Implementing Dialectical Behaviour Therapy into child and adolescent mental health services : a pilot study of implementation strategies and initial clinical outcomes

Abstract

Adolescent clients presenting to Child and Adolescent Mental Health Services (CAMHS) with suicidal behaviour, depression and Borderline Personality Disorder (BPD) represent a highly complex and compromised group of consumers. Their risk for ongoing suicidal behaviour and mental illness requires timely access to effective treatment programs. The current study describes the design, development and implementation of a comprehensive DBT program with a focus on evaluating initial clinical outcomes. Dialectical Behaviour Therapy for suicidal adolescent clients was identified as a comprehensive treatment most capable of providing for the needs of adolescent clients and their families presenting to ACT CAMHS. DBT is an established outpatient treatment for adult clients presenting with suicidal behaviour and multiple social and emotional difficulties. The CAMHS DBT program was based on standardised DBT with additional adaptations developed for adolescent populations and their parents. The intent was to make the treatment as adherent as possible to the standardised model in order to maximise the potential for the program to assist clients and families to change. The 20 week program consisted of weekly individual therapy, skills group, team consultation group, as needed phone coaching and family therapy sessions. Some amendments were required due to the service characteristics of CAMHS. The development of the program included identifying and problem solving a number of barriers to implementation. Barriers to successful implementation of DBT included lack of access to skills based training for clinicians and limited clinical supervision, limited leadership and lack of treatment fidelity. After identifying these barriers and their potential to impact deleteriously on implementation, an implementation strategy was designed including a numbers of phases and concurrent practices. The implementation strategy included exploring and then adopting a treatment design, workforce development, pilot implementation and evaluation. A program evaluation was undertaken to measure the initial clinical effectiveness of the program. The primary outcome for the current study was to reduce suicidal and non-suicidal self-injurious behaviour. Secondary outcomes consisted of reducing symptoms of depression, core clinical features of Borderline Personality Disorder and increasing factors protective against suicide such as concerns about suicidal behaviour and future hopefulness. At follow-up, CAMHS clients who completed the program reported both clinical and statistically significant reductions in suicidal behaviour, depression and core clinical features of Borderline Personality Disorder such as: interpersonal chaos, impulsivity, emotion dysregulation and confusion about self. Apart from concerns about suicidal behaviour no other statistically significant increases in protective factors were found. Limitations of the current study are described. Overall, the clinical results of the current study provide encouraging initial evidence for the ongoing use, program development and evaluation of DBT within CAMHS. Show more