Assignment 2

Research Project 1

Literature Review

Dialectical Behavioural Therapy for Adolescents (DBT-A)

A Pre-Post-Test Efficacy Study of a 12-week DBT-A Program for the Treatment of
Borderline Symptomology in an Early Intervention Youth Mental Health Service

Background and Rationale

Borderline Personality Disorder (BPD)

BPD is a severe but treatable mental health (MH) condition (Choi-Kain, Albert & Gunderson
2017; Kaess, Brunner & Chanen, 2014), which is characterised by marked functional
impairment and significant emotional and interpersonal difficulties (McMain & Pos, 2007).
The Diagnostic and Statistical Manual 5 describes BPD as “a pervasive pattern of instability
of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in
early adulthood and present in a variety of contexts.” (American Psychiatric Association,
2013, p. 663). A diagnosis is made when five of nine criteria are met. The criteria include 1)
Frantic efforts to avoid abandonment, 2) unstable and intense interpersonal relationships, 3)
identity disturbance, 4) impulsivity, 5) recurrent suicidal behaviour or self-mutilation, 6)
affective instability, 7) chronic feelings of emptiness, 8), inappropriate, intense anger or
difficulty controlling anger and 9) transient, stress-related paranoid ideation or severe
dissociative symptoms (American Psychiatric Association, 2013).

The Scope of the Problem

Prevalence
BPD is the most common personality disorder (Chanen, 2015). The onset of clinically
distinct borderline symptoms is typically in late childhood to early adolescence (Fonagy et
al., 2015). For example, research indicates 30% of individuals with BPD begin self-harming
at age 12-years or less, with another 30% commencing self-harm between the ages of 13 and
17 (Zanarini, Frankenburg, Ridolfi & Jager-Hyman, 2006). Longitudinal data reveals an
increase in BPD traits after puberty which reaches its peak in early adulthood then decreases
across the remainder of the life course (Tackett, Balsis, Oltmanns & Krueger, 2009).
In the general population, 1.4% meet BPD diagnostic criteria by the age of 16. This rises to
3.2% by the age of 22-years (Johnson, Cohen, Kasen, Skodol & Oldham, 2008). In clinical
settings the rates of BPD are even higher, with approximately 11% of patients meeting full
criterion in outpatient settings (Chanen et al., 2008) and up to 50% in inpatients (Johnson et
al., 2008).

High Personal, Social and Economic Burden

BPD is associated with severe impairment in psychosocial functioning (Stepp, 2012) and
quality of life when compared to non-disordered controls or controls with other MH disorders
(Feenstra et al., 2012). Additionally, it is associated with increased risk of injury and
mortality (Chanen, 2015) and high individual and societal monetary costs (Kaess, et al.,
2014).
The high-risk profile associated with BPD is particularly pronounced in adolescents due to
decreased impulse control typical of this developmental period (Macpherson, Cheavens &
Fristad, 2013). Research indicates adolescents with BPD commonly display higher rates of
self-harm, suicidal and other impulsive behaviours when compared to adults with BPD
(Chanen, 2015; Macpherson et al., 2013). The mortality rate in BPD is high, with up to 10%
of people with BPD successfully suiciding, a rate 50-times higher than the general population
(NMRC, 2012).
Other risk-taking behaviours, such as substance use and risky sexual practices also increase
during adolescence (Dawes, Mathias, Richard, Hill-Kapturczak & Dougherty, 2008; Stepp,
2012). Adolescents with BPD are even more likely to engage in these behaviours compared
to controls. This is reflected in the higher prevalence rates of Substance Use Disorder (Kaess
et al., 2012) and risky sexual behaviour when compared to adolescents with no MH issues or
other MH disorders (Chanen, McCutcheon, Jovev, Jackson, & McGorry, 2007). Collectively,
this contributes to the high rates of morbidity and mortality in adolescents with BPD
compared to both non-BPD adolescents and adults with BPD.

Further contributing to the burden associated with adolescent BPD is the high occurrence of
psychiatric co-morbidity. A research study examining co-morbidity in adolescence with BPD
found almost all outpatients and all inpatients had co-occurring MH disorders (Kaess et al.,
2014). The most common where Eating Disorders, Mood Disorders, Dissociative and Post
Trauma Disorders, Substance Use Disorders and others Personality Disorder’s (Kaess et al.,
2014). The frequency of comorbid disorders in adolescents with BPD was significantly
higher than in adolescents with other MH disorders (Kaess et al., 2012) and research indicates
that co-morbidity is higher in adolescents compared to adults with BPD (Kaess et al., 2014).

Finally, BPD is linked to the extensive use of MH services (Chanen, 2015), even in the
absence of a full diagnosis (Ten Have et al., 2016), in addition to significant family/carer
burden (Bailey & Grenyer, 2013). Further it is highly correlated with receiving disability
benefits even when compared to other MH conditions, such as depression and anxiety (Kaess
et al., 2014). As a result, BPD is associated with high social and economic costs. Therefore,
BPD in YP is prevalent, disabling and costly, these findings highlight the need for
intervention early in the disorders course.
The Need for Early Intervention (EI)
Research indicates there is a negative correlation between the duration of untreated illness
and prognosis in BPD (Fonagy et al., 2015). A staging model of illness applied to youth MH
guides the provision of evidence-based interventions appropriate to the stage-of-illness
exhibited (McGorry, 2013). This staging approach predicts early identification and treatment
of adolescent BPD will reduce chronicity and the related adverse health-effects (McGorry,
2013). Empirical data indicates delays to specific BPD treatment limits its effectiveness,
especially functional outcomes. (Bateman, Gunderson & Mulder, 2015). Currently,
longitudinal follow-up studies specific to the efficacy of EI for BPD is limited (Choi-Kain et
al., 2017).
However, existing research clearly indicates adolescents with a variety of MH issues
including BPD who do not receive satisfactory input struggle in various psychosocial areas
when compared to those who do (Fonagy et al., 2015). Specifically, a lack of intervention is
correlated with academic and behavioural deficits, difficulties finding and maintaining
employment (Essau, Lewinsohn, Olaya & Seeley, 2014) and increases the probability of
becoming involved in criminal activities in adulthood (Zara & Farrington, 2013).
Research indicates BPD during adolescences in linked with poorer adult psychosocial
functioning (Punnoose, 2011). For example, Winsper and colleagues (2015) reported in a
systematic review of the literature, the presence of borderline symptoms before the age of 19-
years is predictive of poorer long-term outcomes in role and social functioning, life-
satisfaction, academic and occupational achievement and the attainment of other important
adult milestones, when compared with those without BPD. This trend was also reported in a
longitudinal study by Winograd, Cohen and Chen (2008). Further, they reported that overall,
those with higher levels of early adolescent borderline symptoms scored consistently lower in
role/social functioning, and life satisfaction from middle-adolescence through to middle-
adulthood. These impairments remained stable for up to two decades post initial-diagnosis,
despite BPD symptom reducing with age.

Collectively, the finding highlights that much of the harm associated with BPD emerges early
and this underscores the importance of effective evidence-based EI to reduce the high
personal, social and economic burden associated with developing BPD in adolescence.

Historically, intervention for adolescents with BPD has been absent or non-specific (Kaess et
al., 2014), which may explain the poor longitudinal outcomes and prognosis reported in the
literature. It is proposed that EI could reduce the documented acute distress and chronicity of
BPD through mitigating and/or avoiding disruption to an adolescent’s developmental
trajectory and so exposure to learning opportunities linked to positive psychosocial
development. EI may also aid in avoiding or reducing adolescent morbidity and mortality
(Chanen et al., 2012).
Despite the documented need, diagnosis and BPD specific-treatment is commonly delayed
(Chanen et al., 2012). This decreases the treatments effectiveness and provides time for
potential iatrogenic complications to become entrenched (Bateman et al., 2015). However,
research indicate that BPD traits in adolescences are flexible and malleable (Lenz et al.,
2016) and adolescent BPD features respond to intervention (Chanen, 2015).
Barriers to Early Intervention
Unfortunately, there is a long-standing controversy regarding diagnosing BPD in adolescents,
due to concerns that the personality is not fully developed and that some BPD diagnostic
criterion, such as identity instability and emotional dysregulation may be developmentally
normative, increasing the possibility of making a false-positive diagnosis (Chanen & Kaess,
2012). However, a 20-year longitudinal study by Chanen and colleagues (2007) found a BPD
diagnosis differentiates the adolescent BPD group as having more severe symptoms and
lower levels of psychosocial functioning than those with other PDs or no PD at all.
Indeed, the data indicates that BPD is a reliable and valid diagnosis in adolescents (Stepp,
2012). The diagnosis has strong concurrent, divergent (headspace, 2016) and predictive
validity in youth (Chanen & Kaess, 2012; Miller, Muehlenkamp & Jacobson, 2008).
Empirical data indicates that a BPD diagnosis given in adolescence is as reliable as one given
in adulthood (Chanen et al., 2004; Miller et al., 2008). Cumulatively, this provides evidence
for the early-diagnosis of adolescent BPD.

Regrettably, BPD is also frequently seen in pejorative terms and is often associated with
stigmatising and pessimistic attitudes regarding diagnosis, prognosis and treatment (Choi-
Kain et al., 2017; Stepp, 2012). Research indicates that BPD is highly stigmatised among
health professionals (Aviram, Brodsky & Stanely, 2006) and traditionally clinicians have
attempted to protect young people (YP) from the stigma by withholding diagnosis (Aviram et
al., 2006). Indeed, underdiagnosis and misdiagnosis remains common (Choi-Kain et al.,
2017).

Unfortunately, if a correct diagnosis isn’t made, it reduces the probability of the individual
receiving evidence-based treatment, whilst increasing the likelihood of an incorrect diagnosis
being made. This increases the likelihood of inappropriate interventions being administered.
Which in turn elevates the potential for iatrogenic harm (i.e., polypharmacy effects).
Furthermore, it increases the duration of untreated illness, which is positively correlated with
poorer psychosocial outcomes (Fonagy et al., 2014).
Therefore, a strong empirical and ethical argument exists for early diagnosis and treatment of
BPD in adolescence (Kaess, et al., 2014). The DSM 5 and national guidelines for the
treatment of BPD in Australia and the UK reflect the mounting clinical support for EI
(American Psychiatric Association, 2013; NHMRC, 2012; NICE, 2009). There are several
evidence-based treatments available for adolescents with BPD symptomology.

Evidence Based Treatments for BPD

Currently the most common intervention for BPD is psychotherapy, a meta-analysis by Perry,
Banon, and Ianni (1999) suggests psychotherapy is linked with a recovery-rate seven times
faster than the illness-course of untreated BPD.
At present it is reasoned Universal Prevention (targeting whole population) of BPD is not
warranted or practicable. This is because BPD prevalence rates are not large enough to
justify a universal approach, and additionally the type and dose of intervention needed to
achieve Universal Prevention is unknown (Kaess et al., 2014). Similarly, Selective
Prevention (targeting those with risk factors for BPD) is not supported due to the lack of
specificity regarding most risk-factors related to BPD (Kaess et al., 2014) and BPD’s broad
diagnostic criterion, which makes determining the target group problematic (Byrne & Egan,
2018). Therefore, Indicated Prevention (targeting people with clinical signs and symptoms of
BPD) is currently the only evidence-based intervention (Chanen et al., 2007).
A number of therapeutic models are effective in the treatment of BPD (Fonagy, Luyten &
Bateman, 2017). The most studied and validated of these include; Dialectical Behaviour
Therapy (DBT), Mentalization-Based Treatment, and Transference-Focused Psychotherapy
(Choi-Kain et al., 2016).

The Efficacy of Psychotherapeutic Models

Cristea and colleagues (2017) recently analysed the efficacy of DBT, Psychodynamic
Therapies (Mentalization and Transference-Focused Therapy) and CBT for the treatment of
BPD in a meta-analysis of 33 studies of specialised psychotherapy with adult BPD patients.
Overall, specialised therapies where more effective than non-specialised in reducing BPD
symptoms, levels of general psychopathology and MH service utilisation. These effects
where maintained for up to two-years post-intervention. This study reported a small to
moderate effect size supporting DBT and Psychodynamic Therapies as superior to non-
specific treatment or TAU. CBT was not found to be more effective than non-specialised
therapies or TAU and there was no significant difference between DBT and Psychodynamic
therapies. The analysis also revealed no adverse effects from the interventions,
demonstrating psychotherapy for BPD is both effective and safe (Fonagy, et al., 2017).
Currently, no single validated specialised treatment is consistently superior to others in
producing outcomes (Choi-Kain et al., 2017; Cristea et al., 2017). However, DBT has been
selected as the preferred intervention because it’s the most researched of the evidence-based
treatments (Kaess et al., 2014), training is widely available (Choi-Kain et al., 2017) and it is
recommended for use by several international guidelines (Cristea et al., 2017).

Dialectical Behavioural Therapy

DBT was developed by Linehan (1993) to treat adults with chronic suicidality and BPD.
Linehan theorised these conditions were linked to a pervasive emotional-regulation deficit
(Linehan et al., 2015). Linehan’s (2015) biosocial model, proposes this is the consequence of
two interacting factors, the individual’s biological predisposition for emotional reactivity
interacting with an inconsistent and invalidating environment. DBT combines elements of
Cognitive Behavioural Therapy and acceptance techniques taken from Zen Buddhism within
a Dialectical framework (Fonagy et al., 2015) to aid the individual to identify problems and
develop specific skills to become more effective. Standard DBT includes participation in
weekly manualised skills-group, in addition to concurrent weekly individual sessions, phone
coaching and weekly therapist-consultation group, usually for a duration of 12 months
(Linehan, 2015).
Randomised Controlled Trial’s (RCT’s) with adult populations indicate DBT is associated
with improvements in suicidal ideation and behaviour, non-suicidal self-injury (NSSI),
attrition and hospitalisation (Macpherson et al., 2013) in addition to increasing coping skills
and psychosocial functioning (Linehan et al., 2015). RTC’s also demonstrated DBT’s
superior efficacy when compared with TAU and manualised non-specialised control
intervention on reducing BPD symptoms, level of general psychopathology and MH service
utilisation (Cristea et al., 2017).
Linehan et al., (2015) recently examined the active components of DBT by conducting a
study which dismantled DBT into the following groupings: skills-training plus case
management; DBT individual-therapy plus activities group and standard DBT. All groupings
were shown to be effective in decreasing suicidality. However, the standard DBT package
was not superior to the other groupings. The findings revealed groupings which included
skills-training were more effective in improving MH difficulties and reducing self-harm. The
findings challenge prior claims regarding the necessity of providing the standard DBT-
program in order to produce effective outcomes (e.g., Linehan, 1993). Furthermore, Cristea
and colleagues (2017) meta-analysis revealed treatment intensity in terms of duration and
hours per week was not correlated with outcomes.
This provides support to suggest modifications could be made to the form, duration and
intensity of a DBT-program to match the given treatment setting (i.e., tertiary or primary
MH) and the patients’ stage of illness without compromising the treatments effectiveness.
Thus, in EI where intensive work may not be necessary for the stage of illness, a reduced
dose of DBT could be delivered as recommended by the stepped-care model of youth MH
(Choi-Kain et al., 2017; McGorry, 2013). Further research on the optimum intensity for EI
settings is needed.
The efficacy of DBT for adults has been consistently demonstrated (Fonagy et al., 2017) and
as a consequence this success has prompted the adaption of DBT for adolescent populations.

DBT-A
Rathus & Miller (2015) developed DBT-A, designed as more developmentally fitting for
adolescents and their families. This program retains the adult-DBT theoretical framework
and approach, but increases the family involvement, shortens the length of the therapy from
one year to 12-16 weeks, reduces the number of skills taught and adds an adolescent-specific
skills module to increase comprehension and relevance to adolescents and their caregivers
(Lenz, Del Conte, Hollenbaugh & Karisse, 2016). The DBT-A program is a multimodal
treatment, designed specifically to address symptoms of emotional dysregulation and to help
individuals and their families develop new skills to effectively regulate emotions, reduce
impulsive behaviours and become more interpersonally effective (Hollenbaugh & Lenz,
2018). DBT-A includes a manualised multifamily skills-group, in addition to concurrent
weekly individual sessions, phone coaching and weekly therapist-consultation group (Rathus
& Miller, 2015).
Family inclusiveness in DBT-A
The rationale for family-inclusion in DBT-A is to capitalises on the evidence that family
inclusiveness is linked to improved MH (Young, O’Hanlon, & Weir, 2017). Rathus and
Miller (2015) suggest family inclusion in skills-training supports in-vivo coaching with both
parent and adolescent. It is anticipated this will increase DBT-A’s treatment outcomes by
increasing communication in the family, increasing parental sense of competence and
parental well-being, factors which has been associated with improved adolescent MH
outcomes (Hoagwood et al., 2010; Reinherz et al., 2008). However, to date no specific
research regarding whether parental involvement in skills training does actually increase
parental well-being and sense of competence has been conducted (Chanen, 2015; Choi-Kain
et al., 2017).

DBT-A’s efficacy
Preliminary research regarding DBT-A is promising, producing statistically significant
reductions in psychopathology for a number of MH conditions linked to emotional
dysregulation (Cook & Gorraiz, 2016; Hollenbaugh & Lenz, 2018). For example,
McPherson and colleagues (2015) reviewed 18 efficacy-studies of DBT–A examining
differing adolescent psychiatric disorders (with emotional-dysregulation as the core feature)
and found when compared to TAU, DBT–A was associated with significant reductions in
hospitalisation, attrition and behavioural incidents. Further, an RTC study of a community-
based 19-weeks DBT-A program, examining 77 adolescents with repetitive deliberate-self-
harm reported medium to large effect-sizes relative to TAU in reducing suicidal ideation,
depression and BPD symptoms (Mehlum et al., 2014).
More recently Hollenbaugh and Lenz’s (2018) meta-analytical study examining 12 high
quality RTC studies of DBT-A efficacy revealed small to medium effect sizes in reducing
depression, anxiety and self-injury and suicide risk when compared to TAU and alternative
treatment in an adolescent population.
Researchers have also successfully adapted DBT-A to treat other MH conditions in
adolescents, including; Eating Disorders (Ben-porath, Federici, Wisniewski, & Warren,
2014), Oppositional Defiant Disorder (Lenz et al., 2016) and Substance Dependence
(Savinsky, 2012). Additionally, the efficacy of DBT-A has been demonstrated in a variety of
inpatient and community settings, such as schools for example (Lenz et al., 2016). This
provides evidence that DBT-A may be appropriate for use at headspace centres.

The Australian Context and headspace Centres

The headspace model, was developed in Australia to create cohesive health centres for young
people aged 12-25 experiencing mild to moderate MH issues to aid access to evidence-based
early intervention (McGorry, Goldstone, Parker, Rickwood, Hockie, 2014; Rickwood,
Mazzar, Tetford, Parker, & Tanti., 2015). Central to the headspace model, is a cost-free and
easily accessed MH services for all Australian YP and their families. Services are free,
because out-of-pocket costs are a well-researched barrier to services access in youth
populations (Rickwood et al., 2015). headspace centres are resourced though a mixed
funding model (Federal core funding delivered through State bodies and additional
resourcing provided through Australia’s Medicare System) – this means health professionals
providing clinical intervention are often solely funded through Medicare, resulting in capped
session numbers. Therefore, headspace clinical programs must be designed to meet this
structure.
headspace centres are a logical vehicle to make early-intervention DBT-A readily available
to a large number of YP in Australia, due to the prevalence of headspace centres throughout
Australia (100+), and headspaces scope of practice (for a detail description see headspace,
2018). This may go some way in rectifying the lack of available BPD treatment options for
YP with BPD, which is identified as a key contributor to the poor outcomes associated with
BPD (Choi-Kain et al., 2017).

Limitations in the Literature

Unfortunately, despite the promising evidence regarding DBT-A’s efficacy in treating
adolescences, the research base is currently limited (MacPherson et al., 2015) and there is
little to no research looking at DBT-A’s efficacy in EI MH-setting, such as headspace with
limited time and resources. Further, the existing research is restricted by methodological
flaws which hamper cross-study comparisons and limit generalisability. It is noted that many
studies are open trials, which lack comparison groups, making it impossible to determine if
the positive-results reported are linked to other non-treatment-based factors which are
unrelated to the DBT-intervention. Improved, but still problematic, many studies utilise a
quasi-experimental design, comparing DBT-A with TAU. These studies lack random
assignment, and as a result make it impossible to prove that systematic differences across
groups did not create the outcomes reported (MacPherson et al., 2015).
Additionally, the majority of empirical studies tend to conduct trials with female-only
populations. This is problematic because currently researchers and clinicians are unable to
state if DBT-A can be justifiably offered to young males with BPD.
The meta-analyses of DBT-A also included studies with diverse populations taken from
various settings. This may affect the efficacy levels reported as the interventions
effectiveness may be more appropriate for one-specific setting. It is suggested that future
research should focus on particular setting and populations to further refine statements about
efficacy for specific treatment settings and groups.
Few studies (RTC’s or quasi-experimental studies) clearly define in their methodology what
TAU is, making it difficult to determine if the TAU is an adequate control and it limits the
ability to replicate the study, compromising the integrity of the study.
There are also significant variations in the inclusion criteria employed for study participation,
in addition to the tools used to measure BPD symptomology and DBT-A’s efficacy. This
again makes between-study comparison difficult and limits the interpretability of the
findings. Further complicating this picture, is the well documented concerns regarding the
high level of heterogeneity created by the DSM 5’s diagnostic criteria for BPD (Choi-Kain et
al., 2017). Although a detailed exploration of this issue is outside the scope of this literature
review, this issue may lead to the effectiveness of interventions for subgroups in this
diagnostic category being obscured and complicates cross-study comparisons and the
conclusions which can be drawn.
These limitations highlight the importance of ensuring clearly defined inclusion criteria
which are empirically justifiable. In addition, evidence-based and well-described diagnostic
tools should be employed in selecting experimental participants, which will lead to clearly
described and detailed documentation of the studies participants. Lastly, evidence based and
well-described outcome measures should be employed to assess DBT-A’s effectiveness.
Additionally, there are currently no published Australian studies that examine the
effectiveness of DBT-A at an EI stage. Research examining DBT-A’s utility in a primary
health setting such as headspace would provide needed information on the empirical utility of
EI to reduce symptomology at the earlier stages of the disorder as described in the stepped-
care model of MH and central to headspace’s model of practice (headspace, 2018; McGorry
et al., 2014). Further, it would be useful to determine if DBT-A can retain is efficacy in a
truncated format funded solely through the Medicare system.
Finally, there are no empirical studies looking at the effect family inclusion in DBT-A has on
caregiver distress and sense of competence (Chanen, 2015). This is important as such factors
are correlated with adolescent-BPD mental health outcomes (Young, et al., 2017).

Future Research
Therefore, due to the limited methodologically sound research, there is a need for more
rigorously designed empirical studies examining DBT-A in applied primary-care setting at
earlier stages of the disorders manifestation. This is because BPD is common in the
adolescent population and is linked to high individual, social and financial burden and poor
outcomes (Kaess et al., 2014). It is often underdiagnosed and undertreated in YP due to
stigma and historical controversy (Choi-Kain et al., 2017). However, BPD is a reliable and
valid diagnosis among adolescents (Stepp, 2012). The literature reviewed in this paper
highlights that adolescents with BPD benefit from early detection and intervention to alter the
life-course trajectory of the disorder to reduce the documented long-term adverse
consequences of BPD, such as poor psychosocial functioning and high morbidity and
mortality rates. DBT is effective in treating BPD in adult populations and there is increasing
evidence of its efficacy with YP.
Based on this clear need for further additional empirical data, an RTC study has been
designed to address the following gaps in the literature;
1) To address the lack of RCT currently available through conducting a rigorously
designed RTC examining the efficacy of DBT-A for YP.
2) To address the lack of empirical data regarding the use of DBT-A at earlier stages of
the BPD presentation (Mild to Moderate consistent with the headspace stepped-care
model), by employing an EI subject group.
3) To address the lack of empirical data regarding the efficacy of this intervention within
a time and resource limited primary mental health service (Australian Medicare
context) by conducting the RTC in this setting.
 4) To address the lack of RTC that examine the effect family inclusion in DBT-A has on
caregiver distress and sense of competence (Chanen, 2015) through measurement of
this.
5) To address the lack of well described interventions and TAU/control treatments
through sound and clearly communicated methodology
6) To address the lack of clearly outlined criteria for inclusion and inclusion by
employing empirically validated tools and documenting these clearly
7) To include males in the experimental sample to increase generalisability.

Research Aims and Experimental Hypotheses

The primary aim of this RTC study is to explore if participation in a 12-week DBT-A
program can reduce BPD-symptoms and increase psychosocial functionality in YP of both
sexes (13-19 years) with a diagnosis of clinical or subclinical BPD when compared to a
manualised TAU in a community-service. Specifically, the study aims to determine if
positive outcomes are possible in an early-intervention setting, where time and resources are
limited (Australian Medicare context). Additionally, the effect of DBT-Skills participation
for parents/guardian’s sense of well-being and competence will be explored. Based on the
literature, the studies experimental hypotheses are as follows;

The Experimental Hypotheses:

Decreased Psychopathology in YP
1. That YP who participate in a 12-week DBT-A program will report lower levels of
BPD-symptomology and emotional dysregulation following its completion
compared to TAU.
Decreased Distress in Parents/Guardians
2. That Parents/Guardians that participate in a 12-week DBT-A program will report
lower levels of emotional distress following its completion compared to parents
who did not complete the DBT-A group-skills program.
Increased Functioning in YP
3. That YP who participate in a 12-week DBT-A program will report improved
levels of psychosocial functioning following completion of the course compared
with TAU.
Increased Sense of Parental Competence in Parents/Guardians
4. That Parents/Guardians who participate in a 12-week DBT-A program will report
a higher sense of parenting competence compared to parents who did not complete
the DBT-A group-skills program.
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