This feature by Emily Cooney, PhD, Carla Walton, PhD, Mike Batcheler, and Kirsten Davis, DClinPsy, is Part 2 of 2 in a series about DBT in Australia and New Zealand. In the first part, Emily, Carla, Mike, and Kirsten shared the journey so far. Here in part 2, they discuss their efforts to make the treatment relevant and responsive to local, rural and, especially, indigenous communities.
DBT is a worldwide community, and we are excited to shine a light on how DBT has developed in different regions and countries.
In Part 1 of this blog, we discussed how DBT is alive and well in Australia and Aotearoa (the indigenous or Māori name for New Zealand). But clinicians have sometimes struggled with how to make the treatment relevant and responsive to local, rural and, especially, indigenous communities. We’ll discuss our efforts so far and how research has played a vital role.
Research has always been a part of DBT’s methodology so it is only natural it would be integral to local implementation. Passionate and enthusiastic clinicians have also been aware that conducting research is a way to offer access to high-quality supervision and connections with the global community of dedicated, like-minded DBT scientists and treatment developers led by Marsha Linehan. For many years, Emily Cooney from New Zealand (a DBTNZ, DBT Training Australia and BTECH trainer) and Carla Walton from Australia (a DBT Training Australia and BTECH trainer) attended the DBT Strategic Planning Meetings hosted by Marsha Linehan at the University of Washington, which oversaw and coordinated international research efforts to advance DBT. For Emily and Carla, this was inspiring and a major source of mentorship. It created the groundwork for several lines of research directed towards answering questions with immediate relevance to the application and evaluation of DBT within Australia and Aotearoa.
An early question was whether DBT would even work ‘down under’. As noted in Part 1 of this blog, Carter, Willcox, Lewin, Conrad and Bendit (2010) published a randomized controlled trial conducted in a specialist service for Borderline Personality Disorder within public sector mental health service in Newcastle showing a range of positive outcomes for DBT, especially around client disability and quality-of-life measures. One interesting finding was DBT had less of an effect (compared with TAU) on hospitalization rates. This reminds us that our healthcare communities and practices are not the same as North America. Local research is needed to inform local implementation.
In the same service as the initial randomised trial conducted in Australia, Carla Walton and colleagues completed the first randomized clinical trial comparing DBT with the Conversational Model for persons with a diagnosis of borderline personality disorder (BPD) and suicidal and/or non-suicidal self-injury. This showed that an Australian implementation of DBT was effective in reducing non-suicidal self-injury and suicide attempts as well as a range of other outcomes (Walton, Bendit, Baker, Carter, & Lewin, 2020). DBT also showed greater improvements in depression than the Conversational Model.
Nathan Pasieczny and colleagues examined the cost-effectiveness of DBT for BPD in an Australian sample and found that average treatment costs were significantly lower for DBT than TAU (Pasieczny & Connor, 2011). Furthermore, intervention from therapists receiving intensive DBT training was associated with significantly greater reductions in suicidal and non-suicidal self-injury than outcomes associated with 4-day basic training.
In Aotearoa, whānau (the Māori term equivalent to family) is a central aspect of identity, connection, and wellbeing. We are part of the whole. So, what about our families and young people? Emily Cooney and colleagues compared DBT with enhanced usual care for suicidal adolescents and their families. They found that DBT was acceptable and feasible for adolescents, their families and clinicians in Aotearoa (Cooney, Davis, Thompson, Wharewera-Mika, & Stewart, 2010). Emily and other colleagues also found 6 months of DBT skills training was associated with improvements in emotion regulation, anger, and depressive symptoms for men experiencing problems related to anger (Cooney, Mooney, & Ryan, 2016).
Just like the rest of the world, when COVID-19 came along, we all had to scramble around and figure out how to do DBT remotely. Carla Walton, Sharleen Gonzalez, and Emily Cooney examined Australian and Aotearoa DBT team leaders’ descriptions of barriers and facilitators of DBT via telehealth, which generated several recommendations for the implementation of remote delivery of DBT (see Cooney, Walton, & Gonzalez, 2022 for details). These researchers also examined in-person and remote DBT attendance rates in DBT programmes in Australia and Aotearoa and found that clients were as likely to attend their DBT sessions over telehealth as they were face-to-face during the first year of the pandemic (Walton, Gonzalez, Cooney, Leigh, & Szwec, 2023). This had implications for post-pandemic delivery, especially for Australia’s vast rural regions that are very hard to service ‘in-person’.
DBT research has flourished in both countries and has helped local clinicians to figure how to respond to the needs of their communities. Gaps remain. One major concern is how DBT can become more responsive to our indigenous communities.
The indigenous people of Aotearoa New Zealand are collectively known as Māori, and usually Māori identity includes the tribal (iwi) affiliations of that person, as well as the regions from which their ancestors come. Emily Cooney and Kirsten Davis are members of a workgroup of DBT practitioners of primarily Māori and Pasifika (persons of Pacific Island heritage) whose focus is on the development of culturally responsive DBT in New Zealand. This group recently surveyed DBT team members in Aotearoa on the actions they were taking to make DBT more responsive to the needs of Māori, and are in the process of analysing the results. Emily is also working with a number of colleagues (in particular Mike Whaanga, Michael Roguski, John Snowden, Tim Marshall, and Leslynne Jackson) on the development of DBT skills training for family members experiencing family violence and suicidal behaviour, and the development of indigenous DBT within a Māori worldview. Other DBT practitioners (in particular, Horiana Jones and Jamie Kampen) have developed the delivery of DBT skills training on marae (traditional indigenous meeting houses and ancestral community hubs) for juvenile justice and child protection service-involved youth.
In Australia, work has begun to evaluate how to provide greater reach to people in rural areas. In 2022, Carla Walton and colleagues secured grant funding from the Peregrine Centre to trial a model of service delivery where the skills group is provided by telehealth for consumers across rural areas whilst the individual therapy is provided by rural clinicians of the local community mental health service. Feedback from Aboriginal clinicians and consumers about the fit of DBT for First Nations people of Australia (Aboriginal and Torres Strait Islander people) has sparked further research to be conducted collaboratively with First Nations consumers and clinicians regarding how to make DBT more culturally responsive for Australian First Nations consumers.
Collectively, clinicians and researchers in Australia and Aotearoa are thrilled to be a part of the international DBT community as well as working together. Not only is DBT alive and well in Australasia, but local DBT researchers are working with local DBT clinicians and communities to help our people attain lives they experience as worth living. One primary focus at this point is to work on enhancing equitable access to high quality DBT treatment and DBT training in Aotearoa and Australia, and to respond effectively to the needs of our people. We’ve come a long way and it’s only just begun.
Interested to read more about DBT around the world? Check out this blog about DBT in Greece!
Emily Cooney, PhD, is a clinical psychologist, a senior lecturer at Otago University in Wellington, New Zealand, and an assistant professor adjunct at the Yale School of Medicine. Emily is a trainer for Behavioral Tech and DBT Training Australia and a Director and trainer for DBT New Zealand. She has been active in researching, providing and training in DBT since the early 2000s.
Carla Walton, PhD, is a clinical psychologist and Service Director of the Centre for Psychotherapy, a specialist service for Borderline Personality Disorder and Eating Disorders within Hunter New England Mental Health Service in Australia. For the past 15 years she has been involved in research and treatment provision to persons with Borderline Personality Disorder in both public and private sectors in Australia. She is a trainer for Behavioral Tech and a director and trainer for DBT Training Australia.
Mike Batcheler is a clinical psychologist who primarily provides all modes of DBT in New Zealand’s longest established DBT programme in a public mental health clinic. He is a trainer for Behavioral Tech and a director and trainer for DBT New Zealand and DBT Training Australia.
Kirsten Davis (DClinPsy) is a clinical psychologist and CEO of The Psychology Group, an organization which among other interventions provides comprehensive DBT, as well as DBT skills groups for youth seeking primary mental healthcare. She is a trainer for Behavioral Tech and a director and trainer for DBT New Zealand and DBT Training Australia.
Carter, G. L., Willcox, C. H., Lewin, T. J., Conrad, A. M., & Bendit, N. (2010). Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. The Australian and New Zealand journal of psychiatry, 44(2), 162–173.
Cooney, E. B., Davis, K., Thompson, P., Wharewera-Mika, J., & Stewart, J. (2010). Feasibility of Evaluating DBT for self-harming adolescents: a small randomised controlled trial. Auckland, N.Z.: Te Pou o Te Whakaaro Nui: The National Centre of Mental Health Research and Workforce Development.
Cooney, E. B., Mooney, N., & Ryan, P. (2016). Dialectical Behavior Therapy skills training for men with problems related to anger. Poster presented at the Annual Strategic Planning Meeting for DBT, Seattle, WA.
Cooney, E. B., Walton, C. J., & Gonzalez, S. (2022). Getting DBT online down under: The experience of Australian and New Zealand Dialectical Behaviour Therapy programmes during the Covid-19 pandemic. Plos One, 17(10), e0275636.
Pasieczny, N., & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research and Therapy, 49(1), 4-10.
Walton, C. J., Bendit, N., Baker, A. L., Carter, G. L., & Lewin, T. J. (2020). A randomised trial of dialectical behaviour therapy and the conversational model for the treatment of borderline personality disorder with recent suicidal and/or non-suicidal self-injury: An effectiveness study in an Australian public mental health service. Australian & New Zealand Journal of Psychiatry, 54(10), 1020-1034.
Walton, C. J., Gonzalez, S., Cooney, E. B., Leigh, L., & Szwec, S. (2023). Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic. Borderline personality disorder and emotion dysregulation, 10(1), 16.