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Feasibility of Dialectical Behavior Therapy with Suicidaland Self-Harming Adolescents with Multi-Problems:Training, Adherence and RetentionA. J. Tørmoen a , B. Grøholt b , E. Haga a , A. Brager-Larsen c , A. Miller d , F. Walby a f , B.Stanley e & L. Mehlum aa National Centre for Suicide research and Prevention, Institute of Clinical Medicine,University of Oslo , Norwayb Institute of Clinical Medicine, University of Oslo , Norwayc Department of Child and Adolescent Mental Health , Oslo University Hospital, Division ofMental Health and Addiction , Oslo South/North , Norwayd Montefiore Medical Center, Child Outpatient Psychiatry , New York , USAe New York State Psychiatric Institute, Columbia University , New York , USAf Department of Psychiatry , Diakonhjemmet Hospital , Oslo , NorwayAccepted author version posted online: 19 May 2014.Published online: 19 May 2014.
To cite this article: A. J. Tørmoen , B. Grøholt , E. Haga , A. Brager-Larsen , A. Miller , F. Walby , B. Stanley & L. Mehlum(2014): Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training,Adherence and Retention, Archives of Suicide Research, DOI: 10.1080/13811118.2013.826156
To link to this article: http://dx.doi.org/10.1080/13811118.2013.826156
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Feasibility of Dialectical Behavior Therapy with Suicidal and Self-harming Adolescents with Multi-problems: Training, Adherence and Retention
A. J. Tørmoen1, B. Grøholt2, E. Haga1, A. Brager-Larsen3, A. Miller4, F. Walby1,6, B.
Stanley5, L. Mehlum1
1National Centre for Suicide research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway, 2Institute of Clinical Medicine, University of Oslo, Norway, 3Department of Child and Adolescent Mental Health, Oslo University Hospital, Division
of Mental Health and Addiction, Oslo South/North, Norway, 4Montefiore Medical Center, Child Outpatient Psychiatry, New York, USA, 5New York State Psychiatric
Institute, Columbia University, New York, USA, 6Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway
Corresponding author: Anita Johanna Tørmoen, Ph.D. candidate , E-mail :
KEYWORDS: Suicidal behavior, self-harm, psychotherapy, adolescents, treatment
INTRODUCTION
Self-harm among adolescents is a complicated behaviour to treat. Clinical samples of
self-harming adolescents are frequently characterized by affective instability, strong
emotional reactivity and impulsivity (Jacobson et al., 2008; Joiner, Jr. et al., 2005;
Jacobson & Gould, 2007; Nock, 2010; Crowell et al., 2009), and treatment rejection,
drop-out or frequent therapist changes preclude the receipt or completion of treatment
(Trautman et al., 1993; Miller et al., 2007). Self-harm is associated with recurrent
psychosocial problems (Jacobson et al., 2008; Jacobson & Gould, 2007; Tormoen et al.,
2012) and poor long-term outcome (Groholt & Ekeberg, 2009a; Fergusson & Lynskey,
1995). Features of Borderline Personality Disorder (BPD) are often found in adolescents
who self-harm, but BPD is rarely diagnosed in adolescence, even though research has
shown that it may be a valid and reliable diagnosis for this age group (Miller et al., 2008;
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Chanen et al., 2007). Symptoms of BPD in adolescents are related to having other
psychiatric symptoms and functional impairment (Chanen et al., 2007), and are also
found to have negative long term consequences (Winograd et al., 2008). Given the
problems of emotional dysregulation in both self-harming adolescents and BPD patients,
the prevalence of BPD symptoms among adolescents who self-harm, as well as the long
term consequences associated with these symptoms, interventions targeting these
populations are needed. The extent of comorbidity within this patient group makes
adhering to any single traditional treatment protocol problematic, and in fact, traditional
treatments in the cognitive-behavioral spectrum show impaired effectiveness for clients
with personality disorders and self-harm behavior (Steiger & Stotland, 1996; Hazell et
al., 2009; Linehan et al., 1991; Linehan, 1993). One notable exception, is a specialized
treatment program of mentalization-based treatment for adolescents (MBT-A). MBT-A
was found to be superior to TAU in reducing self-harm and depression (Rossouw &
Fonagy, 2012). No other treatment program specially targeting self-harm in adolescents
has so far been shown to reduce self-harm more than usual care, but one study found that
both cognitive analytic therapy and manualized clinical good care equally both reduced
parasuicide (Chanen et al., 2008)
In spite of the seriousness of self-harm, there still is a paucity of empirically supported
treatments targeting self-harm behavior in adolescents. In fact, outpatient treatment
effectiveness studies have often excluded adolescents with self-harm and suicidal
behaviors. Numerous randomized controlled trials have now established Dialectical
Behavior Therapy (DBT) with adults as the most effective treatment for patients with
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Borderline Personality Disorder, repetitive self-harm and suicidal behavior (Linehan et
al., 1994; Linehan et al., 2006; Linehan et al., 1993; Verheul et al., 2003; Koons et al.,
2001; Crowell et al., 2009; Van Den Bosch et al., 2005). DBT was designed to accurately
and effectively target the core symptoms of emotional dysregulation and its subsequent
cognitive, behavioral, self, and interpersonal sequelae.
Adaptations of DBT for adolescents has been developed and provided in various settings
and with various patient groups within which emotional dysregulation is a core symptom
(James et al., 2008; Katz et al., 2004; McDonell et al., 2010; Rathus & Miller, 2002;
Salbach-Andrae et al., 2008; Woodberry & Popenoe, 2008; Fleischhaker et al., 2011;
Goldstein et al., 2007). These treatments all had major deviations from the original
model for adults, considerable variability regarding populations, variability in
descriptions of how and if they adhered to the original DBT protocol, as well as variation
in the structure and format of the treatment. Hence, a recent literature review on DBT for
adolescents concludes that studies with clear descriptions of the intervention, with
intensively trained and adherent therapists are needed (Groves et al., 2012). To date, no
randomized controlled studies (RCT) of DBT for adolescents have been published in a
peer reviewed journal. The present study represents the first research on DBT for
adolescents in Scandinavia. To our knowledge, this is the first study reporting on
feasibility and adherence evaluated by a trained adherence coder documenting adherent
DBT for adolescents.
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The aims of this study were to evaluate feasibility and acceptability of the DBT
treatment approach for adolescents Specifically, the aims were to determine: 1) if
therapists could effectively learn and provide adherent DBT for adolescents, 2) whether
treatment retention among adolescents was possible to achieve in a 16-week DBT
program, 3) if self-harm behavior decreased among those who completed treatment, and
4) if the improvement of those who completed treatment endured over a one year follow
up period.
METHODS
Participants
Participants were 27 adolescents with repeated self-harm behavior recruited from five
child and adolescent psychiatric outpatient clinics in Norway. Inclusion criteria were: 1)
age between 12 and 18 years, 2) more than one lifetime episode of self-harm with one of
the episodes within the last 4 months before referral, 3) three or more criteria of DSM-IV
Borderline Personality disorder, 4) willingness to receive DBT, and 5) ability to speak
Norwegian. Self-harm behavior was defined as an act with a nonfatal outcome in which
the person deliberately engaged in behavior intended to cause harm, such as cutting,
jumping from heights, overdosing or eating non digestible objects (Hawton et al., 2002),
and thus includes both suicidal and nonsuicidal self-harm. Exclusion criteria were 1)
mental retardation, 2) an autism spectrum disorder, 3) psychotic disorder or 4) severe
anorexia nervosa or severe substance abuse disorder requiring specialised treatment. The
clinics screened patients who were newly referred for treatment for current and past
history of self-harm behavior. If screened positively, the patient and the parents were
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invited to a diagnostic interview where the remaining inclusion criteria were checked. A
few additional patients with self-harming behavior were already in other treatment, and,
were transferred to DBT by their therapists after having consulted with the patients and
their parents. Altogether thirty-seven consecutively referred adolescents were evaluated
for inclusion and of these, 27 (73%) fulfilled inclusion criteria and provided both patient
and parental consent to study participation. Seven of the ten who were not included, did
not fulfil the inclusion criteria, and six declined after having been oriented about DBT
comprising both individual therapy and skills group sessions with parents. Three patients
were referred to other treatment because they met exclusion criteria of mental retardation
or psychotic disorder. The study was approved by the Regional Committees for Medical
and Health Research Ethics in South Eastern Norway. Therapy was provided at no cost
to the families, within the framework of the health care system in Norway.
Assessments
Participants were assessed at baseline with structured interviews and self-report
instruments, weekly during the treatment period with self-report instruments and again at
follow up one year after treatment completion with structured telephone interviews.
Interviews were conducted by master’s or doctoral level clinicians trained in the use of
the assessment instruments.
Instruments
DSM-IV Axis I diagnoses were made by the semi-structured Schedule for Affective
Disorders and Schizophrenia, child version (K-SADS) (Kaufman et al., 1997). History of
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psychiatric treatment was also assessed according to the K-SADS interview. The
Structured Clinical Interview for DSM IV for Axis II disorders, Borderline Personality
Module (First, 1997) was used to diagnose Borderline Personality Disorder.
Self-harm was assessed by the structured interview Lifetime Parasuicide Count (LPC)
(Linehan & Comtois, 1996). Self-reported actions and urges to self-harm, at the start and
at the end of the 16 weeks course of DBT, were collected by standard DBT for
adolescents diary cards. They provide self-reported scores on a 5-point scale on a
number of measures related to self-harm, suicidality and feelings. The mean scores
reported during the first two and last two weeks of treatment were compared.
The number of psychiatric hospitalizations during treatment was reported by the
individual therapist for each patient. Since no one had more than one inpatient stay
during treatment, data were categorized into yes or no. Treatment retention was defined
by no more than three absences either in individual therapy or in skills-group and others
were considered as drop-outs. Information on self-harm at follow up was gathered during
a structured telephone interview done by the first author by asking the question “have you
self-harmed in the period since you ended DBT treatment?”
Adherence
Therapists were instructed to tape all sessions and deliver tapes consecutively for
adherence coding. They were not told how many or which of the tapes that would be
coded. A coder trained to reliability by the Linehan Research and Therapy Clinic,
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assessed the therapists' adherence to DBT principles by coding videotaped individual
therapy sessions and skills group sessions using the DBT global rating scale, a 66-item
adherence coding instrument (Linehan & Korslund, 2003). The items are grouped into
categories that follow the treatment components and scores range from 0-5. Altogether 37
treatment sessions were coded. Four of these sessions were multifamily skills groups, as
adherence coding in the course of the on-going development of adherence coding systems
for adolescent skills training groups was a part of the implementation process.
Therapists
Sixteen therapists consisting of clinical psychologists, one educational psychologist and
psychiatrists with experience up to twentyfive years of prior clinical experience
delivering other forms of psychotherapy were recruited. All the therapists were new to
DBT and were trained for the purpose of the study by trainers from the Behavioral Tech,
LLC. After being trained, eleven of the therapists were selected by the principal
investigator to become study therapists based on willingness to commit to both DBT and
the study or adherence coding results. Therapists were organized in two DBT
consultation team, based on their employment in two separate hospitals. Teams held
separate consultation team meetings weekly and received expert supervision from the
DBT trainers throughout the study. Clinicians were additionally trained in suicide risk
assessment and management for the purpose of the study.
Treatment
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DBT is a principle driven, partly manual based treatment, designed for the treatment of
adults with BPD. As its core, cognitive and behavioral change techniques are employed
within an acceptance-based framework. It contains strategies for reducing self-harm,
therapy interfering behaviors and quality of life interfering behaviors, as well as
strategies to increase the use of life skills that are compatible with a life worth living. The
primary focus in the first phase of DBT is stabilizing the patient and achieving behavioral
control by directly targeting self-harm behaviors as a first priority, dealing with behaviors
that interfere with treatment secondly, and then targeting behaviors that interfere in the
adolescent’s quality of life (e.g., depression, school problems, relationship difficulties). In
this study, a version adapted specifically for adolescents by Rathus and Miller (Rathus &
Miller, 2002), comprising all modalities and treatment protocols from the adult standard
DBT version was used. The adolescent version of DBT has a reduced duration (16 weeks
vs. 52 weeks in standard DBT) and consists of the following elements: one hour of
individual therapy per week, one weekly 2 hour multifamily skills training group, family
therapy sessions as needed, and inter-session telephone coaching in skills use as needed;
this was available on a 24-hour basis 7 days every week. Therapists met weekly for DBT
consultation team meetings. The modalities of the treatment serve five functions;
increasing behavioral capabilities, improving motivation, ensuring generalisation of skills
to the natural environment, structuring the treatment environment (i.e. interacting with
people in the environment to ensure that the client is not being reinforced for maladaptive
behaviors or punished for effective behaviors), and enhancing therapists’ ability and
motivation to treat patients effectively. Hand-outs and other materials adapted for
adolescents were translated from the original adolescent version (Miller et al., 2006) into
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Norwegian. The DBT program was provided in five child and adolescent psychiatric
outpatient clinics that participated in the study, all of which belonged to two hospitals in
Oslo. All treatments were conducted and funded by the two hospitals. DBT was the only
psychotherapeutic intervention given during the 16 weeks, but ancillary treatment, like
medication or hospital admissions was provided as needed and is described in the results
section.
Data Analysis
Descriptive data included baseline diagnoses, sociodemographics, global functioning,
previous psychiatric treatment and history of self-harm. Differences between completers
and drop outs were not tested because the small sample size would preclude the finding
of possible statistical differences. Only completers were included in statistical analyses.
McNemar chi square test for categorical data was used to assess change in the number of
patients who self-harmed during the first two weeks of treatment compared with the last
two weeks of treatment. Paired samples t tests were used to assess changes in scores on
continuous variables. SPSS Statistics version 17.0 was used.
Missing Data
Filling in diary cards and attending to them in the sessions was an integral part of the
treatment tool. Despite that diary card data were not collected for the purpose of research,
they nevertheless contained important information and were thus utilized in this study.
From each patient a mean number of 13 diary cards (SD 8.6) were available.
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In two cases of missing data, therapists were asked to provide informations regarding
patients’ non-suicidal self-harm based on the case-notes. Urges to self-harm, divided into
urges to engage in nonsuicidal self-harm and urges to attempt suicide were not always
reported in a readable manner on the diary card, thus reducing the number of patients
with available data on these variables to 14. At one year follow up we were able to trace
10 of 21 participants after two attempts to contact them (the maximum number of times
we were allowed by the ethics committee to attempt to make such contact with the
participants. We do not know if it was change of phone number, change of address, a
matter of bad timing, or other reasons that prevented us to trace the 11 patients who we
were unable to reach. All who were reached, however, agreed to be interviewed.
RESULTS
Total Sample Description
The mean age of the sample of 27 patients was 15.7 years (range 12-18, SD = 1.4) at the
start of treatment. The participants were 26 females and one male and predominantly of
Norwegian ethnicity (85%).
Of the 27 participating adolescents, 21(78%) completed the entire treatment. Six patients
were regarded as drop outs. Two of the dropouts, however, completed more than 50% of
the treatment, whereas 4 dropped out early in the treatment. Diagnostic and other
characteristics of the completers and dropouts are shown in Table 1. Of the whole
sample, eighteen patients (67%) had a primary diagnosis of Mood Disorder (10 with
Major Depressive Disorder, 6 with Mood Disorder not otherwise specified, 2 with
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Dysthymic Disorder). The remaining participants had either ADHD (n=1), panic
disorder without agoraphobia (n=1) substance dependence in early partial remission
(n=1), or no diagnosable axis I disorder (n=6). Forty-four percent of the patients fulfilled
5 or more criteria for BPD. Sixty-four percent had a history of suicide attempt(s) and
19% had received previous inpatient psychiatric treatment.
Adherence
Thirty-seven therapy sessions were coded and scored for adherence to DBT treatment
principles. The mean adherence score was 4.0 (range 3.5-4.2, SD 0.2), which qualifies as
adherent as scores of 4.0 or more indicate adherent sessions. Nearly 60 % of the coded
sessions were adherent. The majority of the non-adherent scores were just sub-threshold
4.0 (data not shown).
Baseline And Completers’ Scores On Repeated Measures
All patients had a history of repeated nonsuicidal self-harm in the four months before
inclusion in the trial. Sixty percent reported more than 20 lifetime episodes of nonsuicidal
self-harm. As shown in table 1 at baseline only two of the treatment completers did not
fulfil the criteria for at least one Axis I disorder. Of the patients with Axis I disorders, 6
had more than one disorder. Twelve of the treatment completers had a history of one or
more suicide attempts at baseline. The proportion of patients who had at least one episode
of nonsuicidal self-harm during the first two weeks of the treatment was compared with
the corresponding proportion during the last two weeks. Whereas 43% of the patients
reported nonsuicidal self-harm behavior during the first two weeks of treatment, only
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14% reported such behavior during the last two weeks. Urges of nonsuicidal self-harm
and suicide attempts were assessed through diary cards. For most patients, a substantial
decrease was observed during the course of treatment in mean scores of urges, for both
nonsuicidal self-harm and suicide attempts.
Differences Between Completers And Drop Outs
As shown in table 1 only one out of six dropouts had a mood disorder vs. 81% of the
completers. Four of the six dropouts did not fill criteria for any Axis 1 disorder compared
to two of the 21 completers. Two of those without any axis I disorder dropped out in the
first two weeks. None of the dropouts fulfilled five or more BPD criteria at baseline.
Thus, it appears that the dropouts had less severe psychiatric problems. Whereas
comparable fractions of the dropout and completer groups had a history of suicide
attempts, a higher percentage of the dropouts (67% vs 43%) reported more than 100
lifetime episodes of nonsuicidal self-harm.
Medication, Hospitalization And Suicide Attempts
One of the treatment completers used psychopharmacological medication during the
treatment period. Three of the completers had had a brief (1-2 days) psychiatric hospital
stay during the treatment period. The hospitalizations were due to single episodes of
attempted suicide with low medical seriousness and no need for somatic intervention.
Follow-Up
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Of the ten patients who were contacted by telephone one year after treatment completion,
seven reported no self-harm in the prior year. They were asked whether they had self-
harmed during the year after having participated in the DBT program.
DISCUSSION
This is the first study to report data on feasibility of implementing DBT for adolescents in
Scandinavia and also the first to report on adherence coding in DBT for adolescents. The
results indicate that DBT for adolescents can indeed be effectively implemented in a
Scandinavian culture and language context and health care system which differs
somewhat from the one in which DBT was developed. Therapists reached adequate
adherence levels, the treatment retention among the adolescents was high, and reductions
in episodes of and urges to self-harm were observed.
Reporting of treatment adherence levels are important to demonstrate the extent to which
the intervention have been delivered according to the treatment developers’ intentions, in
this case the DBT adaptation for adolescents developed and described by Miller and
colleagues (Miller et al., 2007). In this feasibility study, therapists with substantial
clinical experience, but who were new to DBT, were trained through a standard intensive
training program in DBT. Our adherence coding results, which are comparable to the
ones attained for standard DBT by the Linehan group (Linehan et al., 2006), indicate that
they were able to reach adequate levels of adherence rapidly, which is particularly
important when considering the feasibility of implementing such a novel treatment. We
recognize that the procedure of adherence coding and adherence feedback as a part of the
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study may have speeded up the learning process for therapists. Thus, this implementation
study is not totally comparable to clinical implementation per se, where therapists not
always use adherence coding as a part of their consultation to develop their skills as DBT
therapists. Some critics have argued that DBT is a very resource-demanding treatment to
implement. As far as adherence is concerned, this study shows that experienced non-
behavioral therapists can successfully learn, provide, and adhere to the treatment within a
relatively short time-frame.
Adolescents with self-harming behavior typically have a high treatment dropout rate (
67%) (Gould et al., 2003). In the present study, the retention rate was higher (78%), and
comparable to (Rathus & Miller, 2002; Fleischhaker et al., 2011) or higher than
(Woodberry & Popenoe, 2008) rates in other feasibility studies that used similarly
adapted versions of DBT. We do not have comparable studies of retention rate among the
Norwegian population of self-harming adolescents, but a Norwegian study of adolescent
suicide attempters showed that in spite of a large number referred to treatment, there was
low compliance to treatment after the suicide attempt. (Groholt & Ekeberg, 2009b)Our
high retention rate suggests that DBT for adolescents may have an advantage over other
treatments in its ability to keep patients in treatment. Keeping patients in treatment is an
explicit goal of DBT, and the use of motivational strategies and strategies to obtain
patients’ commitment to treatment, may have facilitated the high rate of treatment
completion. It could also be that the shortened duration of the treatment is particularly
appealing to adolescents, as one year can be a long time for adolescents and it may
require too much commitment. However, in a small study providing the one year
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standard DBT to older adolescents (16.4 years) 14 of the 16 participants completed the
whole year, suggesting that the treatment duration could be of less importance than
previously believed, at least for older adolescents (James et al., 2008). The six subjects
who dropped out of our study had fewer diagnosable Axis I disorders, and none of them
fulfilled the full criteria for BPD. This suggests that they may have had lower levels of
distress and lower psychiatric symptom levels and thus may not have felt a strong need
for such a comprehensive treatment program. DBT was originally developed for BPD
patients, and the treatment may thus not necessarily be perceived as equally relevant for
non BPD patients.
A decrease in self-harm behaviors was observed. A substantial number of participants
reported no self-harm behavior already within the first two weeks of treatment, although
they had all reported repeated self-harm within the last 4 months. Only a few of the
patients reported episodes of self-harm within the last two weeks of treatment. This is in
line with another study using a similar adaptation of DBT for adolescents (Fleischhaker
et al., 2011) and in studies of standard DBT (Linehan et al., 2006; Stanley et al., 2007).
Although our study was not designed to give information on treatment effects (DBT vs
standard treatment) or effect sizes, our observations suggest that DBT adapted for
adolescents could lead to early reduction in self-harm behavior.
This assumption is supported by the finding that whereas most of the patients in our
study reported high levels in the urge to self-harm (mean score 3.9) at the start of the
treatment, these scores decreased statistically and clinically significantly (to 1.8) towards
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the end of the treatment. After 14 weeks, only a few participants still had high scores on
urges to self-harm.
The present study cannot make any firm conclusions about why the changes in self-harm
behavior occurred. However according to the DBT treatment target hierarchy, self-harm
is considered the primary target behavior to decrease as long as it is present. It is
therefore likely that directly targeting this behavior increases the likelihood of gaining
control over it.
The observed reductions in self-harm behaviour were stable for seven of the ten patients
who were interviewed in the one year follow-up. We cannot exclude the possibility that
the ten patients traced may represent a positive selection with respect to treatment
outcome and function level even though we had no information indicating that such a
selection bias was present. Our results, in spite of any possible bias, are promising, and in
line with findings from a one year follow up on the German version of the DBT program
for adolescents in which the reduction of suicidal and nonsuicidal self-harm was found to
be stable over the course of one year (Fleischhaker et al., 2011).
Clinical Implications
Twelve clinical studies have reported on DBT for adolescents over the last decade, but
none of these have reported on adherence to the DBT adherence protocol. The present
study therefore adds to the literature by describing the feasibility and acceptability of a
clearly defined adaption of adherent DBT. Comparing the existing studies is difficult due
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to variability in their use of populations, settings and the actual DBT programs. In spite
of this, there is a common finding, among the existing studies, that adolescents treated
with DBT show improvements on a variety of measures of functioning (Groves et al.,
2012). Since none of these studies were designed as efficacy studies, there is now a
strong need for randomized controlled trials (Groves et al., 2012).
Study Strengths And Limitations
Our study adopted a complete DBT program adapted to adolescents according to Miller
and Rathus’ manual (Miller et al., 2006) and published book (Miller et al., 2007) and in
conjunction with the treatment developer. The adaptation included all the modalities that
are included in adult DBT. Among study strengths was the use of independent and
specifically trained evaluators. A major strength was also the use of a systematic
instrument for coding of therapists’ adherence to DBT treatment principles – this
instrument was applied by a coder trained to reliability with the treatment developer.
This aspect of the study provided useful information on the quality level of the treatment
delivered and served to improve the construct validity in this study. Such documentation
was pointed out as a major lack in earlier studies in a recent review of DBT for
adolescents by Groves and coworkers (2012) who suggest that reporting on adherence
should be implemented in future research.
Several limitations of this study should be noted. We did not include a control group or
follow up on those who dropped out of DBT, and thus conclusions about treatment
effects cannot be drawn. Without these data, we do not know if the changes reported are
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due to maturation, clinical instability, medication, placebo, selection bias, or other
effects. The study included baseline information of the whole sample, but only the
completers were followed up regarding the target behaviors, hence we have valid data
only for those who were able to complete the treatment. The acceptability of DBT in the
broader clinical population of adolescents is not described, as we have no information
about how many, if any, who declined to meet for an initial diagnostic interview.
Additionally, follow-up data were limited as they were based on telephone interviews
conducted by a non-independent and non-blinded interviewer.- This may have had
impact on the adolescents answers regarding such a sensitive topic as self-harm over
telephone. Follow up data are also limited because we only interviewed 10 of the
treatment completers. Conclusions about sustainable changes, therefore, cannot be drawn.
Despite the limitations, and in line with the purpose of the feasibility study, we conclude
that DBT for adolescents may be successfully implemented in Scandinavian outpatient
clinics and that clinicians seem to be able to learn and provide adherent DBT relatively
fast. The finding of such positive outcomes related to adherence, retention and reduction
of self-harm is understood as an indicator of acceptability for clinicians, adolescents and
families.
Implications For Future Research
To evaluate the efficacy of DBT with adolescents, a large scale randomized controlled
trial is required, and the first large RCT on DBT with adolescents is currently conducted
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at the National Centre for Suicide Research and Prevention in Norway. Thus, future
research on DBT for adolescents should advance from clinical observational studies such
as the present to efficacy or effectiveness studies. More studies evaluating the
sustainability of reduction in self-harm found during treatment are needed, and
evaluations of the importance of the length of treatment are recommended. Future
directions include examining what factors are of importance in improvement of treatment
adherence as well as the predictors of treatment retention and dropout.
CONCLUSIONS
We conclude that therapists were able to learn and adhere to DBT treatment principles
within a reasonable amount of time and deliver the treatment in a manner well received
by adolescents and their families. The clear reduction in the proportion of adolescents
who engaged in self-harm behavior yields sufficient support for this treatment program to
be tested in a larger RCT. In the developmental stage of adolescence, shortened versions
of effective treatments that are in line with their developmental needs seem to be a
sensible approach. Early reduction of self-harm could speed up the process of recovery
and make possible other therapeutic targets to be addressed, such as decreasing
symptoms of distress and increasing the use of coping strategies associated with a good
quality of life. If treatment effects can be gained relatively quickly, other follow up
treatment could focus on consolidation of gains.
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Table 1. Patients receiving DBT (N=27). Sample characteristics prior to treatment
Baseline characteristics
Measure Total N=27 Completers
N=21
Dropouts N=6
Age, median (SD) 15.7(1.4) 15.7(1.4) 16.0 (1.8)
Female, % (n) 96(26) 95(20) 100(6)
Norwegian ethnicity, % (n) 85(23) 81(17) 100(6)
Any primary mood disorder, % (n) 67(18) 81(17) 17(1)
Any other primary Axis I disorder,
%(n)
11(3) 10(2) 17(1)
Fulfilled 5 or more BPD criteria , % (n) 44(12) 57(12) 0
CGAS, Mean (SD) 61(12) 61(12) 60(10)
Previous outpatient psychiatric
treatment, % (n)
41(11) 38(8) 50(3)
Previous inpatient psychiatric
treatment, % (n)
19(5) 19(4) 17(1)
Previous psychopharmacological
treatment, % (n)
19(5) 19(4) 17(1)
Lifetime history of suicide attempts, %
(n)
64(16) 63(12) 67(4)
Number of lifetime episodes of NSSH
prior to treatment,% (n)
2-20 33(9) 38(8) 17(1)
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21-100 19(5) 19(4) 17(1)
>100 48(13) 43(9) 67(4)
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Table 2. Course of symptoms among completers
Self-harm and urges to self-harm during the treatment period
NSSH, %(n) N=21 completers 250a
First 2 weeks (1-2) 43(9)
Last 2 weeks (15-16) 14(3)
Urges to NSSH,mean (SD) N=14 3.80b*
First 2 weeks (1-2) 3.9(0.7)
Last 2 weeks (15-16) 1.8(1.8)
Urges to suicide attempts, mean (SD)
N=14
1.91b
First 2 weeks (1-2) 2.2(1.9)
Last 2 weeks (15-16) 1.1(1.7)
aMcNemar test for categorical variables (changes in percentage of study subjects
engaging in NSSH during the treatment period)
bPaired t-test for continuous variables (changes in mean score of urges to NSSH and
suicide attempt)
*p<0.01
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