Authors (including presenting author) :
Au CHS(1), Wong EWY(1), Lau SPK(1), Lau WH(1), Lam TY(1)
Affiliation :
(1) Department of Psychiatry, United Christian Hospital
Introduction :
Maintaining the mental wellbeing of adolescents has been a very important aspect of our healthcare. The prevalence of self-injurious and suicidal behaviors amongst adolescents is alarming. Previous local studies found that almost 5% of adolescents have attempted suicide over the course of one year, and almost 14% of Grade 7 students reported having suicidal thoughts (Siu, 2019). Self-injurious behaviors and school refusal are major problems among adolescents who have sought help from our mental health system, leading to an increase in service burden both in the out-patient department and within our in-patient system. Without timely and effective intervention, vulnerable adolescents are at risk of developing chronic and severe mood and personality disorders in need for long term psychiatric care in their adulthood.
Dialectic Behavioral Therapy (DBT; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, 1993a, 1993b) was developed to treat clients with suicidal or self-injurious behavior, combining individual therapy, group skills training, telephone coaching and peer consultation. It was subsequently adapted to cater to adolescents with emotional dysregulation and interpersonal difficulties which result in avoidant and impulsive behavior (Rathus & Miller, 2015).
The five sets of skills taught in DBT for adolescents include Mindfulness, which increases the adolescents’ sense of self-awareness and self-regulation; Distress Tolerance, which offers tools in reducing impulsive behaviors; Emotion Regulation, which accumulate positive emotions and manage negative ones; Interpersonal Effectiveness, which improves and maintains relationships and builds self-respect; and Walking the Middle Path, which teaches methods for reducing family conflicts and enhances effective communication.
Objectives :
In the present pilot study, our treatment team delivered a time-limited, group-based intervention using elements of DBT skills training to adolescents with emotional dysregulation and interpersonal difficulties, and their families. Our aim was to equip the adolescents with skills to regulate emotions, tolerate distress, and to improve their interpersonal and family relationships. Through substituting problematic behaviors with adaptive behavioral skills, the adolescents were expected to lead lives free from the need for long-term psychiatric services; and thereby reducing our patient load and service burden.
Methodology :
Adolescents aged 13 to 17 were recruited from psychiatric out-patient clinics of the United Christian Hospital over the period of February to May, 2019. New referrals to the clinic were also screened for eligibility. Adolescents with intellectual disability, severe level of Autism Spectrum Disorder, or those warranting psychiatric admission were excluded.
The participants were assigned into one of two treatment groups running from June to October 2019. The groups were led by a therapist, co-therapist and a facilitator. Each group comprised of 8 skills training sessions on a biweekly basis, with each session lasting 90 minutes. In each session, the teaching of a specific set of skills was followed by in-group experiential practices. Individualized home-practice tasks were specified for each participant. In-between the group sessions, participants received telephone coaching regarding the use of skills in the home-practice tasks. Participants were welcome to contact staff in situations they required emotion support and advice.
To measure the outcome of the group intervention, participants completed questionnaires before and after the group. Questionnaires used included the Personal Wellbeing Index (PWI), the Chinese Depression, Anxiety and Stress Scale – 21 items (DASS-21), and the World Health Organisation- Five Well-Being Index (WHO-5).
Result & Outcome :
A total of 9 adolescents were recruited for our groups, with 1 drop out. Six of the adolescents achieved full attendance. Prior to the intervention, the mean score of the participants’ PWI was 39.63. It was increased to 44.29 by the end of the intervention [t(6) = 1.07, p = 0.32]. Measures in DASS also reduced, from a mean of 10.63 (anxiety), 12 (stress) and 13 (depression) to 8, 11.29 and 10, respectively [t(6) = 1.15, p = 0.29; t(6) = 0.71, p = 0.51; t(6) = 1.49, p = 0.19]. WHO-5 score increased from 10 at pre-intervention to 12 at post-intervention [t(5) = 0.91, p = 0.41]. None of the changes in pre- and post- test results amounted to statistical significance, possibly due to small sample size. Qualitatively, participants were able to report skills that they would continue to use in daily lives, including mindfulness, leading a value-directed life, utilizing senses for self-soothing, taking a vacation, thinking through on interpersonal situations, and trying to express one’s self. Parents also gave positive feedback and recognized the skill acquisition of the participants. In particular, parents reported that their children practiced mindfulness, had less emotional outbursts, were able to reduce impulsive behaviors, showed more alternative thinking, showed more acceptance, and became more expressive. Some parents also found the skill of middle path helpful in relating with their children. Despite the small sample size, results from this pilot group showed preliminary evidence as a foundation to support the implementation of group skills training in emotional regulation and interpersonal effectiveness among adolescents. Participants of this pilot group reported improvements in their wellbeing as well as reduction in their anxiety, depressive and stress symptoms. They were able to resume their daily lives and at present had not rebooked our psychiatric specialist services. All of the above landed positive evidence for the use of time-limited, group-based interventions as an effective way to help alleviate our service burden while providing evidence-based treatment to adolescents in need.
