Trial of Dialectical Behaviour Therapy Interventions for Young People Experiencing Difficulty Regulating Emotions

INTERVENTION: Randomised Controlled Trial of DBT Interventions for Young People with Emotion Dysregulation ‐ Arm 1: 8‐week intervention ‐ Arm 2: 16‐week intervention Intervention Description: This is a study of Dialectical Behaviour Therapy (DBT) interventions for young people (aged 16‐25 years). Participants in this study will be randomly allocated to a 16‐week or 8‐week Dialectical behaviour therapy (DBT)‐informed program. The 8‐week group will receive weekly 90‐minute DBT‐informed skills training, in a group setting (approx. 10 people). The 16‐week groups will receive an intensive DBT‐informed intervention (including weekly 90‐minute group skills training sessions, weekly 50‐minute individual counselling, and optional phone counselling with a DBT practitioner 12 hours per day). Both DBT interventions will be delivered by qualified mental health practitioners, certified in DBT, who are working at Headspace, Southport. Rationale: Previous research has predominantly examined the efficacy of DBT in reducing self‐harming or suicidal tendencies, emotion regulation and BPD symptoms in adult populations, revealing support in a range of therapeutic settings (Groves, Backer, Van den Bosch & Miller, 2011; Stoffers et al., 2012). Success of the therapy with adult populations has prompted its adaptation to youth populations, but empirical research on DBT for youth is more limited. While much of the research on adolescents/young adult populations is quasi‐experimental, research to date presents promising findings. Participants: The young people in this will be referred to Headspace Southport by local clinicians. Referred young people will be screened by the research team, via telephone, before being randomised to a DBT group (16 week or 8 week). To be included, participants must meet a certain level of symptoms of emotion dysregulation and borderline personality disorder. 16‐week DBT program Physical and informational Materials used: o participant information sheet o diary cards o Online surveys at baseline, 8 weeks, 16 weeks, and 24 weeks (using qualtrics). o Fidelity checklists for group and individual sessions o Attendance sheets for group and individual sessions o DBT Training manual/group skills weekly‐plan for DBT providers o DBT‐relevant handouts given to participants during DBT group‐ skills sessions and individual DBT counselling sessions, for the purposes activities or self‐learning. Procedures: Pre‐commitment work: Part of the full DBT program is pre‐commitment work. To include this component of DBT in the RCT, we will randomise participants to their group (8‐week or 16‐week) just over two weeks before their first DBT session. This will allow two weeks for each clinician to engage with the 16‐week client(s) (participants) they have been assigned, and complete pre‐commitment work with them. This work will include up to 3 brief engagements to build rapport, clarify the details of the program, and complete various 'commitment to therapy' contracts with the client. 16‐week Program Details: o Weekly DBT group skills workshops (90 minutes) and weekly individual DBT counselling (50 minutes) with young person’s assigned DBT practitioner. Individual sessions follow Marsha Linehan’s DBT model for individual counselling, and are aimed at ‘concreting’ skills learned in group sessions, and addressing personal issues. Who will deliver the intervention? Mode of delivery ‐ face to face group sessions (group size: approximately 10 people per group). ‐ Telephone for initial screening ‐ Telephone engagement by DBT practitioners for initial contact ‐ Telephone coac CONDITION: Borderline Personality Disorder Emotion Dysregulation Note: The material delivered to participants during DBT group skills sessions was created by the lead clinician on the project, a senior social worker at headspace Southport, trained in DBT. The materials were created, based on the guidelines set out by DBT founder, Marsha Linehan in her book “DBT Skills Training Manual – Second Edition” (Linehan, 2015). See reference list in “public notes” section for citation. While the DBT group skills sessions closely followed the Linehan’s DBT manual, the sessions also contained some activities (e.g. mindfulness activities), that were added by the lead clinician, based on clinical experience. All DBT practitioners followed the same structure set out by the lead clinician, for each DBT group skills session. The same manual was used by DBT clinicians to guide their individual DBT counselling sessions, with clients in the 16‐week group. o DBT group skills sessions and individual counselling sessions are based on Marsha Linehan’s (psychologist who created DBT) model of DBT, as trained by Peter King at CMHE (centre for mental health education) o Certified mental health professionals (e.g. psychologists, social workers, occupational therapists) working at Headspace (Southport) who are trained and certified to deliver Dialectical Behaviour Therapy (by Peter King from CMHE). PRIMARY OUTCOME: Borderline Personality Disorder Symptoms ; ; ‐ Measured using the International Personality Disorder Examination (IPDE) (Loranger, Janca & Satorius, 1997): The IPDE is a semi‐structured clinical interview designed as a standardised diagnostic tool for identifying mental health disorders. The scale being used in this experiment uses a dichotomous (true/ false) scoring procedure to identify personality traits indicative of a personality disorder. The subscale for borderline personality disorder will be used. ; Emotion Regulation ; ; ‐ Measured using the Difficulties in Emotion Regulation Scale (DERS) (Gratz ; & Roemer, 2004): The DERS was designed to be a comprehensive measure of emotional dysregulation. This is achieved by tapping into the emotional dimensions of; awareness and understanding of emotion, acceptance of emotions, ability to engage in goal directed behaviour whilst refraining from detrimental behaviours when experiencing negative emotions and access to effective emotion regulation strategies. The DERS achieves this by using a five point Likert scale ranging from 1 “almost never” to 5 “almost always”. The final score of the DERS provides insight into how the respondent regulates their emotions, their awareness of their own emotional state and their ability to control their emotions. ; SECONDARY OUTCOME: Functioning ; ; ‐ Measured using the Multidimensional Assessment of Adolescent Functioning (MAFS) (Wardenaar, Johanna, Wigman, et. al., 2013): The MAFS is a 23 item scale, designed to measure everyday functioning in adolescents. The is achieved by use of three separate subscales that tap into: family‐related functioning, peer‐related functioning and general functioning. The MAFS uses a four point Likert scale that ranges from 1 “not at all/ rarely” to 4 “always/ almost always”. The subscales each provide a separate snapshot into a different domain of functioning and when brought together produce simple yet effective evaluation of the respondents general functioning. ; Mindfulness ; ‐ Measured using the 5 Facet Mindfulness Questionnaire – Short Form (FFMQ‐SF; Bohlmeijer et al., 2011): The FFMQ‐SF is a 24‐item scale, found to be highly reliable and valid, assessing different aspects of mindfulness. Anxiety ; ; ‐ Measured using the Depression Anxiety Stress Scale (DASS) (Lovibond et al., 1995): The DASS has been designed to measure the magnitude of three significant emotional states; depression, anxiety and stress. This is achieved by use of a four point Likert scale that ranges from 0 “did not apply to me at all” to 3 “applied to me very much or most of the time”. The resulting score provides feedback about how the respondents functioning over the past week and how each of these negative emotions has been effecting them. Childhood Trauma ; ; The CTQ‐SF is a 28‐item screen for maltreatment histories for use with both clinical and non‐referred populations. The questionnaire has been validated with various populations including adolescents (Bernstein et al., 2003). ; Coping Skills ; ; ‐ Measured using the Coping Inventory for Stressful Situations (CISS) (Endler & Parker, 1990): The CISS has been designed to measure task, emotional and avoidance‐orientated coping styles. Respondents are asked to rate their coping styles on a five point Likert scale ranging from 1 “not at all” to 5 “very much”. The three styles of coping reflect the different ways employed by individuals when handling stressful situations and provide insight into whether they react to stress well or poorly. ; Depression ; ; ‐ Measured using the Depression Anxiety Stress Scale (DASS) (Lovibond et al., 1995): The DASS has been designed to measure the magnitude of three significant emotional states; depression, anxiety and stress. This is achieved by use of a four point Likert scale that ranges from 0 “did not apply to me at all” to 3 “applied to me very much or most of the time”. The resulting score provides feedback about how the respondents functioning over the past week and how each of these negative emotions has been effecting them. ; Impulsivity ; ; ‐ Measured using the Short UPPS‐P Impulsive Behavior Scale (S‐UPPS‐P; Cyders et al., 2014). The UPPS‐P model of impulsivity proposes that impulsivity as a multi‐faceted and multi‐dimensional construct, comprising five impulsive personality traits. Quality of Life ‐ Measured using the Assessment of Quality of Life ‐ 6 Dimensions (AQOL‐6D) (non‐simplified adolescent version) (Richardson, Peacock, Hawthorne, Iezzi, Elseworth, & Day, 2012). The AQOL‐6D measures six dimensions influential to ratings of quality of life then provides a global ‘utility’ score. The dimensions measured are: independent living, relationships, mental health, coping, pain and senses. Severity of Drug Use ; ; Measured using the Australian Treatment Outcomes Profile (ATOP) (Ryan, Holmes, Hunt et. al, 2014): The ATOP is a modified version of the Treatment Outcomes Profile that was adapted for Australian populations. The ATOP is a short instrument that was designed to monitor outcomes in alcohol and drug treatment populations. It assess a range of domains including; substance use, health and well‐being factors over a period of 28 days. ; Stress ; ; Suicidal Ideation: ; ; ; INCLUSION CRITERIA: INCLUSION CRITERIA: · Shows symptoms of emotion dysregulation and/or Borderline Personality Disorder · Has not done DBT before · Is 16‐25 years old ‐ Scores 21.5 or over on the DERS (Difficulties in Emotion Regulation Scale) (Gratz & Roemer, 2004). ‐ Answers True to 3 or more items on the International Personality Disorders Examination (IPDE) (Loanger, Janca & Satorius, 1997). ; ‐ Measured using the Depression Anxiety Stress Scale (DASS) (Lovibond et al., 1995): The DASS has been designed to measure the magnitude of three significant emotional states; depression, anxiety and stress. This is achieved by use of a four point Likert scale that ranges from 0 “did not apply to me at all” to 3 “applied to me very much or most of the time”. The resulting score provides feedback about how the respondents functioning over the past week and how each of these negative emotions has been effecting them. ; ‐ Measured using the Mini‐ International Neuropsychiatric Interview (M.I.N.I.) Suicidality screen (Sheehan et al., 1998): The M.I.N.I. suicidality score is taken from the larger standardised Mini‐ International Neuropsychiatric Interview. As the name suggests, it aims to assess whether the respondent has been suicidal and the magnitude of their suicidality. The scale uses dichotomous response selection with the options being “yes” and “no”.