Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach

BACKGROUND: The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation. METHODS: A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis. RESULTS: Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management. CONCLUSIONS: The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service

Study 2: Major Research Project: Prevalence of mental health distress among Syrian and Iraqi refugees and contextual and culturally relevant indicators affecting their mental health and resettlement experiences in Ireland

Study 1 (A Narrative Systematic Review) Abstract - Objectives: In recent years, a high number of Middle Eastern refugees have resettled in high-income countries. Those families have experienced significant traumatic experiences that impact on the functioning and well-being of whole families. This systematic review examines if family/parental functioning influences child and youth psychosocial outcomes within refugee families from the Middle East who have resettled in high-income countries. Method: PRISMA guidelines were followed for the identification and selection of articles resulting in the inclusion of 19 articles based on 10 separate samples. Due to the heterogeneity of articles, a narrative methodology was applied for the analysis of included studies. Findings: A consistent association between parental trauma/PTSD and child PTSD and mental health was found. A gendered element to the experience of distress in refugee families was indicated with maternal factors in particular being associated with child outcomes. Parental mental health and family factors were identified as risk and protective factors. Child outcomes are impacted by various complex pathways of parental and family factors occurred during pre-settlement and in the resettlement environment. Further, children’s resettlement context, such as peer relationships are suggested to facilitate positive outcomes. Conclusion: While based on a small sample of studies, results support the thorough assessment of whole families. Further research using more consistent measures across studies is required to further promote the understanding of processes involved in the interaction between parental/family factors and child outcomes in Middle Eastern refugee families resettled in high-income countries.Study 2 (Major Research Project) Abstract - Purpose of this study was to explore prevalence rates and nature of mental health presentations among Syrian and Iraqi refugees resettled in Ireland. The second aim was to identify resettlement components based on a participatory construct elicitation method with refugees and their support workers. The third aim was to determine how well those components in addition to demographic variables and resilience predict refugees’ overall mental health distress in the resettlement environment. This study utilised a mixed-methods cross-sectional design. 14 participatory workshops with refugees and professionals supporting refuges were conducted to identify facilitators and barriers for families’ resettlement. Those items were quantified to explore their contribution to mental health distress. Mental health presentations assessed were symptoms of anxiety and depression (HSCL-25), post-traumatic stress disorder (IES-R), somatic complaints (PHQ-15). Additionally, Resilience (Systemic Resources) was measured. Data was collected between February 2018 and January 2019. A total of 64 adults completed the self-report measures. Symptoms of anxiety were found for 44%, symptoms of depression were found for 32%, and symptoms of PTSD for 65%. Mental health symptoms were associated with somatic complaints and self-rated psychological distress. In the model constructed via multiple hierarchical regression, uniquely significant contributions to variances in Mental Health Distress were made by Resilience (Systemic Resources), ‘Major Life Challenges: Caring for Family Members and Personal Issues’, and Number of Children. The findings highlight that Syrian and Iraqi refugees are a vulnerable population in Ireland requiring assessment, access to supports and resources. Besides the access to specialised psychological treatments for mental health disorder, the implementation of programmes fostering resilience and social connection and support is of importance. This needs to be considered for policy and service development to reduce mental health distress and strengthen resilience in refugee families

Standard 12 month dialectical behaviour therapy for adults with borderline personality disorder in a public community mental health setting

Abstract Background Dialectical behaviour therapy (DBT) is noted to be an intervention with a growing body of evidence that demonstrates its efficacy in treating individuals diagnosed with borderline personality disorder (BPD). Evidence for the effectiveness of DBT in publicly funded community mental health settings is lacking however. No study to our knowledge has been published on the effectiveness of a 12 month standard DBT programme without adaptations for individuals with BPD in a publicly funded community mental health setting and no study has included data across multiple time-points. The main objective of the current study was to determine if completion of a 12 month DBT programme is associated with improved outcomes in terms of borderline symptoms, anxiety, hopelessness, suicidal ideation, depression and quality of life. A secondary objective includes assessing client progress across multiple time-points throughout the treatment. Methods Fifty-four adult participants with BPD completed the standard DBT programme across four sites in community mental health settings in the Republic of Ireland. Data was collected by the DBT therapists working with participants and took place at 8 week intervals across the 12 month programme. To explore the effects of the intervention for participants, linear mixed-effects models were used to estimate change utilising data available from all time-points. Results At the end of the 12 month programme, significant reductions in borderline symptoms, anxiety, hopelessness, suicidal ideation and depression were observed. Increases in overall quality of life were also noted. In particular, gains were made during the first 6 months of the programme. There was a tendency for scores to slightly regress after the six-month mark which marks the start of the second delivery of the group skills cycles. Conclusions The current study provides evidence for the effectiveness of standard DBT in publicly funded community mental health settings. As participants were assessed at the end of every module, it was possible to observe trends in symptom reduction during each stage of the intervention. Despite real-world limitations of applying DBT in community settings, the results of this study are comparable with more tightly controlled studies. Trial registration ClinicalTrials.gov ID: NCT03166579 ; Registered May 24th 2017 ‘retrospectively registered