Testing the efficacy of an Emotion Regulation Group Therapy for adolescent non-suicidal self-injury in Aotearoa New Zealand

This randomised control trial (RCT) aims to assess the effectiveness of Emotion Regulation Group therapy (ERGT) in reducing non-suicidal self-injury among adolescents in primary and secondary health services, and secondary school pastoral care, as an adjunct to treatment as usual (TAU). Non-suicidal self-injury (NSSI: direct and deliberate destruction of body tissue) will be the main outcome variable under study. Participants will be randomly allocated either into the TAU condition (control group), or TAU plus ERGT (experimental group). We aim to test the hypothesis that participants in the experimental condition will have significantly greater reductions in their NSSI compared to participants in the control group, over the course of therapy and the follow-up period. Questionnaire data will be collected from participants, their families and clinicians pre-, post- and at follow-up intervals regarding their well being, emotion regulation capacity and self-injury, to assess changes over time. ERGT was originally developed by Kim Gratz and Matthew Tull, to reduce self-injury among adults with significant mental health problems. We have adapted ERGT slightly, for adolescents in New Zealand. Gratz and Tull are collaborating on this project, and will assist with maintaining treatment fidelity, but providing supervision, and reviewing our amended ERGT materials. This will ensure that the project team are adhering to the original tenants of ERGT. Where possible, ERGT sessions will be recorded, and these recordings reviewed during supervision. to assess adherence to the concepts of ERGT. ERGT clinicians will have regular meetings to review their practice. Materials used in the study include a therapy manual, treatment booklet for participants in the experimental group (with ERGT materials and homework exercise), and questionnaires for the collection of data. ERGT involves weekly sessions of group therapy, over a period of 14 weeks. Specifically, there will be 14 weekly sessions; one session per week for 14 weeks. Each session is 90 minutes long. Homework will be assigned each week. The homework will take approximately 20 minutes every week. Intervention will occur at multiple locations, including secondary mental health services (i.e. Child and Adolescent Mental Health Services, CAMHS), primary mental health services (e.g. Evolve in Wellington, a youth health and support agency), and secondary schools, in the Wellington region. Two facilitators will conduct each group, with 6 - 8 participants in a group. Facilitators will be trained in providing psychological treatment to mental health clients, and have a background or some experience in either Dialectical Behaviour Therapy or Acceptance and Commitment Therapy. At least one of the two facilitators of each ERGT group will be trained in ERGT, either at an ERGT training provided by Gratz and Tull, or training provided by the lead clinicians on the research team (Garisch and O'Connell). ERGT training will be run over 3 days. The training resources will include the treatment manual (which will be reviewed), including the client worksheets, and videos of either recorded sessions (with client consent) or videos of mock-ERGT sessions developed for the purposes of training. The training will be delivered face-to-face, and provided in a group setting (attendees will likely come for a range of service backgrounds, including primary and secondary services, and secondary schools). The three day training will occur over three consecutive days, from 9am - 5pm each day. Training will occur well in advance of the start of the intervention. ERGT is aimed at developing clients' emotion regulation capacity. ERGT is aimed at helping clients respond to their emotions in more helpful ways, and learning to better understand the functions of emotions and what information may be gleaned from their emotional experience. The treatment includes psychoeducation regarding emotions, and goes through strategies to enable more healthy responses to emotions. Self-injury and its antecedents and consequences are discussed, as a way to determine what emotions may trigger self-injury, and how these emotional experiences and needs can be met in a healthier way. The later part of the group involves values work, and encouraging clients to act and make decisions in accordance with their values and goals, rather than fall into unhelpful responses to manage their emotional distress. Treatment as usual will be varied. All participants will need to be engaged in face-to-face work with a case manager or individual clinician. All ERGT participants will be engaged in TAU alongside completing ERGT, The ERGT group is a skills group, not a process group. All issues regarding process, and risk, will be managed by participants ordinary clinician and treatment team. Participants in the experimental group will also receive Treatment as Usual (TAU). We are testing whether ERGT improves reductions in NSSI over and above TAU alone. TAU is likely to be varied, and depend on the treatment site, severity of presentation, and the training background of participants' individual clinician or case manager. TAU is likely to include Cognitive Behavioural Therapy (CBT), treatment that includes components of Dialectical Behavioural Therapy (DBT) (i.e. DBT skills taught in individual face-to-face sessions), Acceptance and Commitment Therapy, and psychotherapy. TAU may also include a family therapy component, or psychological support for a primary caregiver (e.g. to assist in their response to their child's mental health concerns). TAU will continue for as long as required under treatment sites usual protocol (i.e. ordinarily until a client shows substantial benefit to no longer need service intervention, or until a participant or their family self-selects to discontinue treatment). The research study will follow participants for a minimum of 12 - 18 months, to enable to collection of follow-up data. Please note that this trial is in the early stages. Several factors may vary once initial groups have been conducted to 'pilot' ERGT in this population and check feasibility. For example, we may reduce the number of ERGT sessions, as the adult materials will be made shorter and less cognitively taxing, which may lead to less time needed to administer the skills group.