supported in part by the Upstate Foundation Inc.’s Suicide and Self-Harm Prevention Endowment. ■