1. Updates to the DBT Intensive Training Model
DBT Functions of Treatment: Results of Intensive Training Anthony P. DuBose, Psy.D. How Can Implementation Science Inform DBT Training? Andre Ivanoff, Ph.D. Key Components in DBT Implementation: A Survey from the Ground Up Linda A. Dimeff, Ph.D., Andre Ivanoff, PhD, & Erin Miga, PhD Proposed Revisions: Academic Experiments Informing DBT Training Programs Marsha M. Linehan, Ph.D., ABPP

2. Marsha M. Linehan, PhD, ABPP
Linda A. Dimeff, PhD
Chief Scientific Officer, Behavioral Tech Research, LLC
Receives royalties on some products sold through Behavioral Tech, LLC
Anthony P. DuBose, PsyD
Owner & President, EBTCS, PLLC (includes DBT Center of Seattle) and receives share of profits
Director of Training, Dissemination, & Implementation, Behavioral Tech, LLC
Andre Ivanoff, PhD
President, Linehan Instute & Behavioral Tech, LLC
Marsha M. Linehan, PhD, ABPP
Receives royalties on authored texts sold through Guilford Press and some products sold through Behavioral Tech, LLC

3. Getting DBT from the Research Lab to the Places where it is needed
Anthony P. DuBose, Psy.D.
Behavioral Tech, LLC; University of Washington; DBT Center of Seattle
Seattle
USA
2ND International Congress on Borderline Personality Disorder & Allied Disorders
Amsterdam
28 September 2012

4. Attempts to Disseminate DBT to Date & What is Still Needed
First, we have to go beyond dissemination and into the world of implementation.

5. What is DBT? Originally a treatment for suicidal behaviors
Expanding beyond original populations
Principle-based treatment that targets problems regulating emotions
So what is it that we are trying to disseminate & implement?
Let’s take a look at the scope of the task.
Disseminating a principle based treatment, rather than a protocol-driven treatment presents a different set of challenges- How to maintain to increase fidelity to the principles of the treatment such that providers can apply them with flexibility without becoming rigid.

6. A continually evolving treatment based on:
What is DBT?
A continually evolving treatment based on:
Evidence
Target Problems
Treatment Settings
Another challenge- the treatment is constantly evolving based on new evidence, and application to new treatment settings and problems. This underscores the importance of continuing education in the treatment, both to stay up to date, and to avoid drift.

7. A growing body of evidence supports this.
What is DBT?
A treatment that teaches skills as an essential step in building a life worth living.
A growing body of evidence supports this.

8. A program intended to meet specific functions
What is DBT?
A program intended to meet specific functions

9. DBT: From the lab to implementation
Importance of focusing on functions of treatment, rather than modes became clear.
Improve client motivation
Enhance client capabilities
Assure skill generalization
Structure environment
Improve therapist skills & motivation
The functions are met with different modes of treatment.
The focus in DBT on function enhances the flexibility of implementation.
Discussion of how focus on function can enhance implementation of DBT.
DBT is principle based, not protocol driven

10. Functions & Modes: Milieu
Improve client motivation
Enhance client capabilities
Assure skill generalization
Structure environment
Improve therapist skills & motivation
Individual Therapy
Skills Training Class
Phone Consultation
Case Management & Outreach
Therapist Consultation Team
Structure environment – case management, outreach, family meetings

11. Functions & Modes: Inpatient
Improve client motivation
Enhance client capabilities
Assure skill generalization
Structure environment
Improve therapist skills & motivation
Behavior mod plan-Commitment w/ attending
Skills Training Class
Coaching by floor staff
Social work and family meetings
Therapist Consultation Team

12. A set of strategies, procedures, and protocols
What is DBT?
A set of strategies, procedures, and protocols

13. Dialectical Communication
Decreasing Therapy-Interfering Behaviors
Dialectical Communication
4/14/2018
Change
Acceptance
Irreverence
Reciprocity
Problem Solving
Validation
Dialectics
Team Consultation
Consultation to the Client
Environmental
Intervention
Case Management
Copyright 2011 by Marsha M. Linehan
DRAFT

14. Other and New Slides to Add
4/14/2018
DBT Procedures
Skills Training
Cognitive Modification
Exposure
Contingency Procedures
Contingency: Chapter 10 (pages )
Skills Training: pages
Exposure:
Cognitive Modification:
Copyright 2011 by Marsha M. Linehan

15. DBT Protocols & Special Strategies
Other and New Slides to Add
4/14/2018
DBT Protocols & Special Strategies
Crisis Strategies
Suicidal Behaviors Protocol
Therapy Interfering Behaviors Strategies
Telephone Strategies
Ancillary Treatment Strategies
Relationship Strategies
Formal Exposure Protocol
Copyright 2011 by Marsha M. Linehan

16. Access Issues Delivery Issues
Getting DBT to the Places Where It Counts
Access Issues Delivery Issues

17. Decreasing Therapy-Interfering Behaviors
4/14/2018
A Problem to Solve
Increase access to services for those who need them
Assure high quality treatment is actually being provided when services are accessed
Provide Widespread Service
Ensure Fidelity to Evidence-Based Treatment
Copyright 2011 by Marsha M. Linehan
DRAFT

18. Access Issues Funding More & Better Qualified Providers
Training
Direct Service
More & Better Qualified Providers
Extensive Waiting Lists
Consumer Education
How do consumers know they are getting high quality / evidence-based treatment
Certification & Accreditation

19. Treatment Delivery Issues
The Program Elements of DBT
DBT Strategies, Procedures, and Protocols (What Therapists Do)

20. Results of Intensive Training
DBT Functions of Treatment:
Results of Intensive Training

21. DBT Intensive Training™:
Expanded training schedule & trial implementation
Team based learning
Contingency management
Address barriers to implementation and sustainability
Developed to address limitations of standard CE formats
the training schedule was expanded to include two 5-day training segments separated by a 6-month self-study and trial implementation,
the structure of ITM and practice and homework exercises were reorganized to target team building and mutual responsibility for learning and implementing DBT
a substantial set of contingency management procedures were instituted
content and coaching on how to use DBT strategies to target barriers to full implementation and maintenance of DBT programs within providers’ organizations was added.
Each of these training components has a strong theoretical and empirical base.

22. Original Dialectical Behavior Therapy Intensive Training™
Part 1
Self-Study
Part 2
5 days- Content
Structure & Elements of DBT
Strategies, Procedures & Protocols
Barriers to implementation
6 months
Homework
Implement program
Consultation to teams
5 days- Consultation
Programs & Cases
Presentations on Outcomes
Training on other areas as needed
Anthony P. DuBose, Psy.D. | Director of Training and Dissemination | Behavioral Tech, LLC | Phone | |

23. Behavioral Tech Training Participants
Numbers Trained
Behavioral Tech Training Participants
( )
2-Day Event, Five Day Foundational, or Intensive
29,825
Teams trained in DBT ITM
953
Individuals trained in DBT ITM
5,106
Patients receiving DBT
Unknown

24. Modes of Treatment Offered Pre- and Post-Intensive Training
The Program Elements
Modes of Treatment Offered Pre- and Post-Intensive Training
Modes Offered
End of ITM (2000)
Oct, 2001
Complete DBT Model with Phone Consultation
28.6%
42.9%
Complete DBT Model without Phone Consultation
50.0%
71.4%
DBT Skills Training Class
78.6%
85.7%
DBT Individual Psychotherapy
Phone Consultation
DBT Therapist Consultation Team
Goal of ITC: stand up a program and have people know basically what to do
Goal isn’t adherence
GOLD = increases in that component
None decreased
Of the 28 teams trained in 2000, 14 (50%) completed surveys
DBT Group Skills Training was the most frequently implemented standard DBT treatment mode
The percentage of teams offering the various treatment modes generally increased
All but one team had successfully implemented at least one DBT treatment mode at the time of the survey
*No pre-implementation measure of what modes were available
DBT Intensive Trainings and Program Implementation
Implementation of DBT Treatment Modes Post-Intensive Training. All leaders of teams receiving intensive training in 2000 were contacted in October 2001 and asked to complete a survey assessing their program’s implementation of DBT treatment modes as well as any barriers to implementation they had encountered. Of the 28 teams that were trained in 2000, 14 (50%) returned completed surveys. These teams worked within the following settings (note that multiple settings could be endorsed): outpatient community mental health clinic (n=10), inpatient (n=4), day treatment/partial hospital (n=3), and residential treatment facility (n=2). As can be seen in Table 6, DBT Group Skills Training was the most frequently implemented standard DBT treatment mode followed by DBT Individual Psychotherapy and DBT Therapist Consultation Team. Between the end of Part II of training and the time of the survey, the percentage of teams offering the various treatment modes generally increased. The percentage of teams offering after-hours telephone consultation increased from 28.6% to 42.9%. This suggests that the DBT programs offered by these teams were becoming more comprehensive as time progressed. Finally, all but one team had successfully implemented at least one DBT treatment mode at the time of the survey. The one team not offering DBT identified barriers to implementation as: 1) inadequate resources and untimely within system restructure, 2) financial limitations, and 3) high turnover and poor coordination.
Comment. These preliminary findings suggest that DBT ITM is effective in helping participants to implement and maintain DBT programs in a variety of clinical settings. Within a year after receiving intensive training, nearly three-quarters of teams offer three of the four standard DBT treatment modes (individual psychotherapy, group skills training, and therapist consultation team). Implementation of the fourth standard DBT treatment mode, after-hours telephone consultation, increased significantly since the end of Part II such that nearly half of the teams were offering it approximately one year later. Given the financial and logistical reality of most community mental health settings (e.g., therapists are paid only to work a strict 40-hour work week), it is quite impressive that half of the teams had managed to find a way to make themselves available to their clients for telephone consultation 24-hours a day.
At the time of application and prior to receiving intensive training, teams report low rates of implementation of the four standard DBT treatment modes (range = 0-50%). While low, however, these rates prior to training are not zero. It is possible that implementation of DBT is simply higher in 2007 across the board than it was in Unfortunately, we do not have pre-training implementation rates for the sample. These findings also suggest, however, that even among groups offering DBT prior to attending a DBT ITM training, providers see a need for further training.

25. The Strategies, Procedures, and Protocols (What Providers Know & Do)
Adherence Measures Are Needed & Are Currently Limited to Treatment Research

26. Knowledge of DBT Theory and Techniques
Increased during and after intensive training.
Participants showed a significant increase in DBT knowledge between all time points
Part I to Mid-Intensive (t(38) = 5.81, p<.001)
Mid-Intensive to Part II (t(49) = 2.43, p<.02)
Part I to Part II (t(39) = 6.99, p<.001)
Knowledge of DBT. A 105 item self-report questionnaire assessing knowledge of DBT theory and techniques was administered to participants (n=70) in the Seattle intensive. Participants were assessed at 3 time points: 1) Part I (following required reading and preparation for the course), 2) Mid-Intensive (3 months after Part I), and 3) Part II (on the first day of Part II, 6 months after Part I).

27. Adherence/Fidelity
Several studies show a strong relationship between treatment fidelity and client outcomes
Multisystemic Therapy (MST)
Assertive Community Treatment (ACT)
Trauma Focused Cognitive Behavior Therapy (TF-CBT)
Functional Family Therapy (FFT) (WSIPP, 2008)
CBT for depression (Feeley, 1999)
DBT for substance abuse (Linehan et al., 1999)
The results of the link between fidelity and outcome in efficacy studies of cognitive-behavioral interventions have been more inconsistent. In two studies evaluating symptom change and treatment adherence to specific techniques in cognitive therapy for depression, adherence to treatment procedures significantly predicted subsequent reductions in depression (DeRubeis & Feeley, 1990; Feeley, DeRubeis, & Gelfand, 1999). In contrast, in a multi-site efficacy trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa, therapist adherence (reflecting both treatment integrity and differentiation) was not associated with patient outcome for either treatment condition (Loeb et al., 2005).
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. American Journal on Addiction, 8(4),
Summary of article:
Linehan et al. (1999) conducted a RCT on a sample of 28 females with comorbid BPD and drug dependence, randomized to either a 1-year DBT treatment condition(N=12) or TAU(N=16). DBT was adapted to more closely address issues surrounding substance use, including the adoption of additional attachment strategies to enhance treatment commitment and a dialectical stance on substance use. The goal of dialectical abstinence is to strive to maintain absolute abstinence while reducing harmful consequences and cultivating acceptance after relapse. Substance-dependent participants in the DBT condition also received a “transitional maintenance” medication replacement program, in which participants gradually transitioned from prescription drug maintenance to prescription- free, in order to reinforce behavioral skills generalization in this final phase of medication replacement. Participants in the DBT condition reported significantly greater reduction in substance abuse throughout treatment and at 1 year follow up, as compared to those in the TAU condition. Further, participants in the DBT condition had greater improvements in social and global adjustment and a significantly lower drop- out rate, as compared to TAU participants. While both conditions evidenced significant reductions in NSSI, suicide attempts, and anger, these reductions were not significantly different between treatment groups.
A notable strength of this study was its attention to the relationship between DBT treatment adherence and clinical outcomes. Results from post hoc analyses revealed a significantly higher proportion of clean urinalyses at 12 months among participants treated by consistently adherent clinicians, as compared to those clinicians who failed to achieve consistent adherence. While a small sample size of DBT clinicians precludes our ability to draw definitive conclusions, these preliminary findings are promising and highlight the importance of examining DBT adherence and treatment fidelity as one important factor in DBT treatment outcome studies.

28. Therapist Adherence Post Intensive Training
Helpful getting DBT into practice
Consultation or adherence feedback is likely needed to attain adherence
Both
Attended intensive training
Adherence rated post hoc
No adherence feedback
New York DBT Study
No supervision
Mean adherence score across therapists was 3.8
RCT in VA setting
2 of 5 received expert supervision briefly
Mean adherence score for all coded sessions was 3.8 (range= )
New York DBT study: adherence rated post-hoc
All therapists attended an Intensive Training Course
No supervision or adherence feedback
Mean score across therapists was 3.8 (below the cut-off for adherence of 4.0)
RCT conducted in a VA setting: adherence rated post-hoc
All but one therapist attended an Intensive Training Course
Two (out of 5) briefly received expert supervision
No adherence feedback
Mean score for all coded sessions was 3.8 (range= )
Adherence to DBT Post-Intensive Training. We have conducted adherence coding on two samples of mental health providers who were trained via the DBT Intensive Training course. First, we coded sessions from a New York DBT study post-hoc where all therapists attended a DBT Intensive Training but did not receive supervision or adherence feedback. In this study, the average adherence rating across therapists was 3.8 (i.e., below the cut-off for adherence of 4.0). In an RCT of DBT conducted in a VA setting (C.R. Koons et al., 2001), adherence ratings were completed post-hoc for 8 sessions from each therapist-patient dyad. In this study, all but one of the therapists attended a DBT Intensive Training and two (out of five) study therapists briefly received expert supervision after attending the training. No therapists received adherence feedback. The mean score for all coded sessions was 3.8, with a range of 3.2 to 4.2.
Comment. These data indicate that while DBT Intensive Trainings are helpful in getting therapists to employ the treatment in their practice setting, supervision or adherence feedback is likely needed in order to help trainees attain adherent scores.

29. Service Provision Issues
Adherence among clinicians who say they practice Evidence Based Treatments:
LOW
Teaching of EBTs in graduate/internship training programs:
DECLINING
Child Services:
"17% of kids in need of services receive a full dose of mental health tx regardless of evi base" (Kazdin, 2008)
First, contrary to the clinicians’ reports, ‘‘standard treatment’’ in these settings was not characterized by a high level of evidence-based therapies. Rather, interventions associated with evidence-based therapies such as CBT (e.g., skills training, focus on cognitions) and Twelve-Step Facilitation (e.g., encouraging meeting attendance, discussions of spirituality) were virtually undetectable in these sessions, in that they occurred at very low levels and in less than 5% of all sessions. Similarly, other important interventions that are assumed to be part of standard treatment for substance use were also rarely observed in these tapes, including HIV⁄STD risk behavior reduction, which was mentioned only 29 times in 379 rated sessions. Thus, a high level of EBP did not characterize ‘‘standard treatment’’ as practiced by these clinicians in these sites.
Second, the clinicians rather consistently overestimated
the amount of time they spent delivering interventions
associated with evidence-based treatment.
That is, when we compared the therapists’ self-ratings
of adherence to those made by the independent raters,
the clinicians consistently rated themselves as spending
significantly more time delivering evidence-based interventions
than did the raters or the clinicians’ on-site
supervisors (Martino, Ball, Nich, Frankforter, &
Carroll, 2009a).
Looked at Santa Ana et al,, 2008; (Martino, Ball, Nich,
Frankforter, & Carroll, 2008), as cited in Carroll et al,. 2010(no train, no gain)
To sum up, the
independent analysis of ‘‘standard treatment’’ as practiced
in community addiction treatment settings suggested (a)
evidence-based treatments are not implemented at high
levels, (b) clinicians frequently overestimate the level of
EBPs they are delivering, and (c) provision of training
and supervision may be associated with more efficient use of session time
(Kazdin, 2008; Martino et al., 2009; Santa Ana et al., 2008; Stewart & Chambless,2007; Woody, Weisz, & McLean, 2005)

30. Getting Providers to Practice with Fidelity/Adherence to the Model
ONSITE COACHING produces Skills Generalization, Higher Fidelity, & Improved Outcomes
Standard workshop training
5% of teachers used new skills
Training & “on-the-job” coaching
95% of teachers used new skills
“ this study, which we briefly introduced last year, sums up what we already know from our DBT model: “in vivo” coaching leads to generalization of new, effective skills among teachers in training. This finding parallels the importance of phone coaching as a tool to enhance “in vivo” skills generalization among our clients in DBT”
Both 1st condition (practice & feedback) & 2nd condition( training and coaching) first had theory and discussion, and demonstration in training
(Joyce & Showers, 2002)

31. Attempts to Solve the Problems with Delivery Issues
More rigorous study of training methods
University of Washington Experimental Training Program
Increase observation, feedback, and “on the job coaching” in DBT Intensive Training Model
Apply the findings of implementation science to DBT training
Study the impact of DBT training on clients

32. Attempts to Solve the Problems with Access Issues
Train more providers
More affordable training methods
More accessible methods
Study the treatment to determine the critical elements and deliver those
Train therapists and consumers to negotiate with funding sources
Assist consumers with evaluating treatment options
Accreditation: Programs
Certification: Therapists