Culturally Adapting Adolescent Dialectical Behavior Therapy for Alaska Native Adolescents

Alaska Native and American Indian (AN/AI) youth constitute the highest risk population for suicidal thoughts and behaviors (STBs) of all racial/ethnic groups in the US, primarily due to colonization, historical trauma, and lack of access to culturally responsive evidence-based interventions (EBIs). This is particularly true in Alaska, where the suicide rates among Alaska Native (AN) youth are over 10x higher than those of their non-AI/AN counterparts nationwide. In addition to contextual risk factors faced by all residents of Alaska (e.g., limited sunlight, cold climate), AN youth are impacted by the ongoing consequences of intergenerational, historical, and culture-based trauma, including disproportionate exposure to adverse childhood experiences (e.g., parental substance use), community exposure to suicide, loss of land, and discrimination. This long history of systematic oppression has been identified as a primary driver of the disparities in STBs observed in AN vs. non-AN youth living in Alaska. Adolescent Dialectical Behavior Therapy (DBT-A) is a family-based, principles-driven, third-wave form of cognitive behavioral therapy that incorporates acceptance- (e.g., mindfulness) and change-based (e.g., emotion regulation) strategies to help emotionally dysregulated adolescents build “lives worth living.” Although DBT-A constitutes the most efficacious EBI for multi-diagnostic youth experiencing STBs, AN youth have been largely excluded from prior DBT-A trials, precluding a true evaluation of the potential fit or efficacy of DBT-A for this high-risk population. DBT-A is a strong candidate for cultural adaptation due to the lack of AN representation in prior trials; diversity with respect to etiological factors driving STBs among AN peoples; and its inherently multicultural dialectical philosophy, which consistent with AN tradition. Culturally-adapted EBIs result in increased acceptability and efficacy and are up to five times more likely to result in clinical remission. To fill these gaps and address a major health inequity, the goals of the current study are to: 1) partner with the AN community and elucidate key factors driving STBs among AN youth as well as barriers and facilitators to implementation of the intervention; 2) iteratively adapt DBT-A in collaboration with AN youth and community stakeholders; 3) conduct a pilot RCT trial (N = 48) of the adapted “DBT-A-AN” intervention vs. Enhanced Treatment As Usual to examine acceptability, feasibility, and preliminary clinical outcomes, mechanisms, and culturally-relevant protective factors. The proposed K23 will further solidify the applicant’s expertise in DBT/STBs and facilitate her development as an independent investigator via training in qualitative and mixed methods for intervention development and cultural adaptation; community-engaged clinical trials methodologies; and Alaska Native history, culture, health, and ethics. This study is directly aligned with NIMH’s new Strategic Framework on Youth Mental Health Disparities and Priority 1 of NIMH’s health disparities agenda: “to investigate ways to reduce suicide and suicidal behavior among specific underserved and minoritized populations.” Results will inform a fully-powered trial of “DBT-A-AN.”