Hindawi Publishing Corporation
Volume 2013, Article ID 145219, 10 pages
Dialectical Behaviour Therapy for the Treatment of Emotion
Dysregulation and Trauma Symptoms in Self-Injurious and
Suicidal Adolescent Females: A Pilot Programme within
a Community-Based Child and Adolescent Mental Health Service
Keren Geddes,1Suzanne Dziurawiec,2and Christopher William Lee2
1Rockingham Kwinana Child and Adolescent Mental Health Service, P.O. Box 288, Rockingham, WA 6968, Australia
2School of Psychology and Exercise Science, Murdoch University, Murdoch, WA 6150, Australia
Correspondence should be addressed to Keren Geddes; firstname.lastname@example.org
Received 12 December 2012; Revised 2 May 2013; Accepted 2 May 2013
Academic Editor: Karen Rodham
Copyright © 2013 Keren Geddes et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. The literature suggests a link between childhood trauma and maladaptive emotion regulation strategies, including
nonsuicidal self-injury (NSSI) and suicidality. We assessed the impact of a pilot dialectical behaviour therapy (DBT) programme
on reducing trauma-related symptoms and improving emotional regulation, suicidality, and NSSI in adolescents. Methods. Six
adolescents attending a community mental health service received 26 weeks of DBT, together with a parent. Independent
assessors collected measures on each participant at baseline, posttreatment, and three-month followup. We implemented further
improvements over past research with the use of adolescent-specific outcome measures as well as independent assessment of
treatment integrity, noted as problematic in previous studies, using videotapes. Results. Firstly, adolescents reported a decrease
in trauma-based symptoms, suicidality, and NSSI following participation in the DBT programme that was maintained at the three-
month followup. Secondly, adolescents also reported improved emotion regulation immediately following treatment, and this was
maintained, albeit more moderately, three months later. Given the burgeoning demand on mental health services, it is notable that
five of the six adolescents were discharged from the service following the DBT intervention. Conclusions. The results of this pilot
programme suggest that DBT has the potential to improve the symptoms of this at-risk population.
A large percentage of adolescents present at community-
injury, such as cutting or burning, due to significant difficul-
ties with self-regulation of their emotions [1–4]. These ado-
lescents often report using self-injury strategies to overcome
emotional numbing , and many experience ongoing suici-
dal ideation, while some go on to make at least one and often
more suicide attempts [3, 5, 6]. Given the nature of their pre-
senting difficulties, many would argue that these adolescents
have an “emerging borderline personality structure” [7–10].
These distressed adolescents, and the family systems in
which they have been developed, have been shown to be
remarkably difficult to treat , so that many will graduate
from child and adolescent mental health settings to become
long-term patients of adult mental health services, with mul-
tiple hospital admissions due to high levels of dysfunction,
extreme management issues, and treatment resistance [3, 12].
The challenges to government-funded health services, both
internationally, are compelling .
There is a well-established body of literature linking
NSSI and suicidal behaviours with emotional dysregulation
[3, 14–16] and childhood traumatic experiences, such as
physical and sexual abuse . In fact, it has been argued
that these behaviours are used as a compensation strategy in
posttrauma adaptation, functioning to assist with intra- and
interpersonal regulations . Thus, emotion dysregulation
and childhood trauma are argued to be intimately linked
2 Psychiatry Journal
suicidal behaviours. Support for the primacy of emotional
dysregulation as a mediator of self-injury was provided
in a randomised controlled trial of cognitive behavioural
therapy (CBT) for 15- to 35-year-olds presenting with these
difficulties . Results indicated that emotion regulation
difficulties, specifically, impulse control and goal-directed
behaviours, partially mediated significant reductions in self-
injury; however, in contrast, measures of depression, anxiety,
mended, therefore, that interventions aimed at reducing self-
injury need to specifically target emotional dysregulation, in
preference to other associated mental health disorders.
A promising intervention aimed at improving emotional
regulation is dialectical behaviour therapy (DBT), devel-
oped by Marsha Linehan [14, 19] to treat chronically suici-
dal women diagnosed with borderline personality disorder
(BPD). Linehan’s biosocial theory, central to this interven-
tion, argues that BPD is principally the result of a dysfunc-
tional emotion regulation system associated with instability
of thoughts, emotions, behaviours, relationships, and self-
The original programme  was conducted over a one-
treatment components: weekly individual psychotherapy;
weekly group skills-based training; telephone consultation
between sessions; and weekly team consultation-supervision
meetings. Using principles and strategies drawn from behav-
iour therapy and Zen Buddhism, DBT is recognised as the
BPD  and has been accepted as an efficacious way of
treating various populations experiencing emotional dysreg-
ulation difficulties [22, 23].
Research to date suggests that adult women diagnosed
with BPD show improvements following DBT intervention.
Specifically, DBT has been found to be effective in reducing
targeted problem behaviours, such as self-injury and suici-
dality, thereby reducing hospital admissions and reducing
treatment dropout rates in severely impaired populations.
In less severe populations, DBT also appears to produce
specific improvements in suicidal ideation, depression, and
hopelessness [20, 23, 24].
to suit 13- to 19-year-old suicidal adolescents presenting with
borderline personality traits . Treatment was reduced
individual psychotherapy was also provided, with family
members included when family issues predominated. A fam-
to act as a coach, improve generalisation of treatment effects,
and reduce family dysfunction. The number of skills taught
was reduced and the language was simplified to improve
learning within 12 weeks. A fifth skills module, “Walking the
Middle Path,” was also added. Adolescents who completed
consultation group, which relied on peer teaching and rein-
forcement, so that adolescents were able to help each other
strengthen the skills learnt in the first three months of the
At the time of the current study development, only
three clinical trials of the DBT-A group had been conducted
on adolescents presenting with suicidal and self-injury
behaviours. The first was a nonrandomised controlled trial
for adolescents, aged 14–19 years, who were predominantly
females, and compared a DBT group with a treatment-as-
usual group . The DBT-A group included adolescents
who had attempted suicide and who also presented with
a minimum of three additional borderline features. The
treatment-as-usual group included suicide attempters only.
No difference was found between the groups on rates of
suicide attempts; however, DBT-A adolescents had a lower
rate of treatment dropout and fewer days of inpatient care.
Within the DBT-A group, significant reductions in suicidal
ideation, anxiety, and depression were shown. Significant
reductions were also found in self-reported BPD symptoms
in the areas of confusion about self, impulsivity, emotional
dysregulation, and interpersonal problems .
Another nonrandomised controlled trial was conducted
with adolescent girls residing in three juvenile rehabilitation
units . This four-week adaptation of DBT found mixed
results when comparing measures of behavioural problems
and staff punitive responsiveness between groups of adoles-
ing DBT in a general populationunit, against a treatment-as-
usual group. Notably, no inclusion or exclusion criteria were
used and adolescents in the two DBT comparison groups
were distinctly different from each other in terms of behav-
ioural problems, with the mental health adolescent group
presenting with more severe mood and thought disturbance.
Not unexpectedly, the mental health group showed a marked
reduction in problem behaviours following the four-week
DBT intervention; however, the general population group
showed no reduction in problem behaviours.
In the third trial, adolescents aged between 14 and 17
years were treated with a two-week adaptation of the original
DBT-A programme  in an inpatient psychiatric unit .
Comparisons were made with a treatment-as-usual group
and indicated similar improvements in depression, suicidal
ideation, and hopelessness for both groups. However, the
DBT-A group also showed significantly reduced behavioural
incidents on the ward.
A review of the above studies highlighted that the quality
of the data was highly questionable due to factors of selec-
tion bias, confounding variables, difficulties with outcome
measures, and measurement errors . The review con-
cluded that the efficacy of DBT-A in reducing mental health
symptoms in adolescents was yet to be established. Specific
recommendations for future research were made: firstly, that
treatment needed to occur in outpatient settings to minimise
the influence of confounding environmental factors on treat-
ment outcome, as can occur in hospital-based settings; and
used, as all studies incorporated adult and/or child measures
that were likely to have been clinically insensitive to the
symptomatology of adolescent presentations.
Apart from these three trials, there has also been a
study using a within-case design to test DBT with adolescent
females, aged between 13 and 19 years, presenting with
nonsuicidal self-injurious, and suicidal behaviour within an
outpatient setting . The programme consisted of weekly
individual therapy, a weekly multifamily skills group, and
telephone support, conducted over a 16–24-week period.
Results from this study were promising, with adolescents
showing reductions in nonsuicidal, self-injurious, and suici-
dal behaviour, as well as improvements in interpersonal rela-
tionships, identity disturbance, impulsivity, and depression
over the course of the treatment and at one-year followup.
However, given the lack of a supervision/consultation group,
it could be argued that treatment integrity was somewhat
problematic, given this was one of the four treatment com-
it is difficult to assess whether or not patients actually receive
most recent study to date  did not address the issue of
The aim of the present study was to develop and pilot
a DBT-A programme, based on the original adolescent pro-
gramme , and assess its feasibility and efficacy in treating
a community-based outpatient population of adolescents
presenting with NSSI and suicidality. Based on the literature,
A lead to improvements in adolescents’ capacity to regu-
late their emotions? and, given the links between emotion
dysregulation, borderline personality symptoms, and early
trauma experiences, (2) would improvements in emotion
regulation produce comparable reductions in trauma-related
symptoms, self-injurious behaviours, and suicidality? From
the outset, attention was paid to ensure that the measures
were appropriate to the age group. In addition, all measures
Importantly, emotional dysregulation was operational-
one’s emotions or of one’s behavioural reactions to emotions”
[31, page 241] and relates to the measure of emotional regula-
tion developed for the current study, the Modified Affective
Control Scale for Adolescents (MACS-A) . In the devel-
opment of the original adult measure, the Affective Control
Scale (ACS) , the fear of fear concept was extended to
to internal events, and the perceived ability of individuals to
Linehan  reveals her acknowledgement of the part played
by the fear of anger and of losing control over anger in self-
injuring borderline patients, stating “In almost all cases, the
under expressive borderline individuals have a marked fear
and anxiety about anger expression; at times they fear that
they will lose control if they express even the slightest anger,
and at other times they fear that targets of even minor anger
expression will retaliate” (page 16). Indeed, research in adult
populations has found that the fear of one’s own emotions
is associated with maladaptive psychological outcomes, such
and symptoms of borderline personality disorder [33–35].
Two predictions were generated within the present study.
First, it was predicted that 14- to 16-year-old adolescents
presenting at a community-based Child and Adolescent
Mental Health Service with NSSI and suicidality would
report a decrease in trauma-based symptoms on the Trauma
Symptom Checklist for Children  and reduced acts of
self-injury and suicidal thoughts, following participation in
a 26-week DBT-A programme. Second, it was predicted that
a reduction in trauma symptoms, self-injury and suicidal
regulation as measured by a decrease in scores on the
from the Human Research Ethics Committee at Murdoch
University, Perth, WA, Australia, and the Human Research
Ethics Committee of the South Metropolitan Area Health
Service, WA, Australia. All adolescents and their parents
participating in this research did so voluntarily.
2.2. Participants. Six female adolescents aged between 14.6
in this pilot programme. Three adolescents were current
clients of the Child and Adolescent Mental Health Service
(CAMHS), while the remaining three adolescents had been
recently referred to CAMHS. A parent accompanied all
adolescents to the family skills-training component, so that
the final group included four mothers and two fathers. Of
the six dyads participating, four dyads completed the entire
26-week programme and the remaining two dyads were
prior to treatment completion. All six dyads were available
for posttreatment (t2) assessments, while five dyads were
available for three-month followup (t3).
Adolescents were considered appropriate for the DBT-A
programme based on the following criteria:
(i) Aged between 13 and 18 years.
(ii) Average cognitive ability (clinician’s notes,
school records) and established reading level
(year 5), as measured by the Neale Analysis of
Reading Ability .
(iii) Referred to the service because of deliberate
self-harm and/or suicidal ideation in the previ-
ous 12 months.
(iv) A minimum of three BPD features, as deter-
mined by clinician assessment and according to
(i) A primary diagnosis of a psychotic disorder.
(ii) A primary diagnosis of substance abuse.
(iii) An intellectual disability.
4 Psychiatry Journal
2.3. Design. The process of implementation and assessment
of this 26-week pilot group was as follows:
(i) 8-week engagement and commitment to DBT-A: treat-
ment contracts signed by adolescents and parents,
measures administered prior to engagement.
(ii) 18-week DBT-A treatment: (t2) posttreatment mea-
sures administered at completion of programme.
(iii) Followup: (t3) 3-month follow-up measures adminis-
2.4.1. Intake Measures
of suicidal adolescents presenting with borderline features
have used a structured clinical interview, the SCID-11 ,
the SCID-11 was designed for use with individuals aged 18
years and older and its construct validity and predictive
ability with adolescents has been challenged . Therefore,
assessment of borderline features for the purposes of this
study was determined in a clinical interview, by reference to
criteria set out in the Diagnostic and Statistical Manual IV
Neale Analysis of Reading Ability . Adolescents were
screened individually on this measure of reading ability. The
Neale Analysis is a standardised measure of both reading
accuracy (word recognition in context) and reading compre-
about a passage). A reading age equivalent of age 10 was
needed to understand programme content.
2.4.2. Outcome Measures
Self-Harm/Suicidal Thoughts Questionnaire: Parent and Ado-
lescent Versions. A self-report questionnaire, developed spe-
cifically for this programme, consisted of three sections: sec-
tion one assessed various forms of self-injurious behaviours,
extent of each self-injurious behaviour, including age when
commenced, frequency, and seriousness (requiring medical
treatment); section three assessed frequency of suicidality.
Modified Affective Control Scale for Adolescents (MACS-A)
. This 41-item self-report questionnaire was developed
specifically for the current programme as a measure of ado-
version of an adult measure of emotion regulation, the
AffectiveControlScale (ACS) . Thisscale consistsof four
subscales that measure fear of anger (8 items), fear of depres-
sion (8 items), fear of anxiety (13 items), and fear of positive
emotion (12 items). Participants rate each item on a 7-point
Likert scale, from “very strongly disagree” to “very strongly
in the subscale. An overall scale score is computed as the
mean of all 41 responses, with the higher the mean score,
difficulty in emotional regulation. The MACS-A was found
to be internally consistent in both clinic and nonclinic ado-
lescent samples and to effectively discriminate between these
subscale . For this reason, results from this subscale were
not included in the current analysis.
Trauma Symptom Checklist for Children (TSCC) . This
54-item self-report measure assesses a variety of symp-
toms associated with trauma experiences in children, aged
between 8 and 16 years. Participants rate each item on a
5-point Likert scale, from “not at all characteristic” to “very
characteristic” of themselves. The measure has two validity
concerns and dissociation. There are also two additional
subscales: sexual concerns (sexual preoccupation and sexual
distress) and dissociation (overt dissociation, fantasy). The
reliability and validity of the TSCC were independently
centage witha historyof sexual abuse . These researchers
found that all six scales and four subscales of the TSCC were
a reliable and valid measure of distress in a psychiatric ado-
lescent sample. The current study does not report on results
from dissociation (fantasy) or the sexual concerns subscales.
with the programme coordinator. Programme content and
commitments were explained, and consent forms were com-
pleted including consent for the videotaping of all individual
and group sessions.
3.1. DBT-A Programme Development (Life Surfing). This pro-
gramme was developed over the course of 2005 and 2006,
based on a previous adaptation of DBT for adolescents 
that was modified from adult programme content [14, 19].
Similar to previous versions , there were four treat-
ment components: individual therapy, a multifamily skills-
training group, phone consultation, and a therapist super-
vision/consultation group. All four components were built
into this pilot programme, entitled “Life-Surfing,” with the
of clinician indemnity. In addition, the family skills group
ran for 18 weeks, whereas the original DBT-A programme
 ran for 12 weeks. The following is a description of the
components of the DBT-A, “Life-Surfing” programme.
(1) Individual Therapy. Adolescents were seen weekly (twice
ture of individual treatment was in line with the standard
DBT protocol , which set out a prescriptive treatment
hierarchy consisting of four stages:
(a) a pretreatment stage involved orienting the client to
treatment, gaining commitment, and agreeing on the
goals of treatment;
(b) first stage focused on client stability, connection, and
safety and structured with a specific subhierarchy of
(i) decrease life-threatening behaviours;
(ii) decrease therapy-interfering behaviours;
(iii) decrease quality-of-life interfering behaviours;
(iv) increase behavioural skills;
(c) second stage involved exposure and emotional pro-
cessing of the past;
(d) third stage looked at increasing respect for the self-
and individual goals.
As recommended , family members were invited to
join individual sessions when systemic issues dominated.
(2) Family Skills Training Group. This group was highly
structured and ran for two hours each week. Sessions were
psychoeducational in focus with an emphasis on acquisition
and practicing of new skills. There were five modules written
for the DBT-A programme: Core Mindfulness, Distress Tol-
Path. Modules were presented in the above sequence, and
mindfulness module, which ran for two weeks. Core mind-
fulness skills were revisited throughout the length of the pro-
gramme, and, by the ninth week of the skills training group,
adolescents and/or parents volunteered to run the mind-
fulness exercise that commenced each week’s group skills-
training session. The family skills-training group ran for 18
(3) Phone Consultation. Provided during business hours and
focused on helping adolescents use skills learnt during the
(4) Supervision/Consultation Team. A group of interested
CAMHS clinicians formed the supervision/consultation
out the length of the programme implementation. This was
a multidisciplinary team consisting of individuals trained in
clinical psychology, social work, and psychiatry. Initially, the
purpose of this team was to develop the programme con-
tent and structure, including programme viability, funding,
ethical considerations, and clinical concerns, as well as to
provide ongoing education regarding the implementation of
vided clinical supervision and addressed treatment integrity
training sessions, as recommended .
3.2. Programme Commitments. Adolescents, parents, indi-
vidual and group skills clinicians, and supervision/consulta-
formed the basis of the programme contracts signed by
adolescents, parents, and clinicians as follows:
(i) Adolescents agreed to
(a) weekly individual therapy for the length of the
programme (26 weeks);
(b) weekly family skills-training group (18 weeks);
(ii) Parents agreed to
(a) weekly family skills-training group (18 weeks);
(b) videotaping of all group sessions.
(iii) Clinicians agreed to work with clients for 6 months
(a) weekly individual therapy: 26 weeks (individual
(b) weekly family skills group: 18 weeks (group
(c) clinical consultation/supervision group (2hrs/
(d) videotaping of all therapy sessions.
Individual and group clinicians also agreed to take no
more than two weeks leave within the six-month period of
3.3. Clinician Experience and Training. All members of the
team received one full day of in-house DBT training, con-
ducted by two clinical psychologists who were members of
the DBT consultation/supervision team. One of these clini-
cians had attended a five-day intensive training workshop on
DBT conducted by Linehan’s training organization, Behavior
Tech., while the other clinician was at that time coordinating
an adult DBT programme and was also a coleader of the
group skills-training component of that programme.
3.4. Treatment Adherence Check. An estimate of individual
and group therapist adherence to the basic strategies of DBT
was conducted by rating a random sample of five recorded
individual therapy sessions and five recorded group skills-
training sessions against a DBT adherence rating scale. The
third author, who is a recognised trainer in DBT, rated these
sessions.Themeanadherence ratingwas4.0 outofapossible
5.0, with a range of between 3.5 and 4.5.
The effect of the programme was investigated by using group
mean scores to calculate the Wilcoxon signed-rank test at
6 Psychiatry Journal
Table 1: Pre- (t1) and posttreatment (t2) comparisons on the TSCC for the 6 participants.
Statistics (t1 to t2)
푃 = 0.046∗
푃 = 0.92
푃 = 0.038∗
Effect size 푟
푃 = 0.042∗
푃 = 0.043∗
∗sig < 0.05 (2 tailed).
Table 2: Pre- (t1) and three-month follow-up (t3) comparisons on the TSCC (푛 = 5).
Mean SD Mean
Pretreatment (t1)3-month followup (t3)Statistics (t1–t3)
푃 = 0.043∗
Effect size 푟
푃 = 0.043∗
푃 = 0.138
푃 = 0.068
푃 = 0.043∗
∗sig < 0.05 (2 tailed).
t1 (pretreatment), t2 (posttreatment), and t3 (three-month
large > 0.5. However, in interpreting the meaningfulness of
interpretation is a complex and subjective process .
calculated, basedon thestandardised differencebetween two
means for dependent groups. Initial interpretation of effect
size (푟), set out below, used the general convention provided
effect sizes, it has been noted that a practically significant
result is one that has meaning in the real world, and
by Cohen  as follows: 푟 : small > 0.10, medium > 0.3,
4.1. Changes in Suicidal Thoughts and Deliberate Self-Harm
Behaviours. Prior to commencement of therapy, all six ado-
lescents were reporting suicidal thoughts at a minimum of
twice weekly to a maximum of several times a day. One
sion. During treatment, and 12 months after treatment, no
adolescent attempted suicide. At the end of the programme,
one adolescent reported continuing suicidal thoughts once a
week, one other adolescent reported suicidal thoughts once
a month, while the remaining four adolescents reported no
further suicidal ideation.
All adolescents reported regular DSH for at least three
months prior to entry to DBT-A treatment. At the end of
the programme, five of the six adolescents had ceased to
self-harm over the course of treatment, while the remaining
adolescent reported a 50% reduction in DSH events.
4.2. Comparison between Trauma-Related Symptoms at
Pretreatment (t1), Posttreatment (t2), and 3-Month Followup
(t3). All participants produced valid TSCC protocols at t1,
t2, and t3, as indicated by nonsignificant levels of over- and
underresponding. Table 1 presents pre- and posttreatment
comparisons on subscale scores of the TSCC, revealing large
and statistically significant decreases in mean scores on self-
0.58), and posttraumatic stress (푧 = −2.02,푃 < 0.05,푟 =
followup comparisons on subscale scores of the TSCC,
revealing large and significant decreases in mean scores on
stress (푧 = −2.02,푃 < 0.05,푟 = 0.64). There was also a large
reported anxiety (푧 = −2.07,푃 < 0.05,푟 = 0.60), depression
(푧 = −2.03,푃 < 0.05,푟 = 0.59),anger(푧 = −2.0,푃 < 0.05,푟 =
Table 2 presents pretreatment (t1) and three-month (t3)
self-reported anxiety (푧 = −2.02,푃 < 0.05,푟 = 0.64),
decrease in mean scores at three-month followup on self-
reported anger; however, this decrease was nonsignificant
depression(푧 = −2.02,푃 < 0.05,푟 = 0.64),andposttraumatic
(푧 = −1.83,푃 < 0.05,푟 = 0.58).
4.3. Comparison between Emotional Regulation at Pretreat-
ment (t1), Posttreatment (t2), and 3-Month Followup (t3).
Table 3 presents pre- and posttreatment comparisons on the
whole-scale and subscale scores of the MACS-A. On the
whole-scale measure of fear of emotion, there was a large
but statistically nonsignificant decrease in mean scores (푧 =
and statistically significant decrease in self-reported fear
decrease in fear of depression (푧 = −0.95,푟 = −0.28);
Table 4 presents pretreatment (t1) and three-month
follow-up (t3) comparisons on the whole-scale and subscale
of fear of emotion indicate a moderate decrease in mean
scores from pretreatment to three-month posttreatment;
−1.78,푃 > 0.05,푟 = −0.51) from pretreatment to posttreat-
ment. Comparison of subscale mean scores revealed a large
−2.20,푃 < 0.05,푟 = −0.64) and a small but nonsignificant
of anger between pretreatment and posttreatment (푧
however, the decrease in fear of anxiety was both negligible
and nonsignificant (푧 = −0.21,푃 > 0.05,푟 = −0.06).
Table 3: Pre- (t1) and posttreatment (t2) comparisons on the MACS-A (푛 = 6).
Table 4: Pre- (t1) and three-month follow-up (t3) comparisons on the MACS-A (푛 = 5).
Mean SD Mean
4.6 1.41 3.36
4.4 1.03 2.88
4.01 0.91 3.1
Pretreatment (t1)Posttreatment (t2) Statistics (t1 to t2)
푃 = 0.028∗
Fear of Anxiety
Fear of Anger
Fear of Depression
Fear of Emotion
Effect size 푟
푃 = 0.833 −0.06
푃 = 0.34−0.28
푃 = 0.075
∗sig < 0.05 (2 tailed).
Pretreatment (t1)3-month followup (t3) Statistics (t1 to t3)
푃 = 0.225
Fear of Anxiety
Fear of Anger
Fear of Depression
Fear of Emotion
푃 = 0.138
Effect size 푟
푃 = 0.042∗
푃 = 0.225
∗sig < 0.05 (2 tailed).
−1.21,푃 > 0.05,푟 = −0.38). With regard to the subscales,
(푧 = −0.1.48,푃 > 0.05,푟 = −0.47) and fear of anxiety (푧 =
however, this change was not statistically significant (푧 =
results reveal a large and statistically significant decrease in
self-reported fear of depression (푧 = −1.21,푃 > 0.05,푟 =
ate but nonsignificant decrease in self-reported fear of anger
−1.21,푃 > 0.05,푧 = −0.38) three months after treatment.
The overarching goal of the current study was to develop and
pilot a DBT-A programme, based on the work of Miller et al.
, and to assess both its feasibility and efficacy in a
community-based population of adolescent females present-
ing with DSH and suicidal thoughts. A further focus was
to assess the central tenet of Linehan’s  biosocial theory,
which argues that emotional dysregulation underpins the
DSH and suicidal behaviours associated with a borderline
In discussing the results of the present study, recognition
research . When interpreting the practical significance of
findings, the majority of studies reporting on effect sizes fail
to interpret them in meaningful ways, with three important
factors being highlighted when considering interpretation
[42, page 34]:
(1) context: small effects may be linked to large conse-
quences and that small effects may be cumulative;
(2) contribution to knowledge when conducted in real-
(3) Cohen’s criteria.
current findings, it is important to emphasise the difficulties
of engaging with and treating this population of adolescents.
Effective early interventions are needed, given the high costs
of multiple hospital admissions and the likely probability
of continued treatment through to adulthood. Given this, it
could be argued that even small effect sizes, whereby one or
practically significant over a longer term.
Results of the current study provided support for our
programme would report a decrease in trauma-based symp-
toms on the TSCC and reduced acts of self-injury and
suicidal thoughts. Adolescents reported large and significant
reductions in their symptoms of anxiety, anger, depres-
sion, and posttraumatic stress immediately following DBT-A
treatment. Three months following the end of treatment,
in anxiety, depression, and posttraumatic stress symptoms
meaningful reduction in dissociative symptoms immediately
following treatment, moderate reductions were reported
three months after treatment completion. These results are
consistent with earlier research where significant reductions
by the TSCC, were found in a group of self-harming and sui-
outpatient clinic . Furthermore, the present study find-
ings regarding the cessation of self-harm and reduction in
with earlier DBT-A research .
Results from the present study also provided support for
our second hypothesis that adolescents participating in the
DBT-A programme would show an improved capacity to
tantly, on average, adolescents reported a large reduction in
their fear of emotion following treatment, and this decrease
was maintained, albeit more moderately, three months fol-
lowing treatment. On the fear of anger subscale scores of the
MACS-A, adolescents reported a large a decrease following
8 Psychiatry Journal
treatment, but this was not maintained three months after
treatment. On average, adolescents also reported a small
reduction in their fear of depression immediately following
treatment, and, encouragingly, this reduction became both
large and significant three months after treatment comple-
tion. Although there were no reported meaningful improve-
ments in adolescents’ fear of anxiety on completion of treat-
Overall, these results suggest that this group of adoles-
cents reported an improved capacity to manage their strong
emotions following participation in the DBT-A programme,
months later. In particular, they reported that their fear of
depression and fear of anxiety continuedto decrease over the
three-month period following the end of all treatments. This
result supports previous findings  that treatment gains
made by self-harming adolescent females following DBT
ment, but continued to show further improvement. Given
the importance of the therapy relationship as a container of
emotion,particularlyin this population, the findingthat
to report continuing reductions in their fear of depression
and anxiety three months after the cessation of all treatment
Importantly, specific recommendations made in a review
 of the data from past clinical trials were addressed
within the current study. First, treatment occurred within a
ing effects of environmental factors that are likely to occur
within an inpatient setting. Second, the current study used
the development of a measure that specifically assessed emo-
tional regulation in adolescents in the form of perceived fear
of emotions, shown by past studies to be linked to problem-
atic mental health outcomes, including borderline personal-
The present study determined an acceptable level of DBT
treatment adherence from rating a random sample of taped
individual and group sessions.
Confidence in the findings from the present study was
lect pre-, post-, and follow-up measures, thereby minimising
the potential for bias that has occurred in other studies .
Furthermore, determining adolescents’ capacity to under-
stand the programme material through formal assessment
of their reading level and comprehension has not occurred
in previous studies and adds to the reliability of the current
From a service provision perspective, this study contains
some other specific strengths. Of the six adolescents partici-
pating in the programme, only one remained in therapy fol-
lowing the end of the programme. Notably, one other adoles-
cent, who had been treated at the clinic at various times since
she was six years of age, did not return for any further
treatment following the ending of the DBT-A programme,
with followups revealing that she had moved into full-time
to CAMHS clinics is a common problem, combined with
the high probability for these adolescents to move into adult
mental health services, this finding is of great practical
The current study also had some limitations inherent
within its design. Specifically, as a pilot study, it lacked a
control group, and, therefore, specific conclusions about the
effectiveness of the programme cannot be made. Neither
can it be concluded that the DBT-A programme was more
four of the six adolescents completed the programme, which
is comparable to the 62% completion rate of other studies
. Given the high rates of treatment dropout usual for
this population, this finding provides some support for the
potential effectiveness of DBT-A with these adolescents. A
further limitation of this study was the potential influence
of demand characteristics on self-report measures. Future
studies would benefit from the collection of more objective
markers of treatment effectiveness, for instance, collateral
information from parents and schools.
In this pilot programme, we found preliminary evidence
that DBT-A for the treatment of NSSI and suicidality in
adolescents was both feasible and efficacious. Despite limited
funding for this project, a DBT-A programme was success-
fully developed and piloted in the community setting in
which these high-risk adolescents are most likely to seek
be monitored over time.
Conflict of Interests
The authors declare that they have no conflict of interests.
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