Embedding DBT Skills Training Within a Transactional-Ecological Framework to Reduce Suicidality in a Navajo Adolescent Female

Abstract

American Indian/Alaska Native (AI/AN) youth have higher rates of suicidality than any other ethnic or cultural group in the United States. Dialectical behavior therapy (DBT) is an evidence-based treatment that has been found to reduce suicidality in adolescents, but there is little literature speaking to its efficacy with the AI/AN population. The transactional-ecological model of suicidality helps identify protective factors that can be bolstered at the individual, familial, community, and spiritual levels to reduce suicidality and suicidal contagion in AI/AN youth. The current study examines a case where DBT was culturally adapted and embedded within a transactional-ecological framework to treat a 14-year-old Navajo female with Major Depressive Disorder with psychotic features who presented to a psychiatric inpatient facility following a suicide attempt. The patient's wish to die was motivated by her belief that her death could lead to positive changes in an extended family system plagued by historical trauma, alcoholism, suicide, and domestic violence. Ongoing assessment was conducted using the Suicide Status Form (SSF), Suicide Probability Scale (SPS), Reasons for Living Scale for Adolescents (RFL-A), and the DBT diary card. Navajo healing traditions were used in conjunction with DBT skills training and enhancement of ecological protective factors. Initial reduction in depression and suicidality was complicated by an increase in homicidal ideation. A comprehensive psychiatric evaluation was completed, and treatment was modified through medication changes, increased mindfulness practice, bolstering support systems, and engagement in a Navajo healing ceremony. Implications for clinicians treating suicidality in Navajo youth are discussed.

Cultural adaptations of dialectical behavior therapy: A systematic review.

“…Two studies added visual images of individuals from the clients’ cultures onto handouts (Arunagiri, 2021; Kamody et al, 2020). Two studies described keeping metaphors from the natural world at the forefront to be more consistent with the Native American worldview (e.g., breathing with the rhythm of wind through the trees; Kinsey, 2014; Kohrt et al, 2017). Another study indicated adopting metaphors that were relevant to Brazilian culture, but did not give specific examples (Cancian et al, 2019).…”

“…Another used Mexican Bingo Rewards Card (La Lotería Mexicana Tarjeta de Recompensa) to reinforce diary card completion (McFarr et al, 2014). Two studies focused on Native Americans incorporated healing circles and sweat lodge ceremonies into the treatment plan (Beckstead et al, 2015; Kohrt et al, 2017). One of these studies also used a genogram to “show respect for collectivist cultures and systemic problems, rather than pathologizing the individual” (Kohrt et al, 2017, p. 90).…”

“…Three studies acknowledged the role of intergenerational or historical trauma (Kinsey, 2014; Kohrt et al, 2017; Mercado & Hinojosa, 2017). For example, one study used a genogram to illustrate the intergenerational nature of trauma, and to highlight the importance of the client’s connection to the tribe (Kohrt et al, 2017). One study acknowledged acculturative stressors and challenges unique to being an immigrant (Cheng & Merrick, 2017).…”

“…For example, Beckstead et al (2015) consulted with tribal leaders and added a treatment component that included a credentialed medicine man/spiritual counselor from the local tribe who provided traditional tribal practices of weekly sweat lodge ceremonies, smudging ceremonies, and talking circles (Beckstead et al, 2015). Similarly, in another study participants underwent a traditional healing ceremony (Kohrt et al, 2017). One study added an additional skill of "meaning making" where participants created new meanings through living one's values, engaging in mentorship and civic duty, and processing intergenerational trauma (Kinsey, 2014).…”

Cultural Adaptations to Psychotherapy

“…At the outset of treatment, Maríñez-Lora and Cruz respected their client’s autonomy to remain in her romantic relationship, which was marked by serious interpersonal violence, and worked with the client to target important therapeutic outcomes of importance to her, which targeted traditional cultural roles. For some cases, mid-treatment clinical emergencies such as suicidality, homicidality, and cutting behaviors necessitated pauses in structured treatment to focus on risk assessment and management (Binkley & Koslofsky, 2016; Cumba-Avilés, 2016; Kohrt et al, 2016). Also, there were instances when treatment needed to focus on problem solving with clients to support their ability to meet treatment goals (Benson-Flórez et al, 2016).…”