1. DBT TEAMS IN TRAINING 2008-2011: IMPLEMENTATION FOLLOW-UP
Anthony DuBose, PsyD,1 André Ivanoff, PhD,1,2 Erin Miga, PhD,1,3 Linda Dimeff, PhD,4 & Marsha Linehan, PhD3
1Behavioral Tech, LLC; 2Columbia University; 3Behavioral Research and Therapy Clinics, University of Washington; 4Portland DBT Institute
Seattle Implementation Research Collaborative
2nd Biennial Conference
May 16, 2013

2. DBT Training: Data to Date “The Gold Award”
1 year pilot : Comprehensive DBT conducted by intensively trained clinicians
77% decrease in hospital days
Face to face emergency contact cut by 80%
Vocational status rose: 14%-57% during program
Total treatment costs cut by more than half
*N=14 clients
(Integrating DBT into Community Mental Health,1998)
N=14
One of the first successful DBT Implementations outside of site of treatment development…
2 intensively trained clinicians- started up pilot project
“Dramatic clinical improvements among clients who finished all 4 modules- total cost savings of nearly $375,000”

3. DBT Training: Data to Date Trupin et al 2002
DBT at Echo Glen Childrens’ Center adolescent mental health unit:
Clinicians received 10-day intensive training or 2 day workshop
Only study to look at client outcomes
Intensively trained clinicians:
Significant reduction in adolescent behavior problems (greater than changes on other units)
Used less punitive interventions compared to year before training

4. DBT Training: Data to Date Linehan et al. ABCT 2008
Dialectical Behavior Therapy Intensive Training™
(Linehan, Manning, Ward-Ciesielski, 2008)
Modes Offered
End of IT(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
At 1 year post -intensive,
71% of teams offering DBT without phone coaching
43 % offering comprehensive DBT

5. DBT Training: Data to Date British Isles DBT Swales, Taylor & Hibbs, 2010
117 teams trained between
27% (32) active and fully implemented
Avg length of program:
Active: 38 mos vs. Inactive : 86 mos
Avg staff time delivering program:
Active: 8.4 hrs/week vs. Inactive: 5 hrs/ week
DBT Programme Accreditation Questionnaire(Schmidt et al., 2008)
58 % of programs active, 49% inactive
57 % of active programs fully implemented
36 (53%) are out-patient services, 29 (43%) are inpatient (including high security and prison settings) and 3 (4%) run programmes across inpatient and outpatient settings

6. DBT Training: Data to Date Landes & Linehan, 2012
No controlled training evaluations
Community clinicians trainable
(Hawkins & Sinha, 1998)
Significantly more improvement in clients treated by therapists who attended a DBT Intensive Training Course

7. Our Overarching Question
What actually happens
to DBT Teams once Intensive Training is over?

8. Specifically… Are they alive, well and still doing DBT?
Are they monitoring the treatment over time?
Did they achieve goals they set for themselves?
What factors interfered with goal achievement? What factors helped?
Given the benefit of hindsight, what would they have done differently?
Wanted to extend the 2001 assessment of intensive teams beyond simply-are programs doing comprehensive DBT post intensive training ?
In addition to the modes..
Have they tracked their fidelity to the model or used other standardized assessments of program or client progress?
Further..
What goals did they have in implementing DBT?
Did they reach them?
What barriers did they encounter?
And lastly..
What would they do over if they could? What did they learn from their implementation efforts?

9. Methods Mixed methods approach: Sample:
Online DBT Program Elements of Treatment Questionnaire (PETQ: Schmidt, Ivanoff, Linehan, 2009)
Telephone follow-up interview
Sample:
Randomly drew 50% of all teams who completed BTECH Intensive Training from
Addressed to DBT Team Leaders
Andre: Describe the measure what it covers, purpose.
Post-Survey Interviews: Intent of this was to flush out any specific responses from the survey and to answer any specific questions they had, to be of service.

10. Procedures Invitational email & phone DBT team leader.
Proactive problem-solving (multiple attempts) to reach DBT team leader.
Participation also framed as opportunity for self-assessment & follow-up
Follow-up interviews arranged during initial call

11. Sample
Of 154 teams trained between , 77 randomly selected to participate; 1 team multiplied. Total N=78.
66 (85%) responded to request
8 (10%) no longer had a DBT Program
54 (69%) agreed to participate
Of those who agreed to participate (N=54),
4 (7%) did not complete the survey & interview
47 (87 %) completed survey & interview
66: reached
-of 66, 8: definitely defunct
-of 66, 3: refused
-of 66, 1: deferred to a different team leader who was interviewed to represent 2 randomly selected teams(Debra Bond, CJTS)
-of 66, 54: agreed
-of 54 agreed, 4 did not complete survey nor interview
Didn’t complete survey:
Emmons, kildow, rausch, krueger(4)
12: not reached

12. DBT Team Survival Of the total sample (N=78),
74% (n=58) continue to have a DBT program.
10% (n=8) definitely do not have a DBT program.
16% (n=12) unknown.
In sum..how many teams have survived?

13. Clients Treated in DBT Settings
** other: individuals with ID, juv justice, PTSD, multiple AXIS 1 problems, parents

14. Are DBT teams delivering all modes of DBT?
DBT Program Snapshots
Are DBT teams delivering all modes of DBT?

15. DBT Functions & Modes Enhance capabilities Improve motivation
- Skills training
Improve motivation
- One-to-one intervention
Assure generalization to natural environment
- One-to-one intervention
- Phone coaching
Structure the environment
Enhance therapist capabilities and motivation to treat effectively
- Therapists’ Consultation Team

16. DBT Modes Provided DBT skills coaching = of any kind 80%
After hours = outside regular work day
Notable is that 75% of programs provide after hours access & skills coaching
Do you have a consultation team?
90.2 %(46) yes
3.9%(2) some
2.0%(1) planned
3.9 %(2) no

17. Consultation Team: Enhancing Therapist Motivation & Capabilities
Other and New Slides to Add
9/12/2018
Consultation Team: Enhancing Therapist Motivation & Capabilities
Yes
Some
Planned No
Does your team meet weekly?
73.5%(36)
6.1 %(3)
4.1%(2)
16.3% (8)
Do you have a designated team leader?
79.6%(39)
14.3 %(7)
2.0%(1)
4.1% (2)
Do you have a consultation team?
90.2 %(46) yes
3.9%(2) some
2.0%(1) planned
3.9 %(2) no
Copyright 2011 by Marsha M. Linehan

18. Administrative Support
Does your admin provide:
Yes
Some
Planned No
Ongoing financial support for DBT leaders to obtain consultation & training
38.0%(19)
28.0%(14)
6.0%(3)
22.0%(11)
DBT manual for trainees
70.0%(35)
14.0%(7)
4.0%(2)
10.0%(5)
Time for training as a basic job expectation
62.0%(31)
24.0%(12) 0%
12.0% (6)

19. DBT Adherence & Fidelity Assessment
Are programs closely tracking the treatment they are delivering?

20. Ongoing Self-Assessment of Adherence & Fidelity
DBT TEAMS:
40% conduct self-assessment of DBT program adherence
16% of DBT team leaders and consultants review fidelity performance data
20% of programs give adherence data to teams & supervisors for quality improvement purposes when individual DBT adherence data is collected
Q1- Assessment is “according to manual”

21. At the Bottom Tracking treatment outcomes: Consultation team:
Only 34% consistently use nationally recognized outcome measures that have documented reliability/validity
Only 28% of DBT team leaders consistently monitor treatment completion rates
Consultation team:
Only 29% of DBT teams implement clear contingencies for any DBT provider failing to gain knowledge, skills and/or attend consultation teams
Erin, look across all the data and identify/list the three top things they are NOT doing (or the bottom %) that have the lowest adherence.

22. Qualitative Inquiries
What were your organization’s primary objectives/goals for doing DBT?
What were your team’s most significant accomplishments?
What barriers interfered with implementation of DBT?
If you could do one thing over/differently, what would it be?

23. Organization Goals & Objectives
Reduce Stage 1 Target Behaviors (n=19)
Provide Comprehensive DBT (n=10)
Provide an evidence-based treatment that is effective for BPD and others with Emotion Regulation problems (n=8)
1. Reduce Stage 1 Target Behaviors (n=19)
“To reduce the prevalence of self destructive behaviors (self injury, substance use, eating disorder behaviors) in the community, we are the first in the area to provide DBT in an adolescent outpatient setting, decrease the need for higher level of care.”
“Reduce number of hospitalizations, decrease incidents of self-injury, improve patient outcomes on BASIS-24 (outcome measure), decrease staff turnover rate, decrease suicide attempts, increase attendance of groups for those who were too dysregulated to stay in groups”
2. Provide Comprehensive DBT (n=10)
“Provide adherent DBT(vs. modified DBT)”
“Build an adherent, comprehensive program for adults;”
“To provide DBT, to fidelity.”
3. Provide an evidence-based treatment that is effective for BPD and others with Emotion Regulation problems (n=8)
“Provide a program that would (sic) effective (sic) treat BPD.”
“To provide an EBT that fit the profile of patients admitted as well as provide a consistent treatment modality across the program and community programs.”

24. Most Significant Accomplishments
Lives of our patients who received DBT have significantly improved (n=12)
Built a DBT program despite real obstacles and  haven’t given up (n=7)
3. Have a comprehensive and adherent DBT program (n=5)
Trained a large number of staff in DBT (n=3)
Consultation team continues to meet (post-intensive; n=3)
First in region/area to successfully implement DBT (n=3)
1. Lives of our patients who received DBT have significantly improved (n=12)
“Lives of individuals in program drastically changed for better”“Reducing hospitalizations and thereby increasing patient level of confidence and functioning”
2.Built a DBT program despite real obstacles and  haven’t given up (n=7)
“Sustaining program despite small size, as part of relatively small outpatient CMH.” “We haven't given up”
3. Have a comprehensive and adherent DBT program (n=5)
“Having an adherent comprehensive program” “Model adherence”
Trained a large number of staff in DBT (n=3)
“Many staff members are trained in DBT.”
“Over 50 staff have completed an Intensive or Foundation.”
Consultation team continues to meet (post-intensive; n=3)
“Consultation team continues to meet.” “Forming and maintaining a consultation team.”
6. First in region/area to successfully implement DBT (n=3)
“Successful implementation of DBT structure within the <system name>.”

25. Factors that Helped Reach Implementation Goals
Strong communication, motivation, and commitment amongst consultation team members (n=36)
Administrative support (n=12)
Intensive training: (n=9)
A review of the qualitative data indicate that the team’s top DBT implementation objectives (reduce Stage 1 target behaviors, provide Comprehensive DBT) generally aligned with their self-reported program achievements, despite reports of significant implementation obstacles, including monetary and time constraints, and staff turn-over. The chief factors identified to help programs achieve their implementation goals included strong communication, motivation, and commitment amongst consultation team members (N=36), administrative support (N=12), and intensive training (N=9). Such results substantiate the importance of DBT as a “team-based treatment.” DBT consultation team appears to be a key factor in successful DBT implementations. Consultation team may promote program sustainability through increasing provider skillfulness, commitment and adherence to the model, and decreasing provider burn-out in the context of difficult- to-treat clients.

26. DBT Intensive Objectives: Did DBT Teams Achieve Top Goals?
19% Attained 100% of goal 39% Attained 80-99% 28% Attained 60-79% 4% Attained < 60%
100% achieved means that objective was FULLY met.
Main goal:
100%: 9
90-99 %: 9
80-89%: 8
70-79%: 7
60-69%: 6
25-50%: 5
? Or N/A: 3

27. Barriers to Implementing DBT
Funding constraints*: 12 % (n=14)
Staff turnover: 10% (n=12)
Time constraints: 9% (n=10)
Lack of accurate understanding of DBT amongst staff or administration, or unsupportive statements about DBT made by staff or administration: 7% (n=8)
*lack of funding for ongoing training, lack of financial support for after hours coaching
What were the three most significant barriers your DBT program encountered that impeded attainment of your objectives/targets and/or compromised your DBT program’s success?
Total # Of responses across the 3 sub items of this question: 116

28. What Team Leads Wish They Could “Do Over”
Better overall planning before Intensive Training (n=9)
Selecting who should attend (preference to behaviorally trained; dialectical thinkers)
Include administrators on team
Get additional clinicians in our agency Intensively trained by BTECH (n=8)

29. What Team Leads Wish They Could “Do Over”
Get commitment from administration at outset to do DBT to fidelity; devote sufficient time for strategic planning (n=6)
Have ongoing consultation with DBT experts following completion of the intensive (n=3)

30. The Wonderful
DBT programs survive past the initial intensive training (>74%).
DBT programs report high rates (≥75%) of program fidelity across modes of treatment.
Program objectives map squarely with intensive training goals:
Reduce Stage 1 behaviors
Create/maintain DBT program with high fidelity.
Improve the lives of multi-diagnostic , complex individuals by means of enhancing capabilities throughout their lives.

31. The Work
The greatest reported challenges continue to be receiving financial / other means of support from administration to provide DBT to fidelity.
In retrospect, greater emphasis should be placed on:
Selection of members to the DBT team
Enhancing decision-makers’ commitment to supporting implementation efforts beyond training phase.
(linda’s comments 9/12)Andre, the point about resilience I think is really important. That despite the challenges with admin support, lack of $ that comes out in the data to support initiative, these programs keep doing it. They are no doubt applying dbt skills to themselves which may ultimately make DBT initiatives more lasting than other ebts because of this.
Erin 5/2013: Next steps include gathering more data on WHAT is contributing to programs’ resiliency in the face of scarce resources-

32. DBT programs are resilient.
(linda’s comments 9/12)Andre, the point about resilience I think is really important. That despite the challenges with admin support, lack of $ that comes out in the data to support initiative, these programs keep doing it. They are no doubt applying dbt skills to themselves which may ultimately make DBT initiatives more lasting than other ebts because of this.
Erin 5/2013: Next steps include gathering more data on WHAT is contributing to programs’ resiliency in the face of scarce resources-

33. Limitations & Future Directions
We need…
Outside reports of program fidelity and treatment adherence
In order to…
Decrease risk for social desirability bias
Examine concordance of observer and self-reports of DBT modes/adherence
(linda’s comments 9/12)Andre, the point about resilience I think is really important. That despite the challenges with admin support, lack of $ that comes out in the data to support initiative, these programs keep doing it. They are no doubt applying dbt skills to themselves which may ultimately make DBT initiatives more lasting than other ebts because of this.
Erin 5/2013: Next steps include gathering more data on WHAT is contributing to programs’ resiliency in the face of scarce resources-

34. Limitations & Future Directions
We need…
More rigorous design (RCT) that compares treatment delivered by intensively trained vs. non-intensively trained staff
In order to..
More closely assess whether Intensive training (among a host of others factors) is a chief factor in the success of subsequent DBT implementations.
(linda’s comments 9/12)Andre, the point about resilience I think is really important. That despite the challenges with admin support, lack of $ that comes out in the data to support initiative, these programs keep doing it. They are no doubt applying dbt skills to themselves which may ultimately make DBT initiatives more lasting than other ebts because of this.
Erin 5/2013: Next steps include gathering more data on WHAT is contributing to programs’ resiliency in the face of scarce resources-