A randomized controlled trial published in Borderline Personality Disorder and Emotion Dysregulation indicates that a dialectical behavior therapy (DBT)-based skills training program is more effective than a single-session psychoeducational intervention for specific psychological outcomes in family caregivers of individuals with suicide behavior disorder (SBD). The study, led by Jose H. Marco-Salvador and colleagues, involved 108 caregivers who were randomized to either the Family Connections (FC) intervention or a psychoeducational intervention (PI). While both groups showed improvements in caregiver burden, the FC group demonstrated superior results in family empowerment, validation behaviors, and stress reduction, suggesting that structured multi-component therapy may offer distinct benefits over brief informational sessions for this vulnerable population.
The research addresses a significant gap in mental health care, as family members of individuals who have attempted suicide often experience intense feelings of guilt, depression, hopelessness, and burnout. Although previous studies have suggested that psychoeducational interventions can improve caregiver burden and that DBT helps reduce depression and validating behaviors, no prior research had directly compared the differential efficacy of these two approaches in caregivers of patients diagnosed specifically with SBD. The study aimed to determine whether the DBT-based model provided additional therapeutic value compared to standard psychoeducation in this specific clinical context.
The study was designed as a superiority trial with a two-arm randomized controlled design. Participants were recruited from 11 mental health services in Spain, and the SBD diagnostic status was established by clinical psychologists at the referring specialized treatment centers. Caregivers were included if they were caring for a patient with an SBD diagnosis and provided informed consent. Exclusion criteria included a personal diagnosis of psychosis, schizophrenia, substance dependence, or dementia.
The intervention group received the Family Connections program, which consisted of 12 weekly two-hour group sessions delivered via online videoconference over three months. This program included six therapeutic modules covering psychoeducation on suicide, emotion regulation skills, interpersonal effectiveness, validation strategies, radical acceptance, and problem-solving. In contrast, the control group received a single three-hour group session focused on emotional expression and psychoeducation regarding suicide epidemiology, risk factors, and evidence-based treatments. Both interventions were delivered by general health psychologists with master’s degrees, and adherence to the FC protocol was monitored through weekly clinical sessions and subjective rating scales.
The primary outcomes measured were caregiver burden, assessed using the Burden Assessment Scale (BAS), and the frequency of suicide attempts and non-suicidal self-injury (NSSI) in the patients. Secondary outcomes included family empowerment, depression, anxiety, stress, difficulties in emotion regulation, quality of life, and validating or invalidating behaviors. The study employed intention-to-treat principles using mixed-effects models to analyze pre- and post-treatment data, allowing for the handling of missing data through full information maximum likelihood estimation. This statistical approach ensured that all available observations contributed to the parameter estimation.
Results indicated that both the FC and PI conditions were effective in reducing both objective and subjective caregiver burden. However, there was no statistically significant interaction effect between time and experimental condition for burden, suggesting that the single-session psychoeducational intervention was equally effective in alleviating this specific burden. The effect size for subjective burden was higher in the FC condition (Cohen’s d = 0.58) compared to the PI condition (Cohen’s d = 0.27), but the difference between groups was not statistically significant. This finding supports the notion that even brief informational interventions can significantly impact caregivers’ perceived burden.
Participants in the FC condition showed significantly greater improvements in family empowerment, with an interaction effect between time and condition (F = 13.19, p < .001). Similarly, the FC group experienced greater reductions in stress symptoms compared to the PI group (F = 4.29, p < .04). Furthermore, the FC intervention was more effective in increasing validation behaviors, a core component of DBT, with a significant interaction effect (F = 4.41, p = .03). These results suggest that the structured skills training in FC addresses specific relational and emotional dynamics that a single psychoeducational session does not.
The study also examined the frequency of NSSI and suicide attempts in the patients under the care of the participating caregivers. While the FC condition showed a statistically significant improvement in the frequency of NSSI (F = 4.21, p = .04), the PI condition did not (F = 0.78, p = .37). However, there was no significant interaction effect between the two conditions. For suicide attempts, all participants improved at post-treatment, but neither group achieved a statistically significant reduction within their respective conditions. The authors note that the reduction in NSSI in the FC group may be linked to the development of validation, emotion regulation, and interpersonal effectiveness skills, which can alter family dynamics and reduce interpersonal stress.
Limitations of the study include the lack of a follow-up period, which prevents the assessment of long-term maintenance of results. Additionally, the assessment of NSSI and suicide attempts was based on caregiver reports, which may introduce bias or inaccuracies. The imbalance in treatment dose, with 24 hours of therapy in the FC group versus a single three-hour session in the PI group, limits the ability to attribute differences solely to DBT-specific components rather than general factors like therapist contact and group support. The sample size of 75 participants who completed the study may have reduced statistical power, potentially limiting the detection of smaller but clinically meaningful effects.
The findings suggest that while psychoeducation is a valuable tool for reducing immediate caregiver burden, a comprehensive DBT-based skills training program offers additional benefits in terms of empowerment, stress management, and relational validation. These results support the implementation of structured multi-component interventions in mental health services to address the complex needs of families affected by suicide. The study highlights the importance of providing caregivers with practical skills to manage emotional dysregulation and improve communication, which may ultimately contribute to better outcomes for both caregivers and their relatives.
The study population consisted primarily of female caregivers, with 78% of participants identifying as women and 22% as men. The mean age of the caregivers was 50.16 years, with a standard deviation of 8.94, and the age range extended from 20 to 68 years. Most participants were mothers of the patients, accounting for 58.2% of the sample, while fathers represented 13.2%. Other relationships included children, siblings, and partners, reflecting the diverse family structures involved in caregiving for individuals with suicide behavior disorder. Approximately 62.6% of the caregivers were currently working, indicating that many participants balanced professional responsibilities with the demands of caring for a relative with a serious mental health condition. All participants were non-professional family caregivers, and the SBD diagnostic status of their relatives was established by clinical psychologists at the referring specialized treatment centers.
At baseline, 30.8% of the caregivers met the criteria for a mental disorder according to the DSM-5-TR. Specifically, 15 participants were diagnosed with an anxiety disorder, 10 with a depressive disorder, and three with an eating disorder. The remaining 69.2% did not meet the diagnostic criteria for any mental disorder. The demographic and clinical characteristics of the participants in the two treatment conditions were comparable at baseline, with no statistically significant differences observed in age, gender, marital status, educational level, or income.
The Family Connections intervention was grounded in the Interpersonal Theory of Suicidal Behavior, which posits that suicide attempts are influenced by perceived burdensomeness, thwarted belongingness, and the acquired capacity for suicide. The psychoeducational modules within the FC program aimed to address these theoretical components by teaching caregivers how to create an environment of mutual support and respect, thereby reducing feelings of perceived burden and frustrated belonging. The program also included specific skills training in emotion regulation, interpersonal effectiveness, and problem-solving, which are core components of dialectical behavior therapy. By focusing on these mechanisms, the intervention sought to equip caregivers with practical tools to manage their own emotional responses and improve their interactions with the patient.
The statistical analysis employed mixed-effects models with full information maximum likelihood estimation to handle missing data, which was primarily observed in the post-treatment assessment. This method allowed all available observations to contribute to the parameter estimation, avoiding the need for additional data imputation. The intention-to-treat principle was applied, ensuring that the analysis included all participants who were randomized, regardless of whether they completed the intervention. Effect sizes were calculated using Cohen’s d, providing a standardized measure of the magnitude of the differences between the treatment conditions.
The study’s findings contribute to the growing body of evidence supporting the use of dialectical behavior therapy-based interventions for caregivers of individuals with suicidal behavior. While the single-session psychoeducational intervention was effective in reducing caregiver burden, the multi-component FC program offered additional benefits in terms of empowerment, stress reduction, and validation behaviors. These results suggest that a more intensive, skills-based approach may be necessary to address the complex psychological needs of caregivers who are dealing with the ongoing challenges of supporting a relative with SBD.
Subject of Research: Dialectical behavioral therapy-based skills training program for family members of suicide attempters: a randomized controlled trial
Article Title: Dialectical behavioral therapy-based skills training program for family members of suicide attempters: a randomized controlled trial
Article References: Marco-Salvador, J. H., Perez-Rodriguez, S., Diaz-Sanahuja, L., Grau, A., Paredes-Mealla, M., & Guillen, V. (2026). Dialectical behavioral therapy-based skills training program for family members of suicide attempters: a randomized controlled trial. Borderline Personality Disorder and Emotion Dysregulation, 13(1), Article 29. https://doi.org/10.1186/s40479-026-00353-3
Image Credits: AI Generated
DOI: 10.1186/s40479-026-00353-3
Keywords: Dialectical, behavioral, therapy-based, skills, training, program, family, members, suicide, attempters, randomized, controlled
