A comparison of online and face-to-face Dialectical Behaviour Therapy: A parallel group randomized trial and pragmatic evaluation

This project will compare the outcomes of face-to-face provision of Dialectical Behaviour Therapy (DBT) with online delivery in a naturalistic setting. The standard DBT programme consists of individual therapy, skills training (undertaken in groups), the opportunity for out-of-session skills coaching if required and therapists who are supported by attendance at a weekly consultation group. Multiple mental health practitioners employed by The Australian DBT Institute will deliver the intervention. Practitioners qualifications comprise Psychologist's, Mental Health Social Workers and Mental Health Nurses. The DBT Institute utilises a DBT- trauma informed (DBT-TI) adaptation to the standard DBT program developed by Marsha Linehan (1993). DBT-TI was developed by the DBT Institutes founder Dr Peter King to address the gap in trauma informed practice in DBT. The Institute’s comprehensive DBT-TI program comprises all modes of treatment identified in standard DBT (Linehan, 1993): Individual Therapy (including commitment), DBT Skills Training, Phone Coaching and Consultation team with a trauma informed lens. Individual therapy is typically 60-90 minutes duration and held weekly. Group skills training is typically 3 hours duration, face-to-face and 90 minutes undertaken online. In the trauma informed DBT approach, Individual Therapy consists of a pre-treatment stage, in addition to psychosocial assessment, orientation and commitment, in conjunction with specific assessment of trauma conducted by an intake clinician. Following this, there is a phase of stabilization conducted by an individual therapist, trained in the trauma informed DBT approach, in which patients are assisted to become aware of existing resources and to promote a sense of self-agency in participants that also includes feeling safe and contained. Furthermore, psychoeducation, neuroeducation and a learning style assessment are carried out so that individuals gain awareness and understanding of their presenting symptoms, triggers, somatic markers as well as ways of maintaining themselves in the regulated zone or ‘window of tolerance’ (Baldini et al., 2014) and preventing autonomic dysregulation with strategies such as ‘applying the brakes’ (Rothschild, 2017, p. 79) in distressing situations. Part of the stabilization phase is weekly engagement in DBT skills training in a group setting where participants learn how to integrate the new skills into their environments. Attendance is recorded for both group engagement and individual therapy. The 27 week group therapy program consists of three modules each of 9 week duration. Outcome measures are administered at the beginning of each 9 week module and consist of • The Depression Anxiety & Stress Scale 21 (DASS-21) (Lovibond & Lovibond, 1995) • Difficulties in Emotion Regulation Scale (DERS-16) (Gratz & Roemer, 2004) • The Borderline Symptom List (BSL-23) and supplementary behavioural questions (Kleindienst et al., 2020). All standard measures generally used in DBT programs. DBT is focused on a treatment hierarchy commencing with life threatening behaviours, therapy interfering behaviours and those which interfere with quality of life (Linehan, 1993; Linehan, 2015). The incidence of negotiated treatment targets (thoughts, feelings or behaviours) are recorded on bespoke diary cards unique to each individual. It is therefore proposed that individuals provide a brief statement about what their aspirations are at the beginning of treatment and a summary of what they have addressed and what is important to them at commencement and at the end of each skills module. Qualitative Interviews The purpose of these qualitative interviews are to provide a case series to illustrate in a more personal way how people progress in DBT, what outcomes are most meaningful and what is most helpful in achieving those outcomes. The most closely matched client who consents to being interviewed (according to baseline measures) in the face-to-face therapy will be matched with an on-line allocated client (most closely matched) for each therapist. These clients will be interviewed near commencement, approximately half-way through the programme, on completion and at 36 weeks (3 months follow-up). With their permission they will be interviewed with their therapist. A minimum of 6 clients will be interviewed. Whilst the focus will largely be on the client’s experience interviewing the therapist and client together acknowledges the importance of the therapeutic alliance between personal therapist and client (Bedics et al., 2015) and enables the therapist to work through any issues which might arise for the client in that conversation. Discussions about treatment goals and progress with DBT therapists is a usual practice and open discussion about the alliance which includes shared goals and understanding is considered so important that tools have been developed to facilitate such conversations at every session and across psychotherapeutic approaches (Duncan et al., 2003). Actual skill use has been found to be a predictor of symptom improvement and retention in therapy (Barnicot et al., 2016). Gauging which skills individuals have learned, used and found useful will provide a potentially rich insight into the process of therapy. The interviewer will be an experienced DBT therapist (with no association with the Australian DBT Institute) and the and will address in a semi-structured way the following questions: 1. What the expectation and focus of treatment has been; 2. What elements of the process have been considered most helpful or challenging; 3. What have been the most personally significant outcomes for individuals; 4. What skills have been acquired and been found to be useful. The qualitative data will be analyzed using inductive methods informed by grounded theory (Corbin & Strauss, 2014). Members of the team have utilized a similar method to describe the process of change in a naturalistic DBT programme (Lakeman & Emeleus, 2020).