emily cooney, kirsten davis, pania thompson, julie wharewera-mika & joanna stewart

Feasibility of researching Dialectical Behaviour Therapy for

suicidal and self-injuring adolescents

Emily Cooney, Kirsten Davis, Pania Thompson, Julie Wharewera-Mika & Joanna Stewart

Why do this study?

• Self-harm remains a significant problem for adolescents in our country. Despite several trials focussing on treatment for self-harm, we don’t really know what works for suicidal young people.

• Dialectical Behaviour Therapy (DBT) seems effective for adults with chronic suicidality and severe emotional instability (Linehan et al, 1991, 1993, 2006, McMain et al., 2009, Verheul et al., 2003)

• Field trials evaluating adaptations of DBT for use with adolescents suggest that DBT shows promise for young people (Goldstein et al., 2007, Katz et al., 2004, Rathus & Miller, 2002).

But before we can do a big study….

…..we have some big questions

? Is comprehensive DBT acceptable to adolescents, families and clinicians in New Zealand?

? Is random assignment acceptable to suicidal adolescents, their families and treatment services in New Zealand?

? Are our assessments and screens feasible and acceptable? ? Will emotionally vulnerable adolescents tolerate the

screening and assessment measures? ? What participant retention rate can we expect?

Feasibility questions

Participants

Young people (and their families) seen at two government-funded community mental health outpatient services who

– were aged between 13 and 18 years*– had self-injured or attempted suicide in the

previous 3 months– didn’t meet criteria for a psychotic disorder or

life-threatening Anorexia Nervosa– didn’t have an intellectual disability– could speak and read English

• Self-harm• Suicidal ideation and reasons for living• Substance use• Emotion Regulation • Therapist burnout

We measured

DBT• Multifamily skills groups• Individual therapy• 24/7 phone consultation• Consultation team for therapists• Family sessions and parent sessions as

needed

TAU• Depended on what the team, therapist and

family thought would be helpful• Range of therapy approaches, with

cognitive-behavioural therapy being the most common treatment

• Provided by clinical psychologists, social workers, occupational therapists, and alcohol & drug counsellors

• Medication

• Respite care

• Hospital

If needed, participants in both conditions could access:

2 not eligible2 not eligible

15 (30%) declined15 (30%) declined

2929

50 young people and families had an orientation meeting

50 young people and families had an orientation meeting

Screening assessmentScreening assessment

DBT = 14DBT = 14TAU = 15TAU = 15

4 discontinued during the

assessments

4 discontinued during the

assessments29 completed the pre-treatment

assessment29 completed the pre-treatment

assessment

Ethnicities of participants

UK10%

South African7%

NZ European77%

Other European

3%NZ Māori

3%

Pre-treatment characteristics of DBT and TAU participants

Treatment condition

Dialectical Behaviour Therapy (N=14)

Treatment as Usual (N=15)

Gender - female - n (%) 10 (71%) 12 (80%)Age - mean (SD) 16.2 (.98) 15.7 (1.1)# self-harm acts in past 3 months – median (SD) 7.5 (17.6) 4 (10.1)

At school - n (%) 9 (64%) 10 (67%)

At work - n (%) 1 (7%) 3 (20%)

Structured activity - n (%) 10 (71%) 11 (73%)

Site - North - n (%) 11 (79%) 14 (93%)

Kia tupato! While nosing through these results, we can’t draw many conclusions about how the treatments compare

• Variable assessment times• Small n• Differences between groups

before they began treatment

Treatment engagement

• 1/14 DBT participants dropped out (4/15 TAU participants ‘dropped out’)

• The mean percent of sessions missed was 9% of individual sessions, and 12% of group sessions for adolescents in DBT (the mean percent of individual sessions missed was 29% for TAU participants).

DBT TAU

Treatment condition Mean SD Mean SD

Individual sessions attended 22.6 6.4 6.5 4.1

Individual sessions not attended 1.9 1.8 3 3.8

Group sessions attended 20.3 5.3 0 0

Group sessions not attended 2.6 3.1 0 0

Family sessions attended 8 3.1 3.1 3.3

Med reviews attended 2.4 2.2 1.6 2.9

Parent sessions attended 3.9 4.1 0.5 0.7

Means and standard deviations of sessions attended and not attended across the 6 months following pre-treatment assessment

Assessment period321

Per

cen

t at

tem

pti

ng

su

icid

e

60%

40%

20%

0%

Treatment as UsualDialectical Behaviour Therapy

Treatment condition

3/14 0/15 2/14 1/159/14 9/15

Results of focus group with DBT participants

• Found DBT valuable and worthwhile

• Parents wanted their own support

• Treatment ending seemed arbitrary and was too abrupt

DBT therapists

• Adherence ratings comparable to “gold-standard” DBT outcome trials

• Therapist burnout scores were within the ‘average’ range before and after treatment

• Team support and adherence feedback were critical

Lessons learned so far• Randomisation is acceptable to families

and clinicians. Dual roles of research staff complicate this

• Consider risk factors for self-harm when deciding how to randomise

• Treatment ending has to be managed very carefully

• Contagion is potentially a greater concern than with adults

• Consider recruiting outside of services

Acknowledgements

• staff from Auckland DHB• Dr. Sue Crengle • Dr. Sarah Fortune • the families who took

part in this research • Dr. Melanie Harned • Dr. Simon Hatcher • Dr. Kathryn Korslund • Dr. Marsha Linehan

• Dr. Sally Merry• Dr. Alec Miller • Dr. Jill Rathus • the research therapists

(Mike Batcheler, Helen Clack and Ben Te Maro)

• Sharon Rickard • Amy Rosso • Dr. Paul Vroegrop• staff from Waitemata

DHB

• This study was funded by the New Zealand Ministry of Health• We are very grateful to the following people for their help and

support: