-->PONE-D-25-63596-->-->Unraveling dynamic factors in Dialectic Behavioural Treatment for Adolescents (DBT-A): a study protocol-->-->PLOS One

Dear Dr. de Weerd,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The authors are to be commended for their efforts in preparing this manuscript. The three reviewers have now completed their evaluations. Overall, I found this protocol paper to be well structured and clearly written, and the authors demonstrate strong expertise in the field. The reviewers provided insightful methodological comments, particularly regarding aspects that would benefit from further clarification. In particular, the rationale for defining the participant age range as 12 to 23 years warrants more explicit explanation. An age span that bridges adolescence and adulthood is relatively uncommon in the DBT-A literature. If this age range reflects a context specific to the Dutch healthcare system (e.g., transitional youth services), it would be helpful to elaborate on this for readers from diverse international and cultural backgrounds, so that the applicability and rationale of this choice can be more clearly understood.

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Please submit your revised manuscript by Apr 11 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the ’submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Kyoung-Sae Na, M.D., Ph.D.

Academic Editor

PLOS One

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When submitting your revision, we need you to address these additional requirements.

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3. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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Reviewers' comments:

Reviewer’s Responses to Questions

-->Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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-->5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Dear Authors,

Thank you for the opportunity to review your study protocol. I would like to begin by acknowledging the significant value of this work.

Below are my formal comments and the issues that should be addressed before the protocol can be considered for publication.

1. Rationale and Research Questions

The manuscript provides a valid and well-justified rationale. By moving beyond aggregate quantitative data to explore individual "trajectories," you address a critical gap in understanding why some adolescents do not respond to DBT-A. The research questions are clearly stated and align with the proposed qualitative longitudinal design.

2. Methodology and Replicability

The protocol is technically sound and the use of Reflexive Thematic Analysis (RTA) combined with Framework Analysis is appropriate. However, to ensure full replicability, the following points must be addressed:

Interview Guides: While you identify themes like "alliance" and "motivation," the specific semi-structured interview prompts are not included. Please provide the interview topic guides as supporting information.

Definition of a "Case": Given the high-risk nature of this population, dropout is likely. You must explicitly define what constitutes a "complete case" for your analysis. If a parent or therapist leaves the study but the adolescent remains, will that trajectory still be included? Clarifying the "minimum data set" is essential to prevent undisclosed flexibility in the analysis pipeline.

3. Feasibility and Potential Biases

Recruitment Bias: Because therapists recruit their own patients, there is a significant risk of "cherry-picking" stable or "likable" cases. I suggest the authors describe a more randomized recruitment approach (e.g., inviting the next three eligible patients) to ensure the data includes the "difficult" dynamics the study aims to unravel.

Parental Dyads: You mention a preference for interviewing parents together. This "dyadic" approach can suppress conflicting views or domestic tensions. Please justify this choice or mention a protocol for offering individual "break-out" sessions if tension is observed.

4. Data Availability and Ethics

PLOS Data Policy: You have correctly identified that the data is sensitive and will require restricted access. However, for publication, you must provide contact information for an independent Data Access Committee or Ethics Committee. Relying solely on "available upon request from the authors" does not meet current transparency standards.

Sentence Completion: Please review page 13; the sentence ending in "...and to" appears to be cut off.

5. Language and Presentation

The manuscript is written in high-quality standard English. Your disclosure regarding the use of AI for translation and linguistic refinement is appreciated and aligns with ethical transparency, provided you maintain full accountability for the technical content.

Optional Suggestions for the Study Plan

Member Checking: To mitigate attrition over the 9-month period, consider offering participants a brief, clinically appropriate summary of the general themes found in the study as an incentive for their continued contribution.

Power Dynamics: In the triadic model, the researcher must be careful not to be perceived as "part of the clinical team." Clearly emphasizing the independence of the research team during the consent process will be vital for obtaining honest critiques of the therapy.

Reviewer #2: A very interesting study with relevant objectives. Congratulations!

Methodology:

It would be important to better describe the type of study. From what I understand, it is a mixed, prospective study with interviews, questionnaires, and scales.

Why not put it in a flowchart? To better understand the study design.

Why adolescents aged 12-23? You should explain this better, defining the term “adolescent”, especially since there are social, mental and behavioural differences between the different stages of adolescence.

Is this protocol registered?

My ethical concerns are clearly described, as are the limitations of this study.

Reviewer #3: This protocol delves into an aspect of DBT (especially in Adolescents),that could be elusive. It is a well constructed paper with exhaustive literature review and a solid framework for data collection and interviews.

General questions

Have you considered individual therapist, and parental factors that could create bias and therfore confound results? (For example competence of the therapist?)

Are we exploring the transferance-counter transference dynamic and it’s effects? If so hasn't that been well documented.

Since you've included ages from 12 to 23, which is a wide range of psychological development stages, do you plan on addressing the potential effect of age in the analysis and discussion?

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-->7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review?  For information about this choice, including consent withdrawal, please see our Privacy Policy.-->

Reviewer #1: No

Reviewer #2: Yes: Patricia Alves

Reviewer #3: No

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To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->PONE-D-25-63596R1-->-->Unraveling dynamic factors in Dialectic Behavioural Treatment for Adolescents (DBT-A): a study protocol-->-->PLOS One

Dear Dr. de Weerd,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Although invitations were sent to the three reviewers who evaluated the original submission to review the revised manuscript, unfortunately none of them were able to accept the re-review request. Accordingly, as the handling editor, I personally examined the reviewers’ major comments, the authors’ responses, and the corresponding revisions made to the manuscript. Overall, the authors appear to have addressed the reviewers’ concerns thoroughly and have substantially improved the manuscript. However, I believe the following two points would further strengthen the methodological clarity and transparency of the study.

#1. Regarding Reviewer #2, Comment 12

Recently, preregistration has increasingly been encouraged in qualitative research as well, as it can help clarify methodological and analytical decisions made prior to examining the actual data, and distinguish exploratory elements from a priori decision-making. Of course, given the nature of qualitative research, preregistration is not expected in the same manner as in quantitative hypothesis-testing studies, and it is not a mandatory requirement for publication in this journal.

Nevertheless, if the authors ultimately decided not to preregister this study, I would ask them to state more explicitly in the manuscript the rationale for this decision, as well as what alternative measures (e.g., reflexivity procedures, audit trails, documentation of analytic decisions) will be used to ensure transparency and methodological rigor in place of preregistration.

<h4>#2. Regarding Reviewer #3, Comment 13</h4>

The authors state that participating therapists work in a “highly specialized setting” and are “extensively trained” in DBT. However, as currently written, these descriptions may appear somewhat subjective, making it difficult for readers to objectively assess the therapists’ level of expertise and training. Therefore, if possible, I encourage the authors to provide more concrete and objective criteria—such as DBT certification, formal training pathways, supervision structures, or minimum levels of clinical experience—which would further strengthen the methodological transparency and credibility of the study.

==============================

Please submit your revised manuscript by Jul 09 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the ’submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:-->

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

-->

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Kyoung-Sae Na, M.D., Ph.D.

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

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Unraveling dynamic factors in Dialectic Behavioural Treatment for Adolescents (DBT-A): a study protocol

PONE-D-25-63596R2

Dear Dr. de Weerd,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Kyoung-Sae Na, M.D., Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: