An evaluation of the skills group component of DBT-A for parent/guardians: a mixed methods study.

OBJECTIVES: Previous research indicates that dialectical behaviour therapy for adolescents (DBT-A) is effective in treating emotionally dysregulated adolescents with self-harm and/or suicidal ideation. As part of the DBT-A programme, parents attend the weekly skills group with their child. However, few studies have evaluated parental outcomes in DBT-A. This multi-site study aims to explore the outcomes and experiences of parents who participated in a 16-week DBT-A programme in Ireland. METHODS: This study was conducted in community-based child and adolescent mental health services (CAMHS) in the national public health system in Ireland. Participants were parent/guardians of adolescents attending a DBT-A programme in their local CAMHS. Participants attended the group skills component of the DBT-A programme. This study utilised a mixed methods approach where both quantitative and qualitative data were collected from participants. Self-report measures of burden, grief and parental stress were completed at pre-intervention, post-intervention and 16-week follow-up. Qualitative written feedback was obtained at post-intervention. The data were analysed using multi-level linear mixed-effects models and content analysis. RESULTS: One hundred participants (76% female) took part in this study. Significant decreases were reported for objective burden, subjective burden, grief and parental stress from pre- to post-intervention (p < 0.01). Participants reported that the skills component of DBT-A was useful in meeting their own needs and the needs of their child. DISCUSSION: DBT-A shows promise for parents as well as their adolescent child. Future studies should evaluate changes to family relationships following completion of the programme and also include controlled comparison groups.

Dialectical Behavior Therapy for Individuals With Borderline Personality Disorder: A Systematic Review of Outcomes After One Year of Follow-Up.

Dialectical behavior therapy (DBT) has a growing evidence base for treating individuals with a diagnosis of borderline personality disorder (BPD). Less is known about the long-term effects of the treatment, which is an important consideration when treating a chronic disorder such as BPD. The current systematic review explores outcomes after 1 year of follow-up for individuals who engaged in DBT. A systematic search of four databases (PsycInfo, PubMed, Scopus, CINAHL) was performed. Controlled and uncontrolled studies were included. A total of 10 articles were identified pertaining to seven primary research studies. Overall, improvements following treatment with DBT extended over the follow-up period. These findings suggest that the effects of DBT in treating BPD are maintained at least 1 to 2 years postintervention. Given a lack of long-term follow-up in randomized controlled trials, evidence for the efficacy of DBT in the longer term is unclear.

Individuals who report having benefitted from dialectical behaviour therapy (DBT): a qualitative exploration of processes and experiences at long-term follow-up.

BACKGROUND: Qualitative research in the area of DBT is limited, particularly at follow-up. The current study explored the follow-up experiences of individuals who previously received a diagnosis of borderline personality disorder and self-report having benefitted from DBT at the time of treatment. METHODS: Individuals who completed 12 months of standard DBT and were a minimum of two years post-completion were recruited. Individual semi-structured interviews were completed with a total of twelve participants. RESULTS: A thematic analysis generated three main themes which indicated that participants found DBT had a positive impact on their lives in the years after the programme and enabled further development; gave them control over their lives and the ability to manage setbacks and difficult situations; and contributed to healthier and more meaningful relationships with others. CONCLUSIONS: The findings of this study indicated that DBT contributed positively to the participants' lives and helped advance their recovery in the years after the programme. Despite the positive impact of DBT, participants required further support in the years following the intervention. Clinical and research implications of these findings are discussed.

Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach.

BACKGROUND: The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation. METHODS: A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis. RESULTS: Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management. CONCLUSIONS: The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.

Multisite Implementation and Evaluation of 12-Month Standard Dialectical Behavior Therapy in a Public Community Setting.

Dialectical behavior therapy (DBT) is an effective intervention for treating adults with emotional and behavioral dysregulation. The National DBT Project, Ireland was established in 2013 to coordinate the implementation of DBT across public community mental health settings at a national level. This study describes the implementation and evaluation of DBT across multiple independent sites in adult mental health services (AMHS). The Consolidated Framework for Implementation Research was used to guide this national implementation where barriers and facilitators to DBT implementation were considered. Nine AMHS teams completed DBT training and delivered the standard 12-month program. One hundred and ninety-six adults with borderline personality disorder participated in the program, and outcome measures were recorded at four time points. Significant reductions on outcome measures, including frequency of self-harm and suicidal ideation, were observed. This study highlights that DBT can be successfully implemented in community mental health settings as part of a coordinated implementation.

Dialectical behaviour therapy for adolescents: a comparison of 16-week and 24-week programmes delivered in a public community setting.

BACKGROUND: Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. Previous studies have reported on varying lengths of treatment, however, and optimal treatment duration has not yet been identified. While the treatment developers initially proposed a 16-week programme, they have more recently recommended an extension to 24 weeks. This study compares outcomes for adolescents and parent/guardians who participated in 16- and 24-week DBT-A programmes in a community setting. METHODS: Eighty-four adolescents and 100 parent/guardians participated in 16-week DBT-A, while 68 adolescents and 67 parent/guardians participated in the 24-week programme. Outcome measures for adolescents included the presence and frequency of self-harm, suicidal ideation and depression; and for parents were burden, grief and parental stress. Outcomes were assessed at pre- and postintervention. Linear mixed-effects models were used to estimate the treatment duration effect (24-week vs. 16-week) utilising all available data at pre- and postintervention. RESULTS: Data analyses showed a reduction in the presence and frequency of self-harm at postintervention for adolescents in both programmes. Both adolescent and parent participants in the 16- and 24-week programmes also showed changes indicating significant improvement on all self-report outcome measures (p < .05). A treatment duration effect was identified with adolescents in the 24-week programme reporting greater gains on measures of suicidal ideation and depression (p < .05). However, drop-out rates were higher for the 24-week programme. CONCLUSIONS: The findings of the current study indicate that 24-week DBT-A may have additional benefits in comparison to 16-week DBT-A in terms of further reductions in suicidal ideation and depression. Given the nature of this study, it was not possible to explore a potential time effect, however, so these results should be interpreted with caution. Further research will assist in determining an optimal programme duration of DBT-A.

Innovations in Practice: Dialectical behaviour therapy for adolescents: multisite implementation and evaluation of a 16-week programme in a public community mental health setting.

BACKGROUND: Dialectical behaviour therapy for adolescents (DBT-A) is an intervention with a growing evidence base for treating adolescents with emotional and behavioural dysregulation. This study describes the implementation and effectiveness of 16-week DBT-A across multiple sites in publicly funded child/adolescent mental health services (CAMHS) in Ireland. METHOD: The Consolidated Framework for Implementation Research was used to guide this national implementation. Fifty-four clinicians from seven CAMHS teams completed DBT training and delivered the 16-week DBT-A programme. Eighty-four adolescents with emotional and behavioural dysregulation participated in the intervention and outcome measures were administered at preintervention, postintervention and 16-week follow-up. RESULTS: Significant reductions on all outcome measures were observed for DBT-A participants including presence and frequency of self-harm, suicidal ideation and depression. Reductions in the number of acute inpatient admissions, bed days and emergency department visits were also reported. CONCLUSIONS: DBT-A can be successfully implemented in CAMHS settings and yield positive outcomes for adolescents with emotional and behavioural dysregulation.

Correction to: Dialectical behaviour therapy for treating adults and adolescents with emotional and behavioural dysregulation: study protocol of a coordinated implementation in a publicly funded health service.

Upon publication of the original article (1) it was highlighted by the authors that there was just one error in the manuscript in the 'Sample size' subsection of the Methods/Design.

Dialectical behaviour therapy for treating adults and adolescents with emotional and behavioural dysregulation: study protocol of a coordinated implementation in a publicly funded health service.

BACKGROUND: In the Republic of Ireland, borderline personality disorder (BPD) is a feature of approximately 11-20% of clinical presentations to outpatient clinics within mental health services. These estimates are similar to other countries including the UK and USA. Dialectical behaviour therapy (DBT) is an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with BPD. While a number of randomised controlled trials (RCTs) have demonstrated the efficacy of DBT, there is limited research which evaluates the effectiveness of this model when applied to real world settings. Funding was secured to co-ordinate DBT training in public community-based mental health services across Ireland. As no other study has evaluated a co-ordinated national implementation of DBT, the current study proposes to investigate the effectiveness of DBT in both adult and child/adolescent community mental health services across Ireland, evaluate the coordinated implementation of DBT at a national level, and complete a comprehensive economic evaluation comparing DBT versus treatment-as-usual. METHODS/ DESIGN: This study takes the form of a quasi-experimental design. Individuals attending community mental health services who meet criteria for participation in the DBT programme will be allocated to the intervention group. Individuals who live in areas in Ireland where DBT is not yet available, and individuals who choose not to participate in the intervention, will be invited to participate in a treatment-as-usual comparison group. Self-report clinical measures and health service use questionnaires for DBT participants (and parent/guardians as appropriate) will be administered at pre-, mid- and post-intervention, as well as follow-up for participants who complete the intervention. Survey and interview data for DBT therapists will be gathered at three time points: prior to DBT training, 6 months after teams begin delivery of the intervention, and 2 years following training completion. DISCUSSION: It is anticipated that the results of this study will provide evidence for the effectiveness of DBT for patients, and report on recommendations regarding best practice guidelines for implementation of DBT and its economic merit in a publicly funded service. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03180541 ; Registered June 7th 2017 'retrospectively registered'.

Standard 12 month dialectical behaviour therapy for adults with borderline personality disorder in a public community mental health setting.

BACKGROUND: Dialectical behaviour therapy (DBT) is noted to be an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with borderline personality disorder (BPD). Evidence for the effectiveness of DBT in publicly funded community mental health settings is lacking however. No study to our knowledge has been published on the effectiveness of a 12 month standard DBT programme without adaptations for individuals with BPD in a publicly funded community mental health setting and no study has included data across multiple time-points. The main objective of the current study was to determine if completion of a 12 month DBT programme is associated with improved outcomes in terms of borderline symptoms, anxiety, hopelessness, suicidal ideation, depression and quality of life. A secondary objective includes assessing client progress across multiple time-points throughout the treatment. METHODS: Fifty-four adult participants with BPD completed the standard DBT programme across four sites in community mental health settings in the Republic of Ireland. Data was collected by the DBT therapists working with participants and took place at 8 week intervals across the 12 month programme. To explore the effects of the intervention for participants, linear mixed-effects models were used to estimate change utilising data available from all time-points. RESULTS: At the end of the 12 month programme, significant reductions in borderline symptoms, anxiety, hopelessness, suicidal ideation and depression were observed. Increases in overall quality of life were also noted. In particular, gains were made during the first 6 months of the programme. There was a tendency for scores to slightly regress after the six-month mark which marks the start of the second delivery of the group skills cycles. CONCLUSIONS: The current study provides evidence for the effectiveness of standard DBT in publicly funded community mental health settings. As participants were assessed at the end of every module, it was possible to observe trends in symptom reduction during each stage of the intervention. Despite real-world limitations of applying DBT in community settings, the results of this study are comparable with more tightly controlled studies. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03166579; Registered May 24th 2017 'retrospectively registered'.