CanSOLVE 2.0 Theme 3.1 Mind the Gap - Dialectical Behavioural Therapy (DBT) Skills Training Program Pilot

CanSOLVE 2.0 Theme 3.1 Mind the Gap: Addressing Mental Health Care Gaps for Canadians Receiving Facility-Based Hemodialysis - Dialectical Behavioural Therapy (DBT) Skills Training Program Pilot Intervention

The goal of this pilot implementation study is to implement and evaluate a 13-week dialectical behavioural therapy (DBT) skills training program to address challenges to mental health and mental wellbeing in people who have recently started facility-based hemodialysis or those who may start within the next 6-12 months.

BACKGROUND:

Mental health "Mental health" refers to the state of one's psychological and emotional well-being. It's about one's feelings and thoughts, whether they are experiencing positive emotions, such as happiness and contentment, or facing challenges like stress, sadness, or anxiety. This is not the same as mental illness, but poor mental health can lead to physical and mental illness.

People with chronic kidney disease face a significant burden on their mental health and although recognized as a serious issue, an approach to addressing mental health care for people with kidney disease and kidney failure is lacking. New models are needed to meet the mental health needs of people with kidney disease in Canada.

In earlier stages of the Mind the Gap project, we identified that the top 5 challenges to mental health in people receiving hemodialysis were:

1. Loss of control
2. Lack of acceptance and/or adjustment to the situation
3. Lack of trust and/or confidence in the healthcare system and providers
4. Dialysis-related symptoms
5. Feeling overwhelmed

Possible solutions identified to the above mental health challenges included counselling/therapy and peer support. Dialectical Behavioural Therapy (DBT) is a form of counselling that focuses on learning ways to change unhelpful thoughts and behaviours and teaches skills for interpersonal relationships. Group DBT could help address most of the priority challenges to mental health listed above and provides an opportunity for peer support.

DIALECTICAL BEHAVIOURAL THERAPY (DBT) Skills Training:

Based on data gathered through the Mind the Gap surveys and the Priority Setting Workshop, we have identified the top 5 challenges to mental well-being in facility-based hemodialysis as: loss of control, lack of acceptance and/or adjustment to the situation, lack of trust and confidence in the healthcare system and providers, dialysis-related symptoms, and feeling overwhelmed. After discussions with various stakeholders, we reached consensus that implementation of a Dialectical Behavioural Therapy (DBT) skills training program, which targets 4 key concepts: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness, has potential to address most of these five challenges. DBT skills training has been used in many different settings (treatment of borderline personality disorder, substance abuse, improving self-esteem in adolescents, improving corporate culture) and populations, but to our knowledge has not been studied in the hemodialysis population.

We will pilot two 13-week group DBT skills training program sessions in Manitoba that will be led by a licensed clinical psychologist who is trained and certified in delivery of DBT. Additional staff (e.g. Licensed Kidney Health Manitoba Social Workers and Occupational Therapists) will co-facilitate the group. An initial DBT skills training group will meet in person at SOGH weekly for 13 weeks. Following completion of and incorporating feedback from the first session, we will consider implementing a second virtual 13-week DBT group session.

STUDY PROCEDURES:

Both in-person and virtual DBT group participants will complete 8 short questionnaires regarding their mental health before the program starts at 6 weeks into the program, and after the DBT program ends (12 weeks). These questionnaires ask questions about your wellbeing, distress tolerance, anxiety, ability to cope, resilience, sleep, pain, anger and will take approximately 20-30 minutes to complete at each study assessment time point. Participants will also complete an end of study questionnaire (10-15 minutes to complete) to gather their perspectives on their experience in the DBT program. Both in-person and virtual DBT group participants will be provided with weekly session reminders and the relevant program materials by the research coordinator. This will include electronic or hardcopies of worksheets and handouts accompanying each week's content and videos that will be delivered by mail/email/drop off in HD unit as per your preference. The group leader or co-leader may also check in with all participants throughout the 13-week program periodically in an individual meeting.

The total time commitment (in sessions and home assignments) for this DBT program study will be approximately 36-39 hours:

Questionnaires will take approximately 1.5-2 hours in total over the 3 study assessment time points (pre-, 6-week, 12-week, post-intervention).

The DBT program content will be 25 hours of commitment (around 2 hours/week + orientation).

Home assignments and program material will take the additional 9-12 hours over the 12-week program.

Inclusion Criteria:

• Age > 18 years old
• Individuals followed in the Manitoba Kidney Health Program at Seven Oaks General Hospital or Health Sciences Centre sites with advanced chronic kidney disease not yet on facility-based hemodialysis but with plans to start within 1 month; OR
• Individuals followed in the Manitoba Kidney Health Program at the SOGH or HSC sites who have initiated facility-based hemodialysis within the last 90 days
• Able and willing to attend weekly DBT sessions (either virtually or in-person)
• Experiencing self-reported psychological distress related to advanced kidney disease or initiation of hemodialysis
• Deemed eligible to participate by study clinical psychologist

Exclusion Criteria:

• Unable to complete intervention due to planned relocation/transplant/modality change

• Unable to communicate in English

• Deemed by hemodialysis unit staff/physician/study psychologist to be unable to participate fully in study activities due to:

  • Actively participating in psychiatric care with psychiatric (DSM-5) diagnosis
  • Requiring referral for psychiatric care as per facility-based HD care provider assessment
  • Current psychotic symptoms
  • Cognitive impairment that would limit ability to participate in group or complete homework
  • Safety risk to staff (e.g. physical aggression)
  • Antisocial personality disorder or other issues that may limit ability to constructively participate in peer group
  • Severe comorbid substance use disorder (if present will offer referral to addictions resources or Addictions Psychiatry)