Emily Cooney, Kirsten Davis, Pania Thompson, Julie Wharewera-Mika & Joanna Stewart

1. Feasibility of researching Dialectical Behaviour Therapy for suicidal and self-injuring adolescents Emily Cooney, Kirsten Davis, Pania Thompson, Julie Wharewera-Mika & Joanna Stewart

2. Why do this study? • Self-harm remains a significant problem for adolescents in our country. Despite several trials focussing on treatment for self-harm, we don’t really know what works for suicidal young people. • Dialectical Behaviour Therapy (DBT) seems effective for adults with chronic suicidality and severe emotional instability (Linehan et al, 1991, 1993, 2006, McMain et al., 2009, Verheul et al., 2003) • Field trials evaluating adaptations of DBT for use with adolescents suggest that DBT shows promise for young people (Goldstein et al., 2007, Katz et al., 2004, Rathus & Miller, 2002).

3. But before we can do a big study…. …..we have some big questions

4. Feasibility questions • Is comprehensive DBT acceptable to adolescents, families and clinicians in New Zealand? • Is random assignment acceptable to suicidal adolescents, their families and treatment services in New Zealand? • Are our assessments and screens feasible and acceptable? • Will emotionally vulnerable adolescents tolerate the screening and assessment measures? • What participant retention rate can we expect?

5. Participants Young people (and their families) seen at two government-funded community mental health outpatient services who • were aged between 13 and 18 years* • had self-injured or attempted suicide in the previous 3 months • didn’t meet criteria for a psychotic disorder or life-threatening Anorexia Nervosa • didn’t have an intellectual disability • could speak and read English

6. We measured • Self-harm • Suicidal ideation and reasons for living • Substance use • Emotion Regulation • Therapist burnout

7. DBT • Multifamily skills groups • Individual therapy • 24/7 phone consultation • Consultation team for therapists • Family sessions and parent sessions as needed

8. TAU • Depended on what the team, therapist and family thought would be helpful • Range of therapy approaches, with cognitive-behavioural therapy being the most common treatment • Provided by clinical psychologists, social workers, occupational therapists, and alcohol & drug counsellors

9. If needed, participants in both conditions could access: • Medication • Respite care • Hospital

10. 50 young people and families had an orientation meeting 15 (30%) declined Screening assessment 2 not eligible 4 discontinued during the assessments 29 completed the pre-treatment assessment TAU = 15 DBT = 14 29

11. Ethnicities of participants

12. Pre-treatment characteristics of DBT and TAU participants

13. Kia tupato! While nosing through these results, we can’t draw many conclusions about how the treatments compare • Variable assessment times • Small n • Differences between groups before they began treatment

14. Treatment engagement • 1/14 DBT participants dropped out (4/15 TAU participants ‘dropped out’) • The mean percent of sessions missed was 9% of individual sessions, and 12% of group sessions for adolescents in DBT (the mean percent of individual sessions missed was 29% for TAU participants).

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

16. 9/14 9/15 3/14 0/15 2/14 1/15

18. Results of focus group with DBT participants • Found DBT valuable and worthwhile • Parents wanted their own support • Treatment ending seemed arbitrary and was too abrupt

19. DBT therapists • Adherence ratings comparable to “gold-standard” DBT outcome trials • Therapist burnout scores were within the ‘average’ range before and after treatment • Team support and adherence feedback were critical

20. Lessons learned so far • Randomisation is acceptable to families and clinicians. Dual roles of research staff complicate this • Consider risk factors for self-harm when deciding how to randomise • Treatment ending has to be managed very carefully • Contagion is potentially a greater concern than with adults • Consider recruiting outside of services

21. Acknowledgements • This study was funded by the New Zealand Ministry of Health • We are very grateful to the following people for their help and support: • Dr. Sally Merry • Dr. Alec Miller • Dr. Jill Rathus • the research therapists (Mike Batcheler, Helen Clack and Ben Te Maro) • Sharon Rickard • Amy Rosso • Dr. Paul Vroegrop • staff from Waitemata DHB • staff from Auckland DHB • Dr. Sue Crengle • Dr. Sarah Fortune • the families who took part in this research • Dr. Melanie Harned • Dr. Simon Hatcher • Dr. Kathryn Korslund • Dr. Marsha Linehan