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Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence, and Retention A. J. Tørmoen d
a b
Miller , F. Walby
b
, B. Grøholt , E. Haga a b e
f
a b
c
, A. Brager-Larsen , A.
, B. Stanley & L. Mehlum
a b
a
National Centre for Suicide Research and Prevention , University of Oslo , Norway b
Institute of Clinical Medicine , University of Oslo , Norway
c
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Oslo University Hospital, Division of Mental Health and Addiction, Department of Child and Adolescent Mental Health, Oslo South/ North , Norway d
Montefiore Medical Center, Child Outpatient Psychiatry , New York , New York , USA e
Department of Psychiatry , Diakonhjemmet Hospital , Oslo , Norway f
New York State Psychiatric Institute, Columbia University , New York , New York , USA Accepted author version posted online: 19 May 2014.Published online: 07 Nov 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, 18:4, 432-444, DOI: 10.1080/13811118.2013.826156 To link to this article: http://dx.doi.org/10.1080/13811118.2013.826156
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Archives of Suicide Research, 18:432–444, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.826156
Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with MultiProblems: Training, Adherence, and Retention A. J. Tørmoen, B. Grøholt, E. Haga, A. Brager-Larsen, A. Miller, F. Walby, B. Stanley, and L. Mehlum We evaluated the feasibility of DBT training, adherence, and retention preparing for a randomized controlled trial of Dialectical Behavior Therapy (DBT) adapted for Norwegian adolescents engaging in self-harming behavior and diagnosed with features of borderline personality disorder. Therapists were intensively trained and evaluated for adherence. Adherence scores, treatment retention, and present and previous selfharm were assessed. Twenty-seven patients were included (mean age 15.7 years), all of them with recent self-harming behaviors and at least 3 features of Borderline Personality Disorder. Therapists were adherent and 21 (78%) patients completed the whole treatment. Three subjects reported self-harm at the end of treatment, and urges to self-harm decreased. At follow up, 7 of 10 subjects reported no selfharm. DBT was found to be well accepted and feasible. Randomized controlled trials are required to test the effectiveness of DBT for adolescents. Keywords
adolescents, psychotherapy, self-harm, suicidal behavior, treatment
INTRODUCTION
frequent therapist changes preclude the receipt or completion of treatment (Miller, Rathus, & Linehan, 2007; Trautman, Stewart, & Morishima, 1993). Self-harm is associated with recurrent psychosocial problems (Jacobson & Gould, 2007; Jacobson, Muehlenkamp, Miller et al., 2008; Tormoen, Rossow, Larsson et al., 2012) and poor long-term outcome (Fergusson & Lynskey, 1995; Groholt & Ekeberg, 2009). Features of Borderline Personality Disorder (BPD) are often found
Self-harm among adolescents is a complicated behavior to treat. Clinical samples of self-harming adolescents are frequently characterized by affective instability, strong emotional reactivity, and impulsivity (Crowell, Beauchaine, & Linehan, 2009; Jacobson & Gould, 2007; Jacobson, Muehlenkamp, Miller et al., 2008; Joiner, Brown, & Wingate, 2005; Nock, 2010), and treatment rejection, drop-out, or
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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 (Chanen, Jovev, & Jackson 2007; Miller, Muehlenkamp, & Jacobson, 2008;). Symptoms of BPD in adolescents are related to having other psychiatric symptoms and functional impairment (Chanen, Jovev, & Jackson 2007), and are also found to have negative long term consequences (Winograd, Cohen, & Chen, 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 (Hazell, Martin, Mcgill et al., 2009; Linehan, Armstrong, Suarez et al., 1991; Linehan, 1993; Steiger & Stotland, 1996). 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 reduced parasuicide (Chanen, Jackson, McCutcheon et al., 2008). In spite of the seriousness of selfharm, 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 Borderline Personality Disorder, repetitive self-harm, and suicidal behavior (Crowell, Beauchaine, & Linehan, 2009; Koons, Robins, Lindsey et al., 2001; Linehan, Comtois, Murray et al., 2006; Linehan, Heard, & Armstrong, 1993; Linehan, Tutek, Heard et al., 1994; Van Den Bosch, Koeter, Stijnen et al., 2005; Verheul, Van Den Bosch, Koeter et al., 2003). 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 (Fleischhaker, Bohme, Sixt et al., 2011; Goldstein, Axelson, Birmaher et al., 2007; James, Taylor, Winmill et al., 2008; Katz, Cox, Gunasekara et al., 2004; McDonell, Tarantino, Dubose et al., 2010; Rathus & Miller, 2002; SalbachAndrae, Bohnekamp, Pfeiffer et al., 2008; Woodberry & Popenoe, 2008). 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, Backer, van den Bosch et al., 2012). To date, no randomized controlled studies (RCT) of DBT for adolescentshave been publishedin 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
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trained adherence coder documenting adherent DBT for adolescents. 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 1-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 between12 and 18 years, 2) more than one lifetime episode of selfharmwith 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. Selfharm 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, Rodham, Evans et al., 2002), and thus includes both suicidal and non suicidal 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 specialized treatment. The clinics screened patients who were newly referred for treatment for current and past history of self-harm behavior. If screened
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positively, the patient and the parents were 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 37 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 groupsessions 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 baselinewith 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, Birmaher, Brent et al., 1997). History of psychiatric treatment was also
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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). Selfreported 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 dropouts. 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 would be coded. A coder trained to reliability by the Linehan Research and Therapy Clinic, 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 psychologists and psychiatrists with up to 25 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, 11 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
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 acceptancebased 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
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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, and 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: 1 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 generalization 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, Rathus, & Linehan, 2006) into 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 admission was provided
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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 dropouts 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 selfharmed during the first 2 weeks of treatment compared with the last 2 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. Although diary card data were not collected for the purpose of research, they contained important information and were thus utilized in this study. From each patient a mean number of 13 diary cards (SD8.6) were available. In two cases of missing data, therapists were asked to provide information 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 1-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
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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.
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).
RESULTS
All patients had a history of repeatednonsuicidal self-harm in the 4 months before inclusion in the trial. Sixty percent reported more than 20 lifetime episodes of non suicidal 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. As shown in Table 2, the proportion of patients who had at least one episode of nonsuicidal self-harm during the first 2 weeks of the treatment was compared with the corresponding proportion during the last 2 weeks. Where as 43% of the patients reported nonsuicidal self-harm behavior during the first 2 weeks of treatment, only 14% reported such behavior during the last 2 weeks. Urges of non suicidal self-harm and suicide attempts were assessed through diary cards. For most patients, a substantial decrease was observed during the course of treatment in meanscores of urges, for both nonsuicidal self-harm and suicide attempts.
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Total Sample Description
The mean age of the sample of 27 patients was 15.7 years (range 12–18, SD ¼ 1.4) at the start of treatment. The participants were 26 females and 1 male and predominantly of Norwegian ethnicity (85%). Of the 27 participating adolescents, 21(78%) completed the entire treatment. Six patients were regarded as dropouts. 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, 18 patients (67%) had a primary diagnosis of Mood Disorder (10 with Major Depressive Disorder, 6 with Mood Disorder not otherwise specified, 2 with Dysthymic Disorder). The remaining participants had either ADHD (n ¼ 1), panic disorder without agoraphobia (n ¼ 1) substance dependence in early partial remission (n ¼ 1), or no diagnosable axis I disorder (n ¼ 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
Baseline and Completers’ Scores on Repeated Measures
Differences between Completers and Dropouts
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 2 of the 21 completers. Two of those without any axis 1 disorder dropped out in the first 2 weeks. None of the dropouts fulfilled five or more BPD
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TABLE 1. Patients Receiving DBT (N ¼ 27); Sample Characteristics Prior to Treatment Baseline characteristics Total N ¼ 27
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Measure Age, median (SD) Female, % (n) Norwegian ethnicity, % (n) Any primary mood disorder, % (n) Any other primary Axis I disorder, %(n) Fulfilled 5 or more BPD criteria, % (n) CGAS, Mean (SD) Previous outpatient psychiatric treatment, % (n) Previous inpatient psychiatric treatment, % (n) Previous psychopharmacological treatment, % (n) Lifetime history of suicide attempts, % (n) Number of lifetime episodes of NSSH prior to treatment,% (n) 2–20 21–100 >100
criteria at baseline. Thus, it appears that the dropouts had less severe psychiatric problems. Where as comparable fractions of the TABLE 2. Course of Symptoms among Completers Self-harm and urges to self-harm during the treatment period NSSH, %(n) N ¼ 21 completers First 2 weeks (1–2) Last 2 weeks (15–16) Urges to NSSH, mean (SD) N ¼ 14 First 2 weeks (1–2) Last 2 weeks (15–16) Urges to suicide attempts, mean (SD) N ¼ 14 First 2 weeks (1–2) Last 2 weeks (15–16)
Dropouts N¼6 16.0 (1.8) 100 (6) 100 (6) 17 (1) 17 (1) 0 60 (10) 50 (3) 17 (1) 17 (1) 67 (4)
33 (9) 19 (5) 48 (13)
38 (8) 19 (4) 43 (9)
17 (1) 17 (1) 67 (4)
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
250a 43(9) 14(3) 3.80b 3.9(0.7) 1.8(1.8) 1.91b 2.2(1.9) 1.1(1.7)
a McNemar test for categorical variables (changes in percentage of study subjects engaging in NSSH during the treatment period). b Paired t-test for continuous variables (changes in mean score of urges to NSSH and suicide attempt). p < 0.01.
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15.7 (1.4) 96 (26) 85 (23) 67 (18) 11 (3) 44 (12) 61 (12) 41 (11) 19 (5) 19 (5) 64 (16)
Completers N ¼ 21 15.7 (1.4) 95 (20) 81 (17) 81 (17) 10 (2) 57 (12) 61 (12) 38 (8) 19 (4) 19 (4) 63 (12)
One of the treatment completers used psycho pharmacological 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
Of the 10 patients who were contacted by telephone 1 year after treatment completion, 7 reported no self-harm in the prior
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year. They were asked whether they had self-harmed during the year after having participated in the DBT program.
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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 implementedin 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 treatment adherence levels is important to demonstrate the extent to which the intervention has been delivered according to the treatment developers’ intentions, in this case the DBT adaptation for adolescents developed and described by Miller and colleagues (Miller, Rathus, & Linehan, 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, Comtois, Murray 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 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 do 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 resourcedemanding 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, Greenberg, Velting et al., 2003). In the present study, the retention rate was higher (78%), and comparable to (Fleischhaker, Bohme, Sixt et al., 2011; Rathus & Miller, 2002) 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 with treatment after the suicide attempt (Groholt & Ekeberg, 2009). 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 1 year can be a long time for adolescents and it may require too much commitment. However, in a small study providing the 1year 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, Taylor, Winmill et al., 2008). The six subjects who dropped out of our study had fewer
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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 within the first 2 weeks of treatment, although they had all reported repeated selfharm within the last 4 months. Only a few of the patients reported episodes of selfharm within the last 2 weeks of treatment. This is inline with another study using a similar adaptation of DBT for adolescents (Fleischhaker, Bohme, Sixt et al., 2011) and in studies of standard DBT (Linehan, Comtois, Murray et al., 2006; Stanley, Brodsky, Nelson 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) toward 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.
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The observed reductions in self-harm behavior were stable for 7of the 10 patients who were interviewed in the 1year followup. 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 1 year (Fleischhaker, Bohme, Sixt 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 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, Backer, van den Bosch et al., 2012). Since none of these studies were designed as efficacy studies, there is now a strong need for randomized controlled trials (Groves, Backer, van den Bosch et al., 2012). Study Strengths and Limitations
Our study adopted a complete DBT program adapted to adolescents according to Miller, Rathus and Linehan’s model, (2006) and published book (Miller, Rathus,
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& Linehan, 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 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, andin 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 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.
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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. AUTHOR NOTE
A. J. Tørmoen, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. B. Grøholt, Institute of Clinical Medicine, University of Oslo, Norway. E. Haga, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. A. Brager-Larsen, Oslo University Hospital, Division of Mental Health and Addiction, Department of Child and Adolescent Mental Health, Oslo South=North, Norway. A. Miller, Montefiore Medical Center, Child Outpatient Psychiatry, New York, New York, USA. F. Walby, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, and Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway. B. Stanley, New York State Psychiatric Institute, Columbia University, New York, New York, USA. L. Mehlum, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Correspondence concerning this article should be addressed to Anita Johanna Tørmoen, NSSF, Sognsvannsveien 21, 0320
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Van Den Bosch, L. M., Koeter, M. W., Stijnen, T., Verheul, R., & Van Den Brink, W. (2005). Sustained efficacy of dialectical behavior therapy for Borderline Personality Disorder. Behaviour Research and Therapy, 43, 1231–1241. Verheul, R., Van Den Bosch, L. M., Koeter, M. W., De Ridder, M. A., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. British Journal of Psychiatry, 182, 135–140. Winograd, G., Cohen, P., & Chen, H. (2008). Adolescent borderline symptoms in the community: prognosis for functioning over 20 years. Journal of Child Psychology & Psychiatry & Allied Disciplines, 49, 933–941. Woodberry, K. A., & Popenoe, E. J. (2008). Implementing Dialectical Behavior Therapy with adolescents and their families in a community outpatient clinic. Cognitive and Behavioral Practice, 15, 277–286.
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Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence, and Retention A. J. Tørmoen d
a b
Miller , F. Walby
b
, B. Grøholt , E. Haga a b e
f
a b
c
, A. Brager-Larsen , A.
, B. Stanley & L. Mehlum
a b
a
National Centre for Suicide Research and Prevention , University of Oslo , Norway b
Institute of Clinical Medicine , University of Oslo , Norway
c
Click for updates
Oslo University Hospital, Division of Mental Health and Addiction, Department of Child and Adolescent Mental Health, Oslo South/ North , Norway d
Montefiore Medical Center, Child Outpatient Psychiatry , New York , New York , USA e
Department of Psychiatry , Diakonhjemmet Hospital , Oslo , Norway f
New York State Psychiatric Institute, Columbia University , New York , New York , USA Accepted author version posted online: 19 May 2014.Published online: 07 Nov 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, 18:4, 432-444, DOI: 10.1080/13811118.2013.826156 To link to this article: http://dx.doi.org/10.1080/13811118.2013.826156
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Archives of Suicide Research, 18:432–444, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.826156
Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with MultiProblems: Training, Adherence, and Retention A. J. Tørmoen, B. Grøholt, E. Haga, A. Brager-Larsen, A. Miller, F. Walby, B. Stanley, and L. Mehlum We evaluated the feasibility of DBT training, adherence, and retention preparing for a randomized controlled trial of Dialectical Behavior Therapy (DBT) adapted for Norwegian adolescents engaging in self-harming behavior and diagnosed with features of borderline personality disorder. Therapists were intensively trained and evaluated for adherence. Adherence scores, treatment retention, and present and previous selfharm were assessed. Twenty-seven patients were included (mean age 15.7 years), all of them with recent self-harming behaviors and at least 3 features of Borderline Personality Disorder. Therapists were adherent and 21 (78%) patients completed the whole treatment. Three subjects reported self-harm at the end of treatment, and urges to self-harm decreased. At follow up, 7 of 10 subjects reported no selfharm. DBT was found to be well accepted and feasible. Randomized controlled trials are required to test the effectiveness of DBT for adolescents. Keywords
adolescents, psychotherapy, self-harm, suicidal behavior, treatment
INTRODUCTION
frequent therapist changes preclude the receipt or completion of treatment (Miller, Rathus, & Linehan, 2007; Trautman, Stewart, & Morishima, 1993). Self-harm is associated with recurrent psychosocial problems (Jacobson & Gould, 2007; Jacobson, Muehlenkamp, Miller et al., 2008; Tormoen, Rossow, Larsson et al., 2012) and poor long-term outcome (Fergusson & Lynskey, 1995; Groholt & Ekeberg, 2009). Features of Borderline Personality Disorder (BPD) are often found
Self-harm among adolescents is a complicated behavior to treat. Clinical samples of self-harming adolescents are frequently characterized by affective instability, strong emotional reactivity, and impulsivity (Crowell, Beauchaine, & Linehan, 2009; Jacobson & Gould, 2007; Jacobson, Muehlenkamp, Miller et al., 2008; Joiner, Brown, & Wingate, 2005; Nock, 2010), and treatment rejection, drop-out, or
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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 (Chanen, Jovev, & Jackson 2007; Miller, Muehlenkamp, & Jacobson, 2008;). Symptoms of BPD in adolescents are related to having other psychiatric symptoms and functional impairment (Chanen, Jovev, & Jackson 2007), and are also found to have negative long term consequences (Winograd, Cohen, & Chen, 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 (Hazell, Martin, Mcgill et al., 2009; Linehan, Armstrong, Suarez et al., 1991; Linehan, 1993; Steiger & Stotland, 1996). 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 reduced parasuicide (Chanen, Jackson, McCutcheon et al., 2008). In spite of the seriousness of selfharm, 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 Borderline Personality Disorder, repetitive self-harm, and suicidal behavior (Crowell, Beauchaine, & Linehan, 2009; Koons, Robins, Lindsey et al., 2001; Linehan, Comtois, Murray et al., 2006; Linehan, Heard, & Armstrong, 1993; Linehan, Tutek, Heard et al., 1994; Van Den Bosch, Koeter, Stijnen et al., 2005; Verheul, Van Den Bosch, Koeter et al., 2003). 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 (Fleischhaker, Bohme, Sixt et al., 2011; Goldstein, Axelson, Birmaher et al., 2007; James, Taylor, Winmill et al., 2008; Katz, Cox, Gunasekara et al., 2004; McDonell, Tarantino, Dubose et al., 2010; Rathus & Miller, 2002; SalbachAndrae, Bohnekamp, Pfeiffer et al., 2008; Woodberry & Popenoe, 2008). 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, Backer, van den Bosch et al., 2012). To date, no randomized controlled studies (RCT) of DBT for adolescentshave been publishedin 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
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trained adherence coder documenting adherent DBT for adolescents. 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 1-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 between12 and 18 years, 2) more than one lifetime episode of selfharmwith 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. Selfharm 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, Rodham, Evans et al., 2002), and thus includes both suicidal and non suicidal 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 specialized treatment. The clinics screened patients who were newly referred for treatment for current and past history of self-harm behavior. If screened
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positively, the patient and the parents were 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 37 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 groupsessions 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 baselinewith 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, Birmaher, Brent et al., 1997). History of psychiatric treatment was also
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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). Selfreported 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 dropouts. 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 would be coded. A coder trained to reliability by the Linehan Research and Therapy Clinic, 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 psychologists and psychiatrists with up to 25 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, 11 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
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 acceptancebased 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
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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, and 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: 1 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 generalization 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, Rathus, & Linehan, 2006) into 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 admission was provided
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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 dropouts 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 selfharmed during the first 2 weeks of treatment compared with the last 2 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. Although diary card data were not collected for the purpose of research, they contained important information and were thus utilized in this study. From each patient a mean number of 13 diary cards (SD8.6) were available. In two cases of missing data, therapists were asked to provide information 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 1-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
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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.
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).
RESULTS
All patients had a history of repeatednonsuicidal self-harm in the 4 months before inclusion in the trial. Sixty percent reported more than 20 lifetime episodes of non suicidal 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. As shown in Table 2, the proportion of patients who had at least one episode of nonsuicidal self-harm during the first 2 weeks of the treatment was compared with the corresponding proportion during the last 2 weeks. Where as 43% of the patients reported nonsuicidal self-harm behavior during the first 2 weeks of treatment, only 14% reported such behavior during the last 2 weeks. Urges of non suicidal self-harm and suicide attempts were assessed through diary cards. For most patients, a substantial decrease was observed during the course of treatment in meanscores of urges, for both nonsuicidal self-harm and suicide attempts.
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Total Sample Description
The mean age of the sample of 27 patients was 15.7 years (range 12–18, SD ¼ 1.4) at the start of treatment. The participants were 26 females and 1 male and predominantly of Norwegian ethnicity (85%). Of the 27 participating adolescents, 21(78%) completed the entire treatment. Six patients were regarded as dropouts. 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, 18 patients (67%) had a primary diagnosis of Mood Disorder (10 with Major Depressive Disorder, 6 with Mood Disorder not otherwise specified, 2 with Dysthymic Disorder). The remaining participants had either ADHD (n ¼ 1), panic disorder without agoraphobia (n ¼ 1) substance dependence in early partial remission (n ¼ 1), or no diagnosable axis I disorder (n ¼ 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
Baseline and Completers’ Scores on Repeated Measures
Differences between Completers and Dropouts
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 2 of the 21 completers. Two of those without any axis 1 disorder dropped out in the first 2 weeks. None of the dropouts fulfilled five or more BPD
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TABLE 1. Patients Receiving DBT (N ¼ 27); Sample Characteristics Prior to Treatment Baseline characteristics Total N ¼ 27
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Measure Age, median (SD) Female, % (n) Norwegian ethnicity, % (n) Any primary mood disorder, % (n) Any other primary Axis I disorder, %(n) Fulfilled 5 or more BPD criteria, % (n) CGAS, Mean (SD) Previous outpatient psychiatric treatment, % (n) Previous inpatient psychiatric treatment, % (n) Previous psychopharmacological treatment, % (n) Lifetime history of suicide attempts, % (n) Number of lifetime episodes of NSSH prior to treatment,% (n) 2–20 21–100 >100
criteria at baseline. Thus, it appears that the dropouts had less severe psychiatric problems. Where as comparable fractions of the TABLE 2. Course of Symptoms among Completers Self-harm and urges to self-harm during the treatment period NSSH, %(n) N ¼ 21 completers First 2 weeks (1–2) Last 2 weeks (15–16) Urges to NSSH, mean (SD) N ¼ 14 First 2 weeks (1–2) Last 2 weeks (15–16) Urges to suicide attempts, mean (SD) N ¼ 14 First 2 weeks (1–2) Last 2 weeks (15–16)
Dropouts N¼6 16.0 (1.8) 100 (6) 100 (6) 17 (1) 17 (1) 0 60 (10) 50 (3) 17 (1) 17 (1) 67 (4)
33 (9) 19 (5) 48 (13)
38 (8) 19 (4) 43 (9)
17 (1) 17 (1) 67 (4)
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
250a 43(9) 14(3) 3.80b 3.9(0.7) 1.8(1.8) 1.91b 2.2(1.9) 1.1(1.7)
a McNemar test for categorical variables (changes in percentage of study subjects engaging in NSSH during the treatment period). b Paired t-test for continuous variables (changes in mean score of urges to NSSH and suicide attempt). p < 0.01.
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15.7 (1.4) 96 (26) 85 (23) 67 (18) 11 (3) 44 (12) 61 (12) 41 (11) 19 (5) 19 (5) 64 (16)
Completers N ¼ 21 15.7 (1.4) 95 (20) 81 (17) 81 (17) 10 (2) 57 (12) 61 (12) 38 (8) 19 (4) 19 (4) 63 (12)
One of the treatment completers used psycho pharmacological 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
Of the 10 patients who were contacted by telephone 1 year after treatment completion, 7 reported no self-harm in the prior
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year. They were asked whether they had self-harmed during the year after having participated in the DBT program.
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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 implementedin 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 treatment adherence levels is important to demonstrate the extent to which the intervention has been delivered according to the treatment developers’ intentions, in this case the DBT adaptation for adolescents developed and described by Miller and colleagues (Miller, Rathus, & Linehan, 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, Comtois, Murray 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 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 do 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 resourcedemanding 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, Greenberg, Velting et al., 2003). In the present study, the retention rate was higher (78%), and comparable to (Fleischhaker, Bohme, Sixt et al., 2011; Rathus & Miller, 2002) 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 with treatment after the suicide attempt (Groholt & Ekeberg, 2009). 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 1 year can be a long time for adolescents and it may require too much commitment. However, in a small study providing the 1year 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, Taylor, Winmill et al., 2008). The six subjects who dropped out of our study had fewer
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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 within the first 2 weeks of treatment, although they had all reported repeated selfharm within the last 4 months. Only a few of the patients reported episodes of selfharm within the last 2 weeks of treatment. This is inline with another study using a similar adaptation of DBT for adolescents (Fleischhaker, Bohme, Sixt et al., 2011) and in studies of standard DBT (Linehan, Comtois, Murray et al., 2006; Stanley, Brodsky, Nelson 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) toward 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.
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The observed reductions in self-harm behavior were stable for 7of the 10 patients who were interviewed in the 1year followup. 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 1 year (Fleischhaker, Bohme, Sixt 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 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, Backer, van den Bosch et al., 2012). Since none of these studies were designed as efficacy studies, there is now a strong need for randomized controlled trials (Groves, Backer, van den Bosch et al., 2012). Study Strengths and Limitations
Our study adopted a complete DBT program adapted to adolescents according to Miller, Rathus and Linehan’s model, (2006) and published book (Miller, Rathus,
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& Linehan, 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 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, andin 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 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.
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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. AUTHOR NOTE
A. J. Tørmoen, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. B. Grøholt, Institute of Clinical Medicine, University of Oslo, Norway. E. Haga, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. A. Brager-Larsen, Oslo University Hospital, Division of Mental Health and Addiction, Department of Child and Adolescent Mental Health, Oslo South=North, Norway. A. Miller, Montefiore Medical Center, Child Outpatient Psychiatry, New York, New York, USA. F. Walby, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, and Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway. B. Stanley, New York State Psychiatric Institute, Columbia University, New York, New York, USA. L. Mehlum, National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway. Correspondence concerning this article should be addressed to Anita Johanna Tørmoen, NSSF, Sognsvannsveien 21, 0320
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