Is there a need to improve the quality of DBT in routine care?

Since Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan in the late 1980’s, it has been widely implemented in routine practice settings around the world. DBT is typically used to treat adolescents and adults at high risk for suicide who have multiple, complex problems that require intensive treatment. To date, more than 40,000 therapists are estimated to have been trained in DBT, making it one of the most successful dissemination efforts of any evidence-based psychological treatment. Although DBT is widely used, the degree to which it is delivered in a manner consistent with the evidence-based model varies considerably across therapists and programs. Research evaluating DBT services in routine care settings has found that 44-48% of the sessions delivered by therapists are not adherent to DBT [1, 2], 25-58% of DBT programs do not deliver all four modes of the treatment [3, 4], and programs provide about 70% of the required elements of the treatment on average [5]. Thus, there is a critical need to improve the quality of DBT being delivered in routine practice to make it more consistent with the empirically-supported intervention.

Why focus on developing pragmatic measures?

To date, a significant barrier to DBT quality improvement efforts has been the lack of pragmatic measures to evaluate therapist adherence and program fidelity. Therapist adherence refers to the degree to which therapists deliver DBT according to the manual, whereas program fidelity refers to the extent to which a program is structured to include the necessary elements of DBT. Without such measures, it has been difficult for therapists and programs to evaluate if they are delivering DBT as intended to the individuals who need it.

Why is therapist adherence to DBT important?

Ensuring that DBT is delivered adherently is an important aspect of quality assurance. In particular, it enables administrators, programs, therapists, and consumers to know that the treatment being delivered is actually DBT. In addition, therapist adherence to DBT has been shown to improve client outcomes, including reducing suicide attempts, psychiatric hospitalizations, substance use, and treatment dropout [6-8]. Therefore, delivering DBT with adherence is a critical component of providing high quality DBT and achieving the best possible outcomes for clients.

Why is DBT program fidelity important?

Program fidelity is also an important aspect of quality assurance as it means that the critical elements of DBT are present in the program. Programs with high fidelity are structured to deliver comprehensive DBT in a manner consistent with the evidence-based model. Although program fidelity does not guarantee the quality of treatment provided, it does ensure that the program is structured in a manner that makes high quality DBT possible. In addition, research has found that DBT programs that are structured to be more consistent with DBT principles have better client outcomes [9].

What have we developed?

Using rigorous empirical methods, we have developed two pragmatic measures that can be used to evaluate DBT therapist adherence and DBT program fidelity. These measures:

• Assess therapist strategies and program elements critical to the high quality delivery of DBT.

• Are brief and easy to use.

• Can be used for multiple purposes (e.g., quality monitoring and improvement, training and supervision, research).

• Can be completed by multiple types of raters (e.g., therapists, supervisors, team members).

• Are freely available on this website.

References:

1. Harned, M. S., Schmidt, S. C., Korslund, K. E., & Gaglia, A. (2023). Therapist adherence to Dialectical Behavior Therapy in routine practice: Common challenges and recommendations for improvement. Journal of Contemporary Psychotherapy. https://doi.org/10.1007/s10879-023-09601-x

2. Harned, M. S., Korslund, K. E., Schmidt, S. C., & Gallop, R. J. (2021). The Dialectical Behavior Therapy Adherence Coding Scale (DBT ACS): Psychometric properties. Psychological Assessment, 33, 552-561. https://doi.org/10.1037/pas0000999

3. Navarro-Haro, M. V., Harned, M. S., Korslund, K. E., DuBose, A., Chen, T., Ivanoff, A., & Linehan, M. M. (2019). Rates and predictors of implementation and reach following Dialectical Behavior Therapy Intensive Training. Community Mental Health Journal, 55, 100-111. https://doi.org/10.1007/s10597-018-0254-8

4. Landes, S. J., Rodriguez, A. L., Smith, B. N., Matthieu, M. M., Trent, L. R., Kemp, J., & Thompson, C. (2017). Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: Results from a national program evaluation survey in the Veterans Health Administration. Translational Behavioral Medicine, 7(4), 832–844. https://doi.org/10.1007/s13142-017-0465-5

5. Ditty, M. S., Landes, S. J., Doyle, A., & Beidas, R. S. (2015). It takes a village: A mixed method analysis of inner setting variables and dialectical behavior therapy implementation. Administration and Policy in Mental Health and Mental Health Services Research, 42(6), 672–681. http://dx.doi.org/10.1007/s10488-014-0602-0

6. Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. The American Journal on Addictions, 8(4), 279-292. https://doi.org/10.1080/105504999305686

7. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17. https://doi.org/10.1016/j.brat.2014.01.008

8. Harned, M. S., Gallop, R. J., Schmidt, S. C., & Korslund, K. E. (2022). The temporal relationships between therapist adherence and patient outcomes in Dialectical Behavior Therapy. Journal of Consulting and Clinical Psychology, 90, https://doi.org/10.1037/ccp0000714.

9. Fox, A. M., Miksicek, D., Veele, S. & Rogers, B. (2020). An evaluation of dialectical behavior therapy for juveniles in secure residential facilities. Journal of Offender Rehabilitation, 59, 478-502. https://doi.org/10.1080/10509674.2020.1808557