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Lakeman, R., Hurley, J., Campbell, K., Hererra, C., Leggett, A., Tranter, R., & King, P. (2022). High fidelity dialectical behaviour therapy online: Learning from experienced practitioners. International Journal of Mental Health Nursing, Early View. https://doi.org/10.1111/inm.13039

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and other problems underpinned by difficulties with emotional regulation. The main components of DBT are skills training groups and individual therapy. The COVID-19 outbreak forced a rapid adaptation to online delivery, which largely mirrored face-to-face programmes using videoconferencing technology. This study aimed to elicit and describe the experiences and learning of therapists involved in providing high-fidelity DBT programmes via the Australian DBT Institute, which established an online delivery platform called DBT AssistTM prior to the COVID-19 pandemic. The report conforms with the consolidated criteria for reporting qualitative research (COREQ). Seven therapists were interviewed. Data were transcribed and analysed thematically. Delivering skills training online, either exclusively or in hybrid form (with face-to-face individual therapy), was acceptable and even preferable to therapists and clients. It was considered safe, the programme was associated with few non-completers, and it improved the accessibility of DBT to those who might otherwise not be able to engage in a face-to-face programme. Skills training utilized a ‘flipped-learning’ approach which improved the efficiency of online delivery. Other unique and helpful features of the online programme were described. The best outcomes associated with online DBT are likely to be achieved through careful adaptation to the online environment in accord with the principles of DBT rather than mirroring face-to-face processes. Further research is required to determine the efficacy of online therapy relative to faceto-face, and who might be best suited to different modes of delivery.

Campbell, K., Massey, D., & Lakeman, R. (2022). Working with People Presenting with Symptoms of Borderline Personality Disorder: The Attitudes, Knowledge and Confidence of Mental Health Nurses in Crisis Response Roles in Australia. Issues in Mental Health Nursing, 1-10. https://doi.org/10.1080/01612840.2022.2087011

Many people diagnosed with or presenting with borderline personality disorder (BPD) attend the emergency department (ED) when in crisis, and are often referred to mental health nurses for further assessment, and to arrange appropriate follow-up (MHNs). Little is known about the knowledge, skills, confidence and competence of MHNs working with this group in these specialist roles. This study sought to describe the attitudes of MHNs working in EDs and crisis services towards people who present with symptoms characteristic of BPD and to explore their knowledge of the diagnostic criteria of BPD. A descriptive survey tool comprised of 23 questions was adapted from a previously used survey with clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online. These MHNs were found to hold positive attitudes towards people with BPD including being optimistic about recovery and treatment. The experience and education of MHNs now employed in EDs may have contributed to positive attitudes and self-reported confidence relative to other nurses. Further research ought to focus on how MHNs assist people with a diagnosis of BPD who present in crisis meet immediate needs and facilitate access to effective ongoing care and treatment.

Lakeman, R., King, P., Hurley, J., Tranter, R., Leggett, A., Campbell, K., & Herrera, C. (2022). Towards online delivery of Dialectical Behaviour Therapy: A scoping review. International Journal of Mental Health Nursing, 31(4), 843-856.https://doi.org/10.1111/inm.12976

Dialectical Behaviour Therapy (DBT) programmes are often the only available treatment for people diagnosed with borderline personality disorder and were rapidly converted to online delivery during the COVID-19 pandemic. Limited research exists surrounding how the major elements of DBT are delivered in an online environment. This scoping review considered the operationalization of online delivery of DBT and its effectiveness. EBSCO host databases were searched using free text. Of 127 papers, 11 studies from 2010 to 2021 investigating online DBT for any clinical population were included in the review. A narrative synthesis of papers selected was undertaken. Seven articles reported results from five clinical trials (n = 437). Most adaptations mirrored face-to-face programmes although there was considerable variation in how therapy was facilitated. Attendance was reported to be greater online with comparable clinical improvements to face-to-face for those who remained in therapy. Additional challenges included managing risk, therapist preparedness and technology difficulties. Online delivery of DBT programmes is feasible and may be more accessible, acceptable and as safe and effective as face-to-face delivery. However, mirroring face to face delivery in an online environment may not be the most effective and efficient way to adapt DBT to online provision. Research is needed to identify areas which require further adaptation.

McCarrick, C., Irving, K., & Lakeman, R. (2022). Nursing people diagnosed with Borderline Personality Disorder: ‘We all need to be on the same hymn sheet’. International Journal of Mental Health Nursing, 31(1), 83-90. https://doi.org/10.1111/inm.12935

The diagnosis of borderline personality disorder (BPD) has been found to carry stigma and poor hope of recovery. More recently, it has been regarded as a treatable condition through psychotherapy. Despite this, patients often experience lengthy hospitalizations, limited access to treatment, and poor outcomes. This paper describes the experiences of psychiatric nurses working with people diagnosed with BPD in acute mental health in-patient settings in Ireland. Seven nurses were interviewed, and the transcripts were analysed using a reflective and inductive approach. Overall, the nurses did not feel confident that their interventions were effective or valued by the wider service or patients. The nurses articulated their invidious professional circumstances, whereby they were required to act in ways, which ran counter to their vision of therapeutic or recovery-focused work. These views and perceptions that in-patient care is often ineffectual are widely echoed in the literature. We contend that the effect of this circumstance for these nurses approaches moral distress. The nurses were aware of more effective methods of care and treatment for BPD but perceived that they were unable to influence the culture of in-patient care.

Campbell, K., & Lakeman, R. (2021). Borderline Personality Disorder: A Case for the Right Treatment, at the Right Dose, at the Right Time. Issues in Mental Health Nursing, 42(6), 608-613. https://doi.org/10.1080/01612840.2020.1833119

There is now compelling evidence that a range of psychotherapeutic treatments are effective in the treatment of borderline personality disorder (BPD). Such treatments are often lengthy, expensive, subject to high rates of incompletion and are rarely available to people with sub-threshold symptoms. There is broad agreement that some combination of vulnerability, invalidating environment, childhood adversity, disrupted attachment in childhood or trauma play a role in the aetiology of the syndrome of BPD. These factors also contribute to problems with the capacity to mentalise, regulate emotions, tolerate distress and impact on psychosocial development with or without self-damaging and suicidal behaviour. This column takes as a given that people with BPD should receive evidence-based psychological treatments such as dialectical behaviour therapy (DBT), interpersonal therapy and cognitive behavioural therapy in a sufficient dose to be helpful. However, to avert an escalating trajectory which may lead to a diagnosis of BPD the right dose of the right therapy at the right time is necessary. Under-dosing or ineffective psychotherapy can be potentially harmful. This column reviews the evidence, such as it is, for therapeutic approaches which may contribute to more skilful negotiation of life?s difficulties and which may avert deterioration in mental health and quality of life in vulnerable individuals and families.

Lakeman, R., & Crighton, J. (2021). The Impact of Social Distancing on People with Borderline Personality Disorder: The Views of Dialectical Behavioural Therapists. Issues in Mental Health Nursing, 42(5), 410-416. https://doi.org/10.1080/01612840.2020.1817208

Dialectical Behavioural Therapy (DBT) is an evidence-based treatment for borderline personality disorder and other problems associated with emotional dysregulation. It has traditionally been deployed as a face-to-face programme comprised of attendance at group skills training, individual therapy and phone coaching. Social distancing measures arising from the COVID-19 pandemic led to a cessation of therapeutic programmes in many places. This survey of DBT clinicians in a regional State mental health service in Australia explored the impact of the cessation of DBT programmes in the region and obstacles to engaging with people via online platforms. Clinicians have been able to engage in DBT informed care, but it was perceived that many people have experienced a clinical deterioration or have increased their use of crisis services, which is entirely appropriate, as group skills programmes have ceased. Movement to online platforms of delivery poses problems, as some people do not have the access to internet or privacy in their home environments to engage in online therapy. Ideally, clinicians need to be supported through education, supervision and coaching in the use of telehealth interventions. Social distancing requirements has enabled an opportunity to carefully consider how programmes can be adapted to enable the extension of these programmes to those who have traditionally been unable to access them.

Lakeman, R., Emeleus, M., Davies, S., & Anderson, S. (2021) A pragmatic evaluation of a high-fidelity Dialectical Behaviour Therapy programme for youth with borderline personality disorder, Advances in Mental Health. 19(2) 116-126. https://doi.org/10.1080/18387357.2020.1761262

Objective: This paper describes and evaluates a high-fidelity Dialectical Behaviour Therapy (DBT) programme for youth (15-25 years). The project was undertaken as a partnership between public mental health services and a non-government organisation in regional Australia. DBT is an evidence-based treatment for Borderline Personality Disorder (BPD) but is rarely accessible within public mental health services.
Method: Participants completed an Adverse Childhood Experiences (ACE) questionnaire, repeated measures of the Borderline Symptom List (BSL-23), supplementary behaviour questionnaire (BSL-Supp) and general well-being questionnaires. Hospital and emergency service use was examined for the year prior to referral to the programme and for the year following completion. The characteristics of those people who did not complete the programme were also described.
Results: Borderline personality symptoms were correlated with the number of reported adverse childhood experiences. Participants who remained in the programme for at least twelve weeks had significant reductions in BSL-23 scores with several reporting no symptoms after completing the programme. Participants had high rates of hospital and emergency department use in the year prior to participation and significantly less use in the year following completion.
Discussion: It is feasible to deliver a high fidelity DBT programme and achieve reductions in symptoms and use of hospital and emergency services in a regional public mental health service.

Lakeman, R., & Emeleus, M. (2020). The process of recovery and change in a dialectical behaviour therapy programme for youth. International Journal of Mental Health Nursing, 29(6), 1092-1100. https://doi.org/10.1111/inm.12749

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and suicidal behaviour. However, it is a complex programme involving individual therapy, participation in skills training groups, and phone coaching aimed at improving emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. Little is known about what elements contribute to its effectiveness, or the characteristics of those who complete the programme and achieve recovery. In this study, six participants in a dialectical behaviour therapy programme for youth were interviewed at three time points over their recovery journey. The transcribed narratives were analysed using inductive methods, and the core processes related to recovery were elucidated and described: ‘Becoming a cheerleader for DBT’ and ‘Learning the language of DBT and consolidation of skills’. Indicators of recovery included having a sound working alliance with the primary therapist and others involved in the programme and noticing meaningful improvements in problem areas which they attributed to particular skills and improved capacity to regulate emotions. The rich narrative description provided by participants might inspire some to remain engaged in a dialectical behavioural therapy programme or clinicians to consider promoting a positive view of the prognosis for borderline personality disorder.

Campbell, K., Clarke, K.-A., Massey, D., & Lakeman, R. (2020). Borderline Personality Disorder: To diagnose or not to diagnose? That is the question. International journal of mental health nursing, 29(5) 972-981. https://doi.org/10.1111/inm.12737

There is considerable controversy around psychiatric diagnosis generally and personality disorders specifically. Since its conception, borderline personality disorder has been controversial because of the stigma associated with the diagnosis and the therapeutic nihilism held by practitioners who encounter people with this high prevalence problem in acute settings. This paper reviews the history of the diagnosis of BPD and summarizes some of the controversy surrounding the categorical nature of diagnosis. Both the DSM 5 and ICD-11 will be discussed; however, for the purposes of this paper, the DSM 5 will take the primary focus due to greater cultural significance. Recent developments in the treatment of borderline personality disorder suggest that it is a highly treatable condition and that full clinical recovery is possible. This paper formulates an argument that despite problems with psychiatric diagnosis that are unlikely to be resolved soon, a diagnosis should be made with an accompanying formulation to enable people to receive timely and effective treatment to enable personal and clinical recovery.

Lakeman, R., Emeleus, M., & Anderson, S. (2018, October 14-26). What makes a difference? Narratives of participation in a high fidelity DBT programme. Presented ACMHN's 44th International Mental Health Nursing Conference Mental Health is a Human Right. Pullman Cairns International, Cairns, Australia

Dialectical behavioural therapy (DBT) is an evidenced based programme of psychotherapy which has been demonstrated to be helpful for some people who manifest with a constellation of problems including suicidal and self‐destructive behaviour, difficulty managing emotions, impulses, maintaining relationships and an unstable self‐image. A high fidelity DBT programme has been run in Cairns for close to 10 years and has included a 20 week skills group programme, telephone coaching as needed, and weekly individual therapy for the duration of client's participation. Little is known about what programme elements are essential in making a difference to people.

Methodology and Methods: Consenting participants in the programme were interviewed near commencement, midway at the end and 3–6 months post completion of the programme. Mental health service use and emergency department use history was also obtained. In this paper a thematic analysis of the aggregated qualitative data is presented orientated to consideration about what was helpful over the course of the programme.

Results: A rich narrative from participants about what was helpful about being in the DBT programme will be presented as well as potential problematic dynamics between clinicians and participants

Outcomes/Significance/Implications for the Profession: DBT is an exceptionally resource intensive and lengthy programme. Little is known about what the key ingredients are. These findings go some way to illuminating what makes a difference. DBT positively changes the discourse around the diagnosis of borderline personality disorder for all involved.

Translation to Policy and/or Practice Change: Recommendations will be made regarding governance of DBT programmes, length of programme, adapting core skills for the audience, matching clinicians to clients, dealing with alliance ruptures and adapting the programme to local circumstances.

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