AIR therapy: a pilot study of a clinician-assisted e-therapy for adolescents with borderline personality disorder

Abstract

Background

While the majority of personality disorder research focuses on adults, research shows that borderline personality disorder (BPD) often emerges in adolescence, highlighting the importance of early intervention for this population. Despite this, there are limited intervention programs tailored specifically for adolescents with BPD, and no research has explored the effectiveness of online therapist-assisted interventions for BPD in adolescents. As such, this pilot study aimed to address this gap in the literature by exploring the effectiveness of a therapist-assisted online intervention (AIR Therapy) with adolescents with BPD.

Method

The intervention involved 6 online weekly learning modules in conjunction with a weekly telehealth consultation session with a clinician. Modules included: introduction to AIR therapy, mindfulness and managing distress, emotions, self and identity, our interpersonal skills, and self-care. Participants were 12 adolescents (83.3% female, M age = 15 years) and 12 clinicians (100% female, M age = 34.3 years) recruited naturalistically from publicly funded mental health services located in rural and remote locations. Adolescents were compared on BPD symptom severity, mental health symptoms and quality of life at baseline and follow-up. Measures and semi-structured interviews were also completed evaluating the effectiveness and acceptability of the intervention at follow-up.

Results

Both adolescents and clinicians rated the intervention positively in terms of its effectiveness and acceptability. Paired-sample t-tests showed significant improvement in BPD symptoms, mental health and health satisfaction from intake to end of therapy. Adolescents’ qualitative responses revealed themes of improving self-regulation and coping, ease of the online workbook, and the value of clinician interaction. Additionally, clinicians’ responses highlighted themes of adding structure to therapy, the value of a brief intervention, enhancing self-insight and helping adolescents build skills that they can utilise in everyday life. Both adolescents and clinicians also highlighted suggested areas for improvement.

Conclusion

The structured online therapist-assisted intervention in the early treatment of BPD was acceptable and helpful for participants and their clinicians in this rural and remote real-world setting. This intervention may also be particularly suited for newer or trainee clinicians, providing structured tools for use with a challenging population.

Borderline personality disorder (BPD) is a complex mental health condition characterised by an unstable sense of self, emotional dysregulation, impulsivity and interpersonal difficulties (American Psychiatric Association, 2013). BPD is often associated with a low quality of life, mental distress, impaired social and professional functioning and an increased risk of self-harm and suicide [1, 2]. Despite most BPD research and treatment being targeted towards adult populations, the typical onset of BPD begins during adolescence [3, 4]. Epidemiological research suggests a prevalence of BPD in the overall juvenile population of approximately 3% [5], while the prevalence within clinical settings ranges from 11% in outpatient clinics to 76% of suicidal adolescents presenting to emergency departments [6, 7]. Indeed, features of BPD are one of the strongest predictors of self-harm and suicidality among adolescents [8]. However, despite this, research suggests that while most clinicians acknowledge personality disorder in adolescence, only a small minority confer diagnoses to the young people they work with, much less offering treatments specifically to target personality disorder pathology [9]. This is particularly problematic due to the significant psycho-social impairment associated with BPD, as research highlights growing chronicity and reduced treatment responsiveness over time [2, 10]. In contrast, early intervention for BPD has been shown to reduce the severity and longevity of associated concerns [10] as BPD traits in adolescents are considerably more flexible than in adulthood, indicating a key developmental period to offer early intervention [1].

While the evidence base for early interventions of adolescent BPD is emerging and there is a need for more high-quality research to draw firm conclusions [11], recent reviews have showed some promising results. For example, a review of eight randomised controlled trials of psychological interventions targeting young people with BPD showed strong support for the effectiveness of early detection and intervention of BPD in adolescence [12]. Another review of 18 studies exploring the empirical outcomes of DBT for adolescents revealed positive effects of treatment in addressing BPD symptomology [13]. Because interventions for BPD tend to be lengthy and resource intensive, brief interventions may be more appropriate for emerging cases of BPD and younger individuals, who may be sufficiently responsive to less-intensive treatment options [14, 15]. This in turn allows more resources to be allocated to individuals who require more longer-term interventions. Research has shown support for the effectiveness of such brief interventions; for example, a systematic review and meta-analysis conducted by Spong et al. [16] indicated that brief (i.e., less than 6 month) psychological interventions for BPD may be an effective and efficient approach to treatment.

Despite early intervention in BPD being identified as a mental health priority area [17], there are often barriers preventing access to receiving appropriate treatment. Common barriers include financial burdens, rigidity and intensity of treatment programs, time constraints and geographic limitations (e.g., travel in rural areas; Barr et al., [18, 19]. While such impediments to accessing treatment are likely common irrespective of age, adolescents with BPD may be at a particular disadvantage [2]. For example, adolescents are significantly more limited in their autonomy and financial capacity to independently organise therapy and generally rely on assistance from external support systems (e.g., family; de Haan et al., [20]. Further, the capacity to offer such assistance may vary considerably from family to family. Indeed, research has shown that only 10–36% of adolescents with a mental illness access mental health services [21]. Further, of those who do access treatment, drop-out rates are high, ranging from 28 − 75%, with most abandoning the treatment within the first few sessions [20]. Importantly, barriers to treatment have been identified as a significant contributing factor to drop-out [20]. As such, there is a clear need for the development of more accessible effective evidence-based interventions for BPD in adolescents, such as online therapy.

Online therapeutic interventions are being increasingly implemented in mental health settings as a way to reduce barriers to receiving care [22]. These interventions offer a more cost-effective, flexible, and readily accessible alternative to face-to-face therapy [23]. This may in turn promote retention rates within therapy, which might otherwise be affected by insufficient treatment access [20]. As such, online interventions may be particularly well-positioned to benefit adolescents, and particularly those living in rural areas, who may experience increased barriers to accessing traditional interventions. The importance of therapist contact within online psychological treatment is widely acknowledged, including enhanced case conceptualisation, treatment individualisation, and a therapeutic relationship (Andersson & Titov, 2014). The necessity for interpersonal contact and therapeutic guidance, such as via Telehealth, alongside online self-guided interventions for BPD has been highlighted within the literature [24] and has been suggested as a means of resolving access barriers to treatment while also offering clients the opportunity for therapist contact [23]. One scoping review determined that app-based interventions may be a feasible and effective method of treating personality disorders when combined with therapist contact [25]. Therapist-assisted online interventions have been found to also confer several benefits for adolescent populations specifically, such as increased engagement due to familiarity with online platforms [26, 27] and feelings of enhanced confidentiality [28, 26, 29]. As such, while online therapies appear poised to help address adolescent mental health challenges, research is still in its relative infancy [30], with no studies specifically investigating the efficacy of a brief online therapist-assisted intervention for adolesents with personality disorder.

Aim of study

The present pilot study seeks to address the gap in the literature by utilising a mixed-method approach to examine the effectiveness and acceptability of a therapist-assisted online intervention (‘AIR Therapy’) for adolescents with BPD. ‘AIR’ refers to Affect, Identity and Relationships, common targets in the treatment of personality disorder.

Method

Intervention

AIR Therapy [31] was offered to adolescents aged 13–19 years old who met criteria for BPD. The treatment consists of six online learning modules. Each module focuses on developing a specific set of skills that have shown to be effective in reducing the core symptoms of BPD. Modules feature psychoeducation, workbooks, exercises and activities and take approximately 30 min each to complete. Table 1 presents the details of each module. After each module, participants then undertake a session with their clinician where they can discuss what they have learned, talk through any issues that arose, ask questions and receive feedback. The intervention features a flexible implementation, in which modules can be completed independently by the young person, or together by the treating clinician and young person during the session. In this study, each module was completed weekly (amounting to a 6-week intervention), although modules and sessions could be contracted (e.g., longer sessions covering multiple modules, or meeting multiple times a week) or extended (e.g., repeating content over more weeks).

Table 1 Intervention modules

Participants and procedure

Mental health professionals at a rural and remote (i.e., outside any major city) publicly funded mental health service were invited to use the AIR Therapy program with their adolescent clients within their local health service following institutional review board approval (2021/ETH01222; 2021/STE02920). Mental health service staff were invited to a three-day training workshop (Day 1: Foundational training; Day 2: Adolescent intervention; Day 3: Virtual ways of working– AIR Therapy) to improve staff knowledge and clinical skill in working with personality disorder, as well as to orient them to the AIR Therapy intervention. Clinicians who took part in delivering AIR Therapy were also offered 2-hr supervision sessions monthly with two clinical psychologists experienced in working with personality disorder for the duration of the project. Adolescents who were identified by their clinicians as potentially suitable for the intervention were provided with information and given the choice to participate. Written consent was obtained from all adolescents and a parent/guardian. Patients all received care and treatment in the service, irrespective of whether they consented to this research study.

Following consent, adolescents engaged in an interview with their clinician to confirm eligibility and complete pre-intervention measures. Eligibility requirements were: (1) meeting clinical cut-off for caseness of BPD (5 of 9 criteria) as assessed by a BPD severity measure (described in the measures section), (2) absence of a primary diagnosis of a severe mental or physical illness (e.g., schizophrenia, cancer) or severe personality disturbance (e.g. requiring intensive care). This was to ensure that participants possessed the capacity to engage in the therapy. To assess severity of disturbance, participants were dichotomously rated (yes/no) by clinicians for displaying elements of ‘Insight’ (e.g., “is the young person able to meaningfully reflect on their difficulties?”), ‘Agency’ (e.g., “is the young person seemingly able to function without extensive external guidance?”) and ‘Motivation’ (e.g., “is the young person relatively self-organised and can they identify factors that are motivating them to engage with the intervention?”) as part of the clinical interview. A majority of ‘yes’ ratings were required for participant inclusion, (3) not acutely suicidal and/or considered to be at immediate risk of harm to themselves or others, (4) aged between 13–19 years, (5) able to read and speak English, (6) provided informed consent (and parental consent for those aged 17 years and under). Eligible participants then commenced the AIR Therapy program.

Following completion of AIR Therapy, adolescents participated in a follow-up interview within a week of the final session where post-intervention measures were collected. Adolescents who completed the program and provided both baseline and follow-up measures are the sample reported here. At the end of the pilot examination, clinicians were also invited to evaluate the program through completing measures and participating in a semi-structured interview about their experience.

Of 53 adolescents identified as eligible for the intervention, 25 commenced the program, 13 dropped out over the course of the intervention, and 12 completed the full course of treatment and provided baseline and follow-up evaluations required for analysis. Most drop-outs occurred very early after one or two contacts. Reasons given for disengagement included moving out of service area, having competing priorities/being unable to commit to treatment, or being lost to service contact. In a remote/rural area, these challenges are well known as families are often under stress and needing to move to seek work or escape from conflicts that are not easy to ignore in small towns (e.g., Humphreys et al., [32, 33]. There were 12 mental health professionals at a rural mental health clinic who delivered AIR Therapy to one adolescent each (i.e. one unique clinician per adolescent participant). As this was a pilot study, a sample size of 12 participants and 12 clinicians was considered suitable and consistent with other published studies of this type based on this being a preliminary investigation of a novel approach to test feasibility and collect qualitative feedback [34]. Table 2 displays the demographics for the sample of adolescents and Table 3 displays the demographics for the sample of clinicians.

Table 2 Participant demographics

Table 3 Clinician demographics

Measures

Quality of life

Four questions were taken from the WHO-QOL Bref [35] to assess quality of life (“how would you rate your quality of life?”), health (“how satisfied are you with your health?”) and interference with daily living (“how much did these difficulties interfere with your life?”) in participants. Participants responded to these questions on a scale from 0 to 100, with higher scores indicating better quality of life (except for one item, interference with daily living, where lower scores indicate better quality of life). The WHO-QOL Bref has been used extensively in previous BPD research [36, 37].

BPD symptom severity

The nine criteria for BPD as outlined in the DSM-5 (American Psychiatric Association, 2013) were assessed during baseline and follow-up in a structured diagnostic interview. Adolescents were asked to respond to whether they experience each criterion (e.g., chronic feelings of emptiness) and the severity of that experience (rated 1 = none of the time, 6 = all of the time). This approach has been utilised in previous studies, demonstrating high validity and internal consistency (e.g. Grenyer et al., [38, 39]. Internal consistency of the items within our sample was acceptable (α = 0.69).

Mental health inventory-5 (MHI-5)

The MHI-5 is a five-item questionnaire from the Short Form-36 (SF-36) used to assess severity of psychological distress [40]. Each question assesses one aspect of mental health: depression, anxiety, positive affect, loss of behavioural/emotional control and psychological wellbeing (e.g., “Over the past two weeks, how much of the time have you felt downhearted and blue?”). The MHI-5 is measured on a six-point scale (1 to 6), with positive items reverse scored. The sum of the scores are transformed from 0 to 100 with higher scores representing better mental health [41]. The MHI-5 has been shown to be a valid measure that demonstrates good sensitivity and specificity [42]. Within our sample, the MHI-5 demonstrated good internal consistency (α = 0.87).

Adolescents’ experience of the intervention

Nine questions were developed to assess participants’ improvement and experience with treatment. Five of these questions involved asking participants to rate the intervention on a scale from 0 to 10 with higher scores indicating more positive ratings (e.g., “How helpful do you think this treatment is for emotional problems?”), and four of these questions prompted qualitative responses (e.g., “What aspects of the treatment were least helpful?”). The internal consistency for these items were excellent (α = 0.90).

Sixteen questions were modified from the user version of the Mobile Application Rating Scale (uMARS; Stoyanov et al., [43] to assess participants’ experience and satisfaction with the online format of the intervention (e.g., “Is the online intervention content (visuals, language, design) appropriate for the target audience?”). Questions were responded to on a 5-point scale, where 1 expresses the least satisfaction and 5 expresses the highest satisfaction. Questions 1, 2, 3 and 5 were also followed by prompts encouraging participants to expand on their response in greater detail to produce qualitative data (e.g., “Why did you select that response? What made the app engaging/not engaging for you?”) and a verbatim transcript was generated of their verbal responses. Internal consistency within our sample was excellent (α = 0.87).

Clinicians’ experience of the intervention

Five questions were developed to assess clinicians’ experience of using AIR Therapy. Questions related to ease of use (e.g., “how would you rate the ease of use of the AIR Therapy platform”), effectiveness (e.g., “how effective do you think the AIR Therapy program is for clinicians working with young clients experiencing symptoms of personality disorder”) and satisfaction (e.g., “how happy do you think your clients were with the AIR Therapy program”). Ratings were provided on a 1–6 scale, with higher scores indicating more positive ratings of the program. Internal consistency within our sample was excellent (α = 0.83).

Clinicians were also invited to participate in a semi-structured interview to obtain qualitative data regarding their experience of the intervention. Interviews lasted approximately 30 min and consisted of nine questions exploring their experience of delivering the intervention in terms of usability, benefits, barriers and therapeutic benefit (e.g., “How would you describe your experience using the AIR Therapy program?”; “Did you notice any improvements or changes in your clients’ symptoms or quality of life across the trial? If so, what changed for them?”). Clinicians were encouraged to answer questions openly and honestly and were ensured that their feedback would be confidential, would not interfere with their relationship with the researchers or the health service setting.

Data analysis

Effect size estimates were provided for the pre-post evaluation of the quantitative measures using the general linear model. Qualitative data were analysed using a reflexive thematic analysis approach [44, 45] and was based on a phenomenological theoretical framework [46]. This approach was utilised with the aim of identifying recurring themes and patterns of meaning in participants’ experiences of AIR Therapy. Audio recordings of the interviews were transcribed, read and re-read by researchers to maximise familiarity with the data. Following this, initial codes were inductively generated from the data (e.g., “self-regulation” and “interpersonal communication”), which were then clustered based on overarching themes (e.g., “skills-building”). Each unit of meaning was then checked to ensure its fit with the overarching theme and confirm that the themes generated reflected the most prominent and frequently occurring sentiments as expressed by participants. Significant statements were extracted and compiled to reflect the clearest examples of each theme. Analysis of adolescent qualitative responses occurred separately to analysis of clinician responses. Four final themes were generated from adolescents’ responses and five from clinicians’ responses.

Results

Effect size estimates demonstrated pre-post significant changes in BPD severity, mental health improvement, and greater health satisfaction, but not other ratings of health (Table 4). There was a significant reduction in the number of participants who met criteria for BPD from baseline (n = 12, 100% of participants) to follow-up (n = 8, 67% of participants), χ²(1, 12) = 4.0, p =.046.

Table 4 Effect size (d) estimates of change in participant baseline and follow-up measures

Adolescents’ experience of the intervention

In general, ratings of the intervention were positive in terms of improving mental health, being an overall success and being helpful. Overall, adolescents indicated that they were satisfied with the intervention and that they would recommend it to others. Adolescents also rated their online experience of the intervention positively (Table 5).

Table 5 Participant perceptions of overall effectiveness and online experience of AIR Therapy (n = 12)

Clinician experience of intervention

Table 6 displays the average ratings for clinicians’ experience of the intervention. Overall, the intervention was rated reasonably positively in terms of its ease of use, effectiveness for clinicians, client happiness, clinicians’ overall satisfaction and effectiveness for clients (median score 4 out of 6). These ratings are presented in Table 6.

Table 6 Clinician perceptions of clinical utility and effectiveness of AIR Therapy (n = 12; range 1–6)

Qualitative findings from adolescent responses

Theme 1: Improving self-regulation and coping skills

The most common theme expressed by adolescents was the benefit of AIR Therapy in promoting self-regulation and coping skills, which they could utilise in their everyday lives and relationships. Specifically, participants noted the value the program had in helping them to focus and think about their difficulties rather than have ongoing distress. For example, one participant commented, “I have been able to make and find new strategies to helm me stay grounded and stay calm” (GR04). Other participants emphasised how the work with the therapist discussing the activities gave them a perspective on their problems, e.g., “learning ways to cope” (YO32). Another participant expressed the particular role that AIR Therapy had in helping them manage their moods and irritability, highlighting that the most helpful aspect of the intervention was “working on ways to reduce anger and work on better coping strategies” (GR46).

Theme 2: Ease of the online workbook

Adolescents expressed appreciation regarding the clarity and ease of use of the online workbooks and their content. For example, one participant commented, “It was easy to use as it explained it very well” (YO32). Another commented, “It was easy to learn and the links. were big and clear” (GR04). One participant also highlighted that they enjoyed that the workbook could be viewed as a PowerPoint presentation due to its familiarity (DE28).

Theme 3: The value of clinician interaction

In addition to expressing positive attitudes towards the online workbook content, adolescents also reflected on the value of clinician interaction in AIR Therapy. One participant noted that they appreciated being able to utilise their clinician to enhance their engagement and learning of the content, highlighting they found the most helpful aspect of the intervention “going through the slides with my clinician” (DE28). Other participants acknowledged the benefits of clinician contact that solely self-guided online interventions cannot afford. For example, on adolescent noted the value of “having [the clinician] validating my experience” (GR39).

Theme 4: Future enhancements

Adolescents made a number of suggestions for improvement of AIR Therapy. Participants commented that the online workbook involved too much reading and would benefit from a more eclectic approach to learning. For example, one adolescent commented, “A lot of reading - needed more pictures” (DE28). Adolescents expressed preference for video or audio modalities of delivering information, for example “Make the slides more fun to read, e.g., short videos: a person dynamically explaining the theory” (SA29), and “Make it an audio book. If I could listen to it, I would take it in” (GR46). One adolescent suggested that the program could be improved by involving other participants in the creation of content (DE28). Other participants commented that AIR Therapy may be more engaging if it included formats more relevant to the current generation such as by using reels/Tik Tok formats.

Qualitative findings from clinician responses

Theme 1: Adding structure to therapy

A frequent comment expressed by clinicians was that the structure of AIR therapy was a benefit to both themselves and their clients. For example, clinicians stated that the structure kept them on track, e.g., “AIR Therapy gave a lot more structure compared to usual therapy. The workbook was really easy to follow, so the structure was dictated by what was in each workbook, which helped because it kept us on track” (#1107), and assisting with session planning, e.g., “I found the structure of AIR Therapy really helpful in planning my sessions with the young person because it gave me a basis for what to talk to them about” (#1106). Benefits of the structured approach for adolescents were described as adding routine and predictability, e.g., “The routine and structure has actually been really good for her because she knows what each session is going to be and she knows what we’re doing, so I think that’s quite helpful.” (#1110) and providing a resource that they can easily review, e.g., “I know the benefits of Air Therapy for my young person was that she had something to go back to. She said that she really liked having the modules and being able to go, ‘you know that skill that I learned, I actually really liked that one, and that’s right, that was in module 2’” (#1106).

Theme 2: An intervention that is brief

Clinicians frequently commented on the value of AIR Therapy as a brief intervention. Specifically, they noted that clients were more willing to engage due to its shorter duration compared to other therapies, for example, “I was able to sell the therapy as a short-term version– as a ‘taster plate’. She was able to engage with that because it was short term, so she was willing to give it a go” (#1105). Clinicians also acknowledged how the benefits of AIR Therapy as a brief intervention may specifically pertain to the population of adolescents with BPD, who may be more reluctant to engage in longer-term therapies, e.g., “It’s been good for me because it’s short, sharp and I go, ‘right, this is good brief therapy’. And I’ve enjoyed having an example of what brief therapy is about. And that’s engaging for this population of young people because they are hard to engage. You do not want be engaging them for too long, and I feel this is long enough for them.” (#1108). Furthermore, clinicians noted utility of AIR Therapy as a brief intervention for more emerging or moderate cases, e.g., “[the intervention] was really helpful with some of the younger kids… those who hadn’t really done any therapy in the past or had more mild BPD traits” (#1109).

Theme 3: Including everyday life skills

Many of the clinicians expressed that AIR Therapy was beneficial in teaching their clients skills that they could utilise in their everyday lives and the real-world impact this had, such as being able to resume in activities of daily living, e.g., “It was life changing. It would help with her dissociation, with the understanding of herself and insight, making healthier choices. She learned a lot of emotion regulation strategies that she would put in place to develop healthier relationships. She didn’t present again to us and was able to study and function better and do things she hadn’t been able to” (#1111). Another clinician described how their client was able to replace self-destructive behaviours with more adaptive ones “by the end of I think it was module 3 or 4, she’d actually stopped searching for ways to find razors and things that she could cut herself with and she had moved into a space of looking for physical activation as opposed to self-harm” (#1106).

Theme 4: Enhancing self-insight

Therapists mentioned the role of improving self-insight, supporting the client to better take charge of their own wellbeing, e.g., “I can see when she’s talking to me now that she is starting to do her own chain analysis about what’s been going on with her” (#1105). This was described as particularly important for adolescent populations, helping them to be able to view themselves through a more realistic and helpful lens, for instance “they liked learning more about themselves because as young people they really struggle with that” (#1107). This also included being able to differentiate the impact of their behaviours on others, to improve self-identity and esteem “a lot of the clients that I had have been told they’re ‘angry’. And so being able to identify as assertive rather than aggressive really built that kind of that self-esteem of like, ‘I’m not always angry’.” (#1107).

Theme 5: Future enhancements

The most common suggestion for improvement was to make AIR Therapy simpler and use different media. Clinicians commented that parts of the online workbook that were too “wordy” or “school-like” which may have deterred adolescents from engaging. For example, one clinician said, “I found it information heavy, so I found that the kids would sort of switch off… As we got to the later modules it was better because it was more activities-based” (#1102). Other suggestions for improvement included enhancing ease of use of the online platform, implementing the modules as an app and allowing flexibility in the order of which the modules can be completed.

Discussion

This is the first pilot study to explore the effectiveness and acceptability of a 6-week therapist-assisted online intervention (AIR Therapy) for adolescents with BPD. Participants experienced reduced BPD symptoms, improved mental health and health satisfaction on most measures following the intervention. Adolescents’ ratings of the intervention were positive in terms of the treatment improving their mental health and their satisfaction with the treatment overall. Adolescents’ qualitative responses supported these findings, revealing themes of improving self-regulation and coping, appreciating the ease and clarity of the online workbook, and the value of integrating clinician interaction. Clinicians’ responses highlighted themes of adding structure to therapy, the value of a brief intervention, enhancing self-insight and helping adolescents build skills that they can utilise in everyday life. Although participants and clinicians overall validated the content of the intervention, its structure, and duration, they also suggested that a written workbook-style intervention could be adapted to make more engaging for clients. For example, adolescents frequently suggested implementing video and audio presentation formats.

These findings are consistent with research highlighting the efficacy of early intervention for BPD in adolescents [10, 12, 13]. Similarly, these findings also support the suggested efficacy of brief interventions for BPD, and particularly for mild or emerging cases [14] or for younger individuals [15] who are more responsive to time-limited therapeutic interventions. Indeed, clinicians in our study reported that AIR Therapy provided clients with timely and focused guidance with which they were better able to engage compared to a longer-term intervention. Further, they expressed that the intervention was particularly effective for early stages of personality dysfunction, consistent with stepped care models of service delivery [15, 48]. Stepped-care approaches for the intervention of BPD are designed to align the level of intervention with the individual’s presenting concerns. They operate on the premise of having available multiple steps, including low-intensity, short-term interventions and more intensive interventions when deemed necessary [48]. A stepped-care model enables individuals with less severe presentations to receive treatment utilising fewer resources, thereby reallocating additional time and personnel to individuals who may need more intensive treatment [15]. Importantly, this model of treatment converges with contemporary conceptualisations of personality disorder, which emphasise that personality pathology exists on a continuum from ‘no impairment’ to ‘extreme impairment’ [49]. From this perspective, interventions such as AIR Therapy may be especially useful for adolescents at the lower end of the personality severity continuum as a ‘first-step’ treatment, which can be stepped up to longer term or more intensive interventions for those who need it.

A further common barrier to accessing evidence-based treatments for personality disorder is the specialised nature of the psychotherapy training and clinical practice. This often deters novice or ‘non-specialist’ clinicians from working with this patient group who instead feel they need to ‘refer out’ to specialist services [50]. Historically, in the absence of specific specialist evidence-based approaches to treatment of personality disorder, treatments have not been organised, coherent or particularly effective. This need to develop less intensive treatment strategies that are more effective and broadly applicable resulted in the creation of ‘generalist’ approaches that are well informed and structured (e.g., Gunderson [51],, and have demonstrated good outcomes [52, 53]. Consistent with this, AIR Therapy would be considered a ‘generalist’ approach in that it does not require rigorous training or an in depth clinical and theoretical repertoire– and instead focuses on foundational psychoeducation of BPD and improving elements of daily living as related to core symptoms. Indeed, in our sample the clinicians who were delivering AIR Therapy did not have extensive specialist psychotherapy training in treating BPD and were relatively inexperienced (typically around 3 years of experience working in mental health). As such, it is not surprising that a benefit of AIR Therapy regularly reported by clinicians was the addition of a ‘structure’ that helped organise the clinician, the patient and provide a common resource. This again would be consistent for implementation within a stepped care model of treatment, in which generalist approaches are attempted first, before escalating treatment to more specialised and intensive options as needed.

Limitations

The main consideration regarding this pilot project pertains to the sample selected for examination. While 53 adolescents were initially identified, most of these potential participants disengaged from the health service prior to being enrolled in the first module. Reasons given for disengagement included moving out of service area, having competing priorities/being unable to commit to treatment, or being lost to service contact. Being a naturalistic pilot study within a rural mental health setting, this level of disengagement is not surprising and reflects typical issues regarding mental health care and access. The sample included in this study was deliberately small and consistent with other naturalistic pilot studies [54] and is considered an appropriate sample for a pilot [55]. Regardless, the impact of small sample sizes on the reliability of quantitative analyses must be acknowledged and caution must be taken particularly when interpreting the quantitative results of this study, such as effect sizes and p-values. A related consideration regarding this research pertains to the nature of the 12 participants who did complete the intervention, and the possibility of a ‘self-selection bias’ [56] influencing results. We know however that this sample was highly symptomatic for both BPD and mental health symptoms at baseline and clinicians validated that the sample studied was consistent with their casework in this rural mental health setting. An additional limitation of this study pertains to the internal consistency of the measure of BPD symptom severity. Although the Cronbach’s alpha value lies within the acceptable range (α =.69), it falls at the lower threshold of acceptability. While this may be reflective of the known heterogeneity of the signs and symptoms making up the BPD diagnosis, due caution should be taken when considering the results of this study. Further research is required around optimal measures of BPD, both categorical and dimensional. Finally, given that this research was a pilot study that did not utilise randomised-controlled trial (RCT) methodology, the current results can only be treated as preliminary, and causality cannot be inferred from these findings. As such, future research implementing full scale RCT methodology is required to more comprehensively and confidently evaluate the efficacy of AIR Therapy.

Conclusion

This pilot study evaluated the effectiveness and acceptability of AIR Therapy, an online therapist-assisted early intervention for BPD in adolescents. Results indicate significant improvement in BPD symptoms, mental health and health satisfaction, and clinicians and participants indicated the structure, brevity and content was appropriate. This intervention may be particularly suited for newer or trainee clinicians, as the structure and content provided much needed guidance when working with this challenging population. Suggestions for improvement included presenting written concepts in audio and video formats These results provide preliminary support for the helpfulness of brief online therapist-assisted interventions in the early treatment of BPD and highlight the need for sustained research into this area.