feasibility of researching dialectical behaviour therapy for suicidal and self-injuring adolescents...
TRANSCRIPT
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Feasibility of researching Dialectical Behaviour Therapy for
suicidal and self-injuring adolescents
Emily Cooney, Kirsten Davis, Pania Thompson, Julie Wharewera-Mika & Joanna Stewart
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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).
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But before we can do a big study….
…..we have some big questions
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? 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
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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
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• Self-harm• Suicidal ideation and reasons for living• Substance use• Emotion Regulation • Therapist burnout
We measured
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DBT• Multifamily skills groups• Individual therapy• 24/7 phone consultation• Consultation team for therapists• Family sessions and parent sessions as
needed
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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
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• Medication
• Respite care
• Hospital
If needed, participants in both conditions could access:
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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
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Ethnicities of participants
UK10%
South African7%
NZ European77%
Other European
3%NZ Māori
3%
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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%)
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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
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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).
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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
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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
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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
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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
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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
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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: