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 eligible 15 (30%) declined young people and families had an orientation meeting Screening assessment DBT = 14 TAU = 15 4 discontinued during the assessments 29 completed the pre-treatment assessment

Ethnicities of participants

Pre-treatment characteristics of DBT and TAU participants

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).

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

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