The assessment and treatment of emotional dysregulation in adolescents who self-harm

Self-harm among adolescents presents unique treatment challenges and significant economic difficulties for community-based Child and Adolescent Mental Health Services (CAMHS). Dialectical Behaviour Therapy adapted for adolescents (DBT-A) is a promising treatment (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997). However, research suggests variability in its implementation, compromising its efficacy. Furthermore, emotion dysregulation, the core theoretical construct underpinning the DBT model, is not generally targeted in measures of treatment outcome. This thesis reviews the literature on emotion dysregulation in the ontogenesis of self-harm, linking it to early developmental experiences of attachment disruption and trauma. A major aim of this thesis is to develop a suitable, validated measure of adolescent emotion regulation for use with clinical populations. The thesis also explores the feasibility of applying a DBT-A programme to self-harming adolescents presenting at community CAMHS clinics in Perth, Western Australia. Part A, consisting of four interrelated studies, investigates the psychometric properties and clinical utility of a reworded version of an adult measure of emotion regulation, the Affective Control Scale (Williams, Chambless, & Ahrens, 1997). The four sub-scales of the MACS-A and its total scale measuring Fear of Emotion were found to be internally consistent in a sample of high school students (N = 2,128) aged between 12 and 17 years. The MACS-A was also found to successfully discriminate between matched clinical and non-clinical samples of adolescents (N = 60) on all of its scales, except for the Fear of Positive Emotion sub-scale. Exploratory factor analysis revealed four factors that explained 35.4% of the common variance. A comparison of factor loadings over a two-week period indicated a relatively stable factor structure. In a further study, the MACS-A was also found to have moderate to high (0.68 – 0.93) internal consistency within a sample of young adults (N=73) aged 18 to 19 years of age. Part B of this thesis sets out the development, implementation and evaluation of the 26-week DBT-A pilot programme, ‘Life Surfing’. All five components of the Miller et al. (1997) programme, with the exception of out-of-hours telephone support and a follow-up patient consultation group, were included. A parent of each adolescent was also required to attend the 18-week family skills group. All individual and group sessions were videotaped for review by the multidisciplinary supervision-consultation team, and for later evaluation of treatment adherence. Baseline, post-treatment and three-month follow-up measures indicated improvements in the ability of adolescents to regulate their affect and a reduction in trauma symptomology. Adolescents’ self-harm behaviours and suicidal ideation also decreased. A general discussion of the unique contributions made by the five studies within Parts A and B of this thesis concludes this work. In particular, pragmatic issues related to further development and use of the MACS-A and recommendations regarding implementation of adolescent DBT programmes within community adolescent clinics are made from a scientist-practitioner perspective.