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. 2023 May 18:1–9. Online ahead of print. doi: 10.1007/s10879-023-09583-w

Coping with Transitions: A Promising Intensive Outpatient DBT Program for Emerging Adults and Their Families

Joseph R Taliercio 1,✉, Talia Wigod 1, Joy Shen 1,2, Lauren Yang 3, Suzanne Davino 4, Elaina Servidio 1, Lata K McGinn 1,2,5, Alec L Miller 1,5
PMCID: PMC10193327  PMID: 37363718

Abstract

Emerging adulthood is a period of significant exploration, transformation, variability, and growth. Simultaneously, this developmental period presents unique challenges as emerging adults work to achieve developmental milestones including self-identity formation, the establishment of long-term intimate relationships, career advancement, and independence from parents. For those who are vulnerable, this period is also marked by the development of significant mental health problems and associated impairment, which prevents individuals from successfully reaching these developmental milestones. To address the various challenges unique to this developmental period, we created and implemented a multifaceted DBT treatment protocol to specifically address emotional dysregulation within emerging adults. The current study presents an evaluation of a novel, intensive, outpatient DBT program called System for Adult Growth and Emergence—Foundations (SAGE-F). We aim to first introduce the SAGE-F treatment protocol, and then to assess both its short and long-term therapeutic value. Participants enrolled in SAGE-F were administered a testing battery assessing symptom severity, functioning capacities, and coping strategies at intake, upon completion of the program 6-weeks later, and at 3-month follow-up. It was found participants who completed SAGE-F reported significant reductions in depression and anxiety symptoms, as well as non-suicidal self-injurious behaviors. Simultaneously, participants also reported improvements in their daily functioning and coping capacities. Follow-up assessments indicated therapeutic progress remained.

Keywords: Emerging adults, DBT, Intensive, Outpatient, Family, Dysregulation

Introduction

Emerging adulthood (EA) is a developmental period, which occurs between the ages of 18 and 25, marked by identity exploration, life transitions, and increasing independence (Arnett, 2000, 2006), and is associated with shifts in social relationships (Lapierre & Poulin, 2020), agency (Schwartz et al., 2005), financial independence (Terriquez & Gurantz, 2014), and professional development (Ranta et al., 2013). In addition, today’s emerging adults (EAs) face a unique landscape compared to earlier cohorts, both due to (Horigian et al., 2021), and independent of the COVID-19 pandemic, resulting in an elongation of this developmental phase (Baggio et al., 2017). Notably, EA is also correlated with a greater vulnerability to mental health problems (Lapierre & Poulin, 2020). Although adolescence is often associated with the onset of mental illness (Kessler et al., 2007), EA is marked by the first onset of many mental illnesses, and unfortunately corresponds with a notably low treatment engagement rate (Adams et al., 2014). While the proliferation of treatments for EAs in recent years is noteworthy, most have been developed to target EAs with specific diagnostic criteria (Li et al., 2018; van Aubel et al., 2020). In contrast, EAs face an extensive array of problem areas, including parental conflict, psychiatric comorbidities, impulsivity, and substance use (Mistler et al., 2016), that require a comprehensive treatment approach. One solution may be dialectical behavior therapy (DBT).

First developed as a treatment for adults diagnosed with borderline personality disorder, who presented with suicidal and non-suicidal self-injurious behaviors (Linehan et al., 1991), dialectical behavior therapy (DBT) combines principles from behaviorism with the aim of building a life worth living via warmth, acceptance, mindfulness, and problem-solving through a hierarchical-targeted progression from life-threatening behaviors towards skill building (Linehan & Wilks, 2015). Comprehensive DBT incorporates three modes of treatment, including skills groups, individual therapy, and phone coaching (Linehan et al., 2015). Since its initial conceptualization, DBT researchers have continued assessing the therapeutic potential of the treatment, finding the treatment is effective when modified for a variety of diagnostic presentations and populations (Ritschel et al., 2012; Uliaszek et al., 2016). Further, comparable to other treatments, DBT is associated with reduced dropout rates, (Neacsiu et al., 2014), and increased cost-effectiveness (Murphy et al., 2020). In summary, both original and modified DBT programs appear to be effective in improving productivity, interpersonal developmental, and the quality of life across a variety of problematic treatment settings (Rakfeldt, 2005; Uliaszek et al., 2016).

To the best of our knowledge, standardized DBT has never been modified to specifically provide treatment to EAs within an intensive outpatient setting. In order to fill this therapeutic gap, and in an attempt to develop evidence-based practices for community settings (Onken et al., 2014), we developed and implemented an intensive, outpatient, augmented DBT program called System for Adult Growth and Emergence—Foundations, (SAGE-F; Davino & Miller, 2017). The current study is a preliminary analysis of SAGE-F and consists of two distinct goals. First, we aim to present on the exact structure and format of SAGE-F, in an effort to encourage and guide the development of similar programs within outpatient settings. Second, we discuss our evaluation of the program’s therapeutic potential in the form of a pilot study. We hypothesized that those who complete SAGE-F will demonstrate both immediate and long-term reductions of depression, anxiety, and non-suicidal self-injurious behaviors. Further, we also predicted that the completion of SAGE-F will be associated with improvements in short- and long-term functioning in daily living as well as perceived coping capacities.

Methods

Participants

Thirty-five patients consented to participate in the current study (see Table 1). Follow-up data was acquired for up to 18 of these participants at either the program’s completion, 6 weeks later, or at a 3-month follow-up. All participants were recruited from a large metropolitan area, with ages ranging from 17 to 31. A majority identified as White (74.30%), cis-gendered (80.00%), heterosexual (42.90%), female (68.60%), college students (51.30%). A minority of participants had a diagnosis of borderline personality disorder (13.50%), with patients presenting with a variety of disorders, including ADHD, bipolar disorder, MDD, GAD, OCD, and substance abuse.

Table 1.

Demographic characteristics

Characteristic n %
Sex at birth
 Male 11 31.40
 Female 24 68.60
Gender
 Male 10 28.60
 Female 18 51.40
 Transgender female 1 2.90
 Genderqueer or gender nonconforming 5 14.30
 Other 1 2.90
Age
 17–19 18 48.60
 20–22 8 21.60
 23–25 7 18.90
 26+ 4 10.80
Race
 White 26 74.30
 Latino 2 5.40
 Multiracial 7 20.00
Sexual orientation
 Heterosexual 15 42.90
 Gay or lesbian 3 8.60
 Bisexual 9 25.70
 Queer, pansexual, or questioning 5 14.30
 Other 3 8.60
Marital statusa
 Single, never married 34 97.10
 Married, or in civil union 1 2.90
Years of completed educationa
 Some high school 3 8.10
 High school 8 21.60
 Some college 12 32.40
 Associate degree 2 5.40
 At least a bachelor’s degree 10 27.00
Current employmenta
 Student 19 51.30
 Employed 6 16.20
 Unemployed 10 27.00
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aSome participants did not respond to this question, equating totals less than 100%

Materials

The System for Adult Growth and Emergence—Foundations, (SAGE-F; Davino & Miller, 2017) was initially developed to fill a therapeutic treatment gap for EAs. As standardized DBT already satisfies many of the recommendations made in working with EAs, incorporating mindfulness (Li et al., 2018), interpersonal development (Lapierre & Poulin, 2020), and living a meaningful life (Schwartz et al., 2013), it provided a well-supported foundation in developing a new treatment. However, modification was required to satisfy additional researcher recommendations, specifically, the importance of familial engagement (Finan et al., 2018) and the need to cope with executive functioning demands (O’Rourke et al., 2018). Finally, as the therapeutic value of brief treatments is becoming increasingly clear (Öst & Ollendick, 2017), the potential of transitioning DBT into a brief treatment format was also an objective.

In practice, SAGE-F, as with comprehensive DBT, consists of weekly individual therapy, skills groups, and phone coaching. Both individual therapy and phone coaching remain unchanged from standard protocols; however, SAGE-F differs in multiple ways. First, SAGE-F is significantly shorter, lasting 6 weeks, as opposed to at least 5 months, with groups occurring for two-and-a-half hours four times a week, Monday through Thursday, from 10:00 am to 12:30 pm. Patients enrolled in SAGE-F have the option of attending treatment in-person, virtual, or in a hybrid setting. If in-person, patients meet in a classroom-like setting with desks, a board, and projector, and are expected to bring group materials each day. Groups consist of a minimum of two people, and a maximum of 10, and is led by two or three group leaders.

Potential group members are typically self-selected; however, patients are occasionally internally referred by other providers in our practice. For those who are interested, they are then asked to participate in a 90-min intake. Intakes for SAGE-F include interviews with the potential patient and at least one guardian. Enrollment in SAGE-F does not require any specific diagnostic presentation; however, exclusionary criteria for program enrollment includes significant developmental disabilities, a primary diagnosis of substance abuse, active psychosis, or active suicidal intent. All group members, regardless of presentation, are expected to complete daily homework assignments, engage in group activities, and participate in group discussions. If after both the intake and a brief orientation to SAGE-F, the potential patient consents, he or she is able to start as early as the following week. All new patients begin SAGE-F on Mondays, which is devoted to orientation and mindfulness – similar to the start of a traditional DBT skills group.

A typical day of SAGE-F begins with a mindfulness exercise. Next, depending on the exact day of the week, group members are oriented to SAGE-F (on Mondays), engage in homework review (Tuesday through Thursday), and/or learn an executive functioning skill (on Tuesdays). After an hour, a 15-min break is provided. Upon returning from break, the remainder of the group is dedicated to either mindfulness, only on Mondays, or a new DBT skill with skills integration, where group members are invited to share real-world problems and engage in a collective solution analysis. DBT skills included in the SAGE-F curriculum are either taken directly or adapted from standard DBT for adults (Linehan, 2015), DBT for Adolescents (DBT-A; Rathus & Miller, 2015), and Skills Training for Emotional Problem Solving for Adolescents (DBT-STEP-A; Mazza et al., 2016) manuals. These skills include mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and walking the middle path skills. At the conclusion of each group, group members are assigned homework based on the material covered that day.

Unlike standard DBT, SAGE-F incorporates an emphasis on executive functioning skills. Prior research demonstrates the effectiveness of utilizing both cognitive-behavioral and DBT-based executive functioning skills within a group setting to improve executive functioning in EA (Hartung et al., 2022). Therefore, SAGE-F aims to build executive functioning capacities by implementing lessons dedicated to being goal-directed, prioritizing, time estimation, procrastination, routine development, and cognitive flexibility. Each executive function lesson was chosen based on the potential for the skill to be integrated into DBT topics covered in a group on that particular week. For example, the lesson on routine development is taught during the same week that lessons on emotional vulnerabilities and regulation are taught.

While comprehensive DBT has no requirement for parental participation (Linehan & Wilks, 2015), DBT-A mandates parental involvement (Mehlum et al., 2014). SAGE-F, which tries to address this development gap between adult and teen protocols, does not mandate parental participation, but does encourage participation in the form of an optional parenting skills group. The transactional nature of emotion dysregulation within a parent–child dynamic is well-documented (Shenk & Fruzzetti, 2011). Relatedly, in an effort to decrease the risk parents unintentionally invalidate (Shenk & Fruzzetti, 2011) or over-accommodate (O’Connor et al., 2020) their EAs, during the SAGE-F intake, we invite parents to participate in a weekly 15-week parenting group. Skills and support are offered in a parent-only group to both normalize parental difficulties and reduce shame (Scarnier et al., 2009). DBT skills taught in this group emphasize mindfulness, validation, dialectics, interpersonal effectiveness, distress tolerance, and pleasant activities. Further, in each group, parents are encouraged to request feedback from other parents, thereby functioning as both a skills and support group.

The Patient Health Questionnaire 9 (PHQ-9; Spitzer et al., 1999) is a self-report measure that was initially created to assess psychiatric symptoms within a primary care unit. Since its original conceptualization, the measure is commonly used as a brief depression assessment tool across treatment settings, and is consistently found to be both a valid and reliable measure (Kroenke et al., 2001). The PHQ-9 consists of nine items and asks that individuals endorse the severity of nine depressive symptoms on a Likert scale, where zero represents “not at all,” and three is indicative of “nearly every day.” The PHQ-9 specifically aims to assess symptom severity over the previous 2 weeks. Scores range from zero to 27, with higher scores representing severe depression.

The Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) is a brief measure of generalized anxiety. Intended to reflect the format of the PHQ-9, the GAD-7 is a seven-item self-report questionnaire that requires participants to endorse responses on a Likert scale, ranging from zero, “not at all,” to three, “nearly every day,” to describe their state over the previous 2 weeks. Scores range from zero to 21, with higher scores indicative of more severe anxiety. The GAD-7 remains a valid measure of generalized anxiety, and continues to be a popular tool to determine the severity of symptoms (Rutter & Brown, 2017).

The Sheehan Disability Scale (SDS; Sheehan, 1983) is a self-report measure that assesses overall functioning capacities. Since its creation, it has been found to be a valid and reliable measure across dozens of studies and treatment settings (Sheehan & Sheehan, 2008). The Sheehan consists of three questions, and requires participants to endorse each item on a Likert scale from zero to 10. Potential scores range from zero to 30, with higher scores indicative of greater impaired functioning in everyday life.

The Difficulties in Emotion Regulation Scale 16 (DERS-16; Bjureberg et al., 2016) is a valid and reliable self-report questionnaire (Hallion et al., 2018) that was adapted from the original 36-item DERS (Gratz & Roemer, 2004). The DERS-16 consists of five subscales assessing various facets of emotion regulation. Only one subscale was included in the current study, the Strategies subscale, which assesses one’s perceived access to effective coping strategies. This subscale consists of five items, with total scores ranging from five to 25. Participants are asked to endorse answers on a Likert scale, from one to five, with higher scores indicating that participants view themselves as having fewer effective coping strategies.

The Deliberate Self-Harm Inventory (DSHI; Gratz, 2001) is the final measure used in the current study, and assesses whether an individual intentionally engages in self-harm behaviors. Widely used today (Swannell et al., 2014), participants are asked to endorse “yes” or “no” across 17-items, with each item defining self-harm in a unique manner. For those who endorse self-harming with a particular method, follow-up questions are asked to assess frequency, severity, and consequences. For the current study, three versions were utilized. At baseline, the DSHI assessed life-long prevalence, while at follow-up, questions were modified to assess for any behaviors since last admission.

Procedures

All patients, (n = 59), who were enrolled within the SAGE-F program, from June 2020 to September 2021, were invited at the end of their intake to participate in the current study. They were informed that their participation was voluntary and that the goal of the study was to evaluate the aggregate outcomes of SAGE-F. If consent was provided, participants (n = 35), were administered the testing battery at three distinct periods, prior to the start of group (T1), upon graduating from group 6-weeks later (T2), and at 3-month follow-up (T3). The same testing battery was administered across all three testing periods. At T1, participants' demographic data was also acquired. The current treatment period occurred during the peak of the COVID-19 pandemic, requiring all participation to be conducted virtually.

Statistical Analysis

Four one-way repeated-measures ANOVAs were calculated to assess decreases in depression and anxiety symptoms and improvements in functioning and emotion regulation. Significant findings were further assessed via a priori repeated-measures t tests. In contrast, Chi-square tests were performed to assess changes in self-harm behaviors from T1 to T2, and then again from T2 to T3.

A priori power analyses were conducted utilizing G*Power 3.1 (Faul et al., 2009). For the repeated-measures ANOVAs, we used a two-tail design, alpha level of ≤ 0.05, a power-level of 80%, and a moderate effect size, with the minimum sample calculated at 16. Utilizing the same parameters to assess for power in the Chi-square tests, a minimal sample of eight was calculated.

Results

To test the current study’s hypotheses, four one-way repeated-measures ANOVAs were calculated (see Table 2). The first evaluation examined differences in participants’ depression scores from T1 through T3. The analysis indicated a statistically significant reduction in depression symptoms, with a large effect size, F = 10.19, p < 0.01, ηp2 = 0.51. Two follow-up repeated-measures t tests were also calculated to further investigate this finding. Comparing T1 (M = 13.76, SD = 7.21) to T2 (M = 9.24, SD = 6.67), results indicated a significant change, with a moderate effect size, t (16) = 3.15, p = 0.01, d = 0.63. In contrast, participants’ depression scores from T2 (M = 8.18, SD = 7.08) to T3 (M = 6.82, SD = 6.90) yielded nonsignificant findings, t (10) = 1.17, p = 0.27, d = − 0.19.

Table 2.

Descriptive characteristics

Variable n M SD
PHQ-9a
T1 33 12.76 7.01
T2 18 9.61 6.66
T3 13 6.15 6.58
GAD-7b
T1 33 8.64 4.99
T2 18 6.83 5.66
T3 13 4.54 4.43
SDSc
T1 26 20.12 5.41
T2 11 15.36 6.19
T3 10 11.40 6.67
DERS-16d
T1 33 16.64 4.76
T2 18 13.39 4.00
T3 12 14.50 5.23
DSHIe
T1 33 0.48 0.51
T2 17 0.22 0.43
T3 12 0.25 0.45
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T1 represents results at intake, T2 represents results 6 weeks later, at the program’s completion, and T3 represents results 3 months following the program’s completion

n sample, M mean, SD standard deviation of the mean

aDerived from the Patient Health Questionnaire—9. bDerived from the General Anxiety Disorder—7. cDerived from the Sheehan Disability Scale. dDerived from the Difficulties in Emotion Regulation Scale—16, only utilizing the Strategies subscale. eDerived from the Deliberate Self-Harm Inventory, with T1 scores representing lifetime reports, and T2 and T3 indicating any subsequent self-harm behaviors following T1

A second one-way repeated-measures ANOVA examined changes to participants’ anxiety scores across the three treatment periods. A significant reduction in anxiety was found, yielding a large effect size, F = 6.66, p < 0.01, ηp2 = 0.40. Follow-up repeated-measures t tests indicated significant changes, with a moderate effect size, from T1 (M = 9.06, SD = 4.51) to T2 (M = 6.29, SD = 5.34), t (16) = 2.39, p = 0.03, d = 0.56, but no significant changes between T2 (M = 6.27, SD = 5.42) and T3 (M = 5.09, SD = 4.57), t (10) = 1.03, p = 0.33, d = − 0.23.

Changes in participants’ functioning capacities were assessed with a third one-way repeated-measures ANOVA. Overall, a significant and large improvement in functioning was found, F = 7.83, p = 0.02, ηp2 = 0.84. Two follow-up repeated-measures t tests were then calculated to further understand this result. In comparing changes from T1 (M = 22.29, SD = 3.04) to T2 (M = 14.86, SD = 4.67), the results were found to be significant, yielding a large effect size, t (6) = 3.76, p = 0.01, d = 1.89. In examining changes between T2 (M = 12.50, SD = 6.69) and T3 (M = 12.83, SD = 7.19) however, results were found to be nonsignificant, t (5) = − 0.14, p = 0.89, d = 0.05.

A final one-way repeated-measures ANOVA was calculated to examine changes in emotion regulation strategies. Results were found to be significant, with participants reporting a large statistical improvement in emotion regulation, F = 6.37, p = 0.01, ηp2 = 0.39. Two follow-up repeated-measures t tests were then calculated. While the comparison between T1 (M = 18.00, SD = 4.57) and T2 (M = 13.00, SD = 3.76) yielded significant differences, with a large effect size, t (16) = 4.32, p < 0.01, d = 1.19, the comparison between T2 (M = 13.18, SD = 3.68) and T3 (M = 15.18, SD = 4.90) was nonsignificant, t (10) = − 1.77, p = 0.11, d = 0.47.

Finally, to examine changes in non-suicidal self-injurious behaviors, two Chi-square tests were calculated. In comparing reports from T1 to T2, results were found to be significant, with a large effect size, X2 (1) = 5.89, p = 0.02, φ = 0.59. However, in examining the differences between T2 and T3, the results were found to be nonsignificant X2 (1) = 3.23, p = 0.07, φ = 0.44.

Discussion

The current study examined the therapeutic potential of SAGE-F, an enhanced DBT program for EAs. In addition to receiving weekly standard individual DBT therapy and access to phone coaching, participants attended 2.5-h groups, four times a week, for 6 weeks, that taught both DBT and executive functioning skills. We hypothesized that completion of SAGE-F would be associated with improvements in general functioning and emotion regulation, and reductions in non-suicidal self-injurious behaviors, in both short- and long-term settings. All hypotheses were supported by the data. Specifically, participants experienced moderate reductions in both depression and anxiety, and large improvements in both daily functioning and emotion regulation over the duration of the 6-week treatment. In all cases, while some change was observed between post-treatment and the 3-month follow-up, the observed change in each of these four cases was found to be nonsignificant. Similarly, non-suicidal self-injurious behaviors demonstrated large reductions following the completion of the treatment program. While there was some recurrence between post-treatment and follow-up, the differences were also not found to be significant. Overall, the enrollment and completion of SAGE-F is associated with substantial reductions in symptom presentation and improvements in functioning.

It is beyond the scope of this study to examine or predict the exact mechanisms responsible for the observed change. However, given that SAGE-F primarily relies on established DBT principles, we estimate similar factors are therapeutically relevant within SAGE-F. Specifically, we suspect the combination of phone coaching skills, individual therapy, and group-enrollment all contributed to the therapeutic growth (Linehan et al., 2015). Further, the group’s emphasis on effective organization, goal prioritization, and peer collaboration may have proven vital, as shown in similar EA programs (Toms et al., 2019). Finally, it is important to note the structure of SAGE-F was influenced by prior studies, which found treatments that are transdiagnostic in their approach (Neacsiu et al., 2014), incorporate parental engagement (Finan et al., 2018), and emphasize individualized goals and autonomy (Schwartz et al., 2005), may contribute to therapeutic gains when working with EAs.

Limitations and Future Studies

While the current study’s preliminary results evaluating the effectiveness of SAGE-F are promising, we recognize limitations to this study. First, this study used a pre-post design with no control group or randomization, which would improve the integrity of the outcomes. Second, our sample size varied between assessments, as a result of attrition, not treatment dropout, and at times was underpowered. Third, we did not assess treatment fidelity. Although psychologists and postdoctoral fellows were trained on a treatment manual developed by senior DBT clinicians (Davino & Miller, 2017), clinicians’ competency in administering the treatment was not formally assessed. Fourth, all acquired data was produced via self-report measures and were not corroborated by clinician assessment or collateral report. Fifth, while the current analyses relied mostly upon acceptable statistical power—with some notable dropout at T2 and T3, examining the sample as one homogenous unit, despite variations in demographic and clinical variables, may have impacted external validity. Finally, a number of potential confounding variables must be considered, including treatment enrollment after completing SAGE-F, parental engagement, and the impact of COVID-19, none of which was assessed, but may impact the generalizability of the study.

Future research should work to address the limitations in this study. To increase the generalizability of the results, we aim to increase our sample size, with the intent to generate a more diverse sample, both in terms of demographic and diagnostic presentations. We also are applying changes in the assessment procedures to increase response rates and reduce attrition. To expand upon our findings, we will assess the long-term benefits of SAGE-F by also assessing participants at 6-months, and plan to evaluate social functioning, parental relationships, and executive functioning capacity. Further, future studies will expand data collection by also assessing participants’ individual treatment providers and their guardians, as we suspect their added insight will contribute to future evaluations directed at predicting dropout and appropriateness in the fit of care. Potential covariance related to participants’ performance and treatment outcomes, such as parental engagement, treatment history, and therapeutic rapport will also be considered. Finally, as treatment returns to an in-vivo setting, future analyses will need to compare the therapeutic outcomes of when SAGE-F is delivered virtually versus in-person.

Finally, distinct from our exact hypotheses, additional suggestions can be derived from our findings, which require further evaluation. While the current study was not initially designed as a response to the COVID-19 pandemic, considering participants at baseline reported significant mood dysregulation and functional impairment, and the study’s entirety was conducted during the acute phase of COVID-19 pandemic, the current findings may suggest the implementation of SAGE-F can be beneficial in combating the ongoing mental health crisis experienced by EAs (Tasso et al., 2021). Further, while SAGE-F was developed as a transdiagnostic treatment program, SAGE-F may also be conceptualized as a secondary preventive program—given that we did not see any worsening of symptoms at 3-month follow-up. None of the participants within the current study reported any significant increase in risk following their enrollment in SAGE-F, which supports the potential that SAGE-F may prevent worsening of symptoms and functioning among EAs.

Summary

In the current paper, we presented a new treatment called SAGE-F. SAGE-F is a modified DBT program specifically for EAs. In practice, the program aims to repair emotional, behavioral, and interpersonal dysregulation, while simultaneously emphasizing executive functioning capacities and parental relations. The current paper also demonstrated the therapeutic value of this program: the successful completion of SAGE-F is associated with significant improvement in psychological wellbeing in both the short and long-term settings. The evaluation of SAGE-F is ongoing, both in an attempt to further the understanding of the program’s therapeutic value and to repair any limitations present within the current study.

Author contributions

All authors contributed to the study conception, design and material preparation, while data collection, analyses, and treatment protocol were implemented by JRT, TW, JS, LY, SD, ES. The first draft of the manuscript was written by JRT, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

None of the authors have any funding sources to disclose.

Declarations

Conflict of interest

None of the authors have any conflicts of interest or funding sources to disclose.

Ethical standards

The current treatment protocol was approved by an IRB, and followed ethical recommendations and requirements.

Informed consent

Informed consent was obtained from all individual participants included in this study.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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