Implementing Dialectical Behavior Therapy

Public mental health authorities, sometimes working through public-sector managed care companies, powerfully influence the allocation of finite public dollars among the range of treatment options. To facilitate the implementation of DBT, these authorities must be aware of the practice, give it high priority, and then support it through effective policies and financing. Several factors keep public mental health authorities from learning about DBT and giving it priority. Adults with borderline personality disorder do not have the backing of any powerful advocacy group, so political pressure to provide disorder-specific services is lacking. Pressures to invest in DBT typically arise from clinicians and program leaders who are disenchanted with current approaches, and occasionally from managed care companies in search of more cost-effective treatments. Nevertheless, some public mental health authorities who appreciate the potential benefits of DBT balk at giving priority to a practice whose effectiveness in typical community health care settings has yet to be firmly established.

For public mental health authorities who do give DBT high priority, further barriers arise in the process of guiding and funding the implementation. Promoting DBT successfully is not simply a matter of contracting for clinician training. Several states have found that when intensive training for clinicians was arranged before mental health program leaders had had a chance to prepare for DBT administratively, the clinicians' lack of orientation, preparation, and commitment has seriously impeded the training effort and start-up. The promotion of DBT can also fail if expectations for program fidelity are not clearly articulated and reinforced. Because no validated fidelity measure for DBT programs has been formulated, mental health authorities and program leaders must rely on DBT experts to determine adherence. In several cases, DBT teams have been funded but then allowed to drift, resulting in such extensive modifications that the treatment no longer resembled DBT.

Finally, implementation can fail if mental health authorities cannot work out funding mechanisms to cover ongoing costs. Some programs have enthusiastically implemented all five standard DBT treatment modes only to discover that available benefit packages cannot easily be adjusted to cover even the first year of costs. In particular, standard benefit packages fail to reimburse fully for a 2.25-hour group, for two group therapists, for telephone consultation outside weekly individual therapy, and for attendance at consultation team meetings.

Mental health program leaders set priorities for care, seek resources, and structure the operational details of practice. Given the challenge of transitioning current clinicians and vulnerable consumers to a new team-oriented model, program leaders must understand and clearly assign priority to DBT to avoid getting sidetracked by crisis situations. The work of program leaders is slowed if they do not strongly believe that individuals with borderline personality disorder are truly suffering, want treatment, and can get better. Some program leaders show a premature readiness to modify the treatment package in response to financial, political, or philosophical pressures, not appreciating that high-fidelity programming may be more effective.

Program leaders face staffing challenges. Recruiting and retaining staff to work with high-risk consumers can be difficult, particularly before the team has developed a track record of providing adequate support to therapists. Even when a team is staffed and going well, losing a trained, skilled staff member can be a demoralizing setback. With the high turnover rates in many community mental health settings, staff recruiting and training is an ongoing process.

Operational barriers can arise as the program leader defines and structures the DBT program within the agency. Some leaders, hoping to maximize the impact of DBT, have made the mistake of modifying DBT for nonstandard populations and contexts before establishing a viable standard program. In a radical departure from the general culture of a community mental health center, DBT practitioners deliberately refrain from consulting with other professionals who are working with the consumer unless it is absolutely necessary, and instead coach the consumer to interact skillfully with other treatment providers. Unless those providers, including psychiatrists, inpatient staff, and emergency services staff, are adequately oriented by DBT practitioners to this policy, they may come to regard the DBT program as noncollaborative. Given the intensity of conflicts that can arise about the care of people with borderline personality disorder, fault lines can consolidate to the detriment of the treatment environment as a whole. Finally, to argue for the ongoing support of the DBT program, leaders must demonstrate the success of the program by tracking important outcomes over time, such as rates of suicidal behavior or days of hospitalization.

Clinicians face barriers in becoming effective DBT therapists. For many clinicians, the shift requires a dramatic reworking of therapeutic belief, a significant role redefinition, and the acquisition of new skills. For some, repeated and painful treatment failures with consumers who have borderline personality disorder have led to pessimism and burnout. Competing demands in a practitioner's work can interfere with the time and focus necessary to learn to practice DBT.

DBT is a behavioral therapy that involves active and directive work to analyze and change target behaviors through cognitive restructuring, skills training, exposure procedures, and contingency management. Access to training in these component protocols is limited during both professional and postgraduate training. Difficulty obtaining DBT supervision can interfere with on-the-job learning. Psychodynamically trained clinicians are sometimes concerned that what they see as the root causes of the problems are being neglected. Those trained to see borderline personality disorder as a manifestation of poorly integrated aggression are likely to see DBT therapy as relatively blind to aggression and its vicissitudes, and therapists trained to be concerned about therapeutic neutrality may have trouble offering the extensive teaching and strategic self-disclosure required in DBT. Some therapists object to DBT's staged approach to posttraumatic stress disorder, in which the systematic processing of memories and affects is attempted only after stability and safety have been established, although this staged approach is normative in current trauma treatment models (46,47,48).

To practice DBT, therapists must do things that many are not accustomed to doing, such as following a treatment manual, giving homework, reviewing a consumer's self-ratings of behaviors, and serving as the coordinator of the consumer's treatment team. The active role of DBT therapists, which includes teaching skills groups, encouraging and coaching consumers in the use of skills, and taking crisis calls, is new to many clinicians. For DBT to work, therapists must also learn to rely on the consultation team for advice, balance, and support rather than trusting only their own judgment or the help of a one-on-one supervisor.

Common barriers that consumers must overcome include changing their expectations of what constitutes treatment, arranging their lives to facilitate DBT treatment, and managing the emotions prompted by entering yet another form of therapy after repeated treatment failures. Having learned in previous treatment that change will come about through processing memories of trauma or through gaining psychodynamic insights, some consumers find DBT's focus on immediate behavioral change to be jarring. For these consumers, the DBT therapist's emphasis on behavioral assessment, behavioral change, self-monitoring of target behaviors, skills training, and homework assignments can seem superficial or off the mark. Even when consumers understand the general goals and logic of DBT, they sometimes cannot link that logic with their own problems to see how the treatment could help them.

DBT requires a considerable commitment from the consumer. To enter DBT, most consumers must terminate treatment with their current clinician or clinical team, to whom they are often very attached. Shifting allegiances to DBT team members who are trained to avoid reinforcing crisis behavior can be difficult for consumers when these same behaviors may have been reinforced for years by the case managers, residential outreach workers, inpatient staff, and emergency services personnel who have cared for them. The time commitment—a session and a lengthy skills group each week for a minimum of one year—can be daunting to consumers, especially if their lives have been too chaotic to make long-term planning possible in the past. The explicit commitment to change behaviors can frighten consumers who cannot envision a life without self-harm or suicidal preoccupation. Finally, the prospect of entering a treatment that explicitly identifies the goal of developing a life worth living can set off consumers' fears that with improvement will come the loss of supports that are in place because of their severe behavioral problems.

Public mental health authorities considering whether to invest in DBT need a primer on the nature and scope of the problem of caring for individuals with borderline personality disorder, a clear description of DBT, a summary of the research on outcomes for consumers in DBT, tips on implementing DBT, an estimate of the nature and costs of a DBT training sequence that would result in functioning DBT programs, a tool that can be used to measure program fidelity, and a list of other public mental health authorities that have undertaken implementation and that can provide consultation.

In an example of a successful process, one of the authors (CRS), acting as director of training for DBT and as regional medical director in the Massachusetts Department of Mental Health, provided consultation to the Massachusetts Behavioral Health Partnership (MBHP), the statewide managed care company for behavioral health in the public sector, on the development of DBT resources for public-sector consumers. MBHP clinical managers reviewed the research and clinical literature in advance of an orientation meeting in November 1997. At the meeting, special attention was paid to research outcomes, qualifications of DBT practitioners, and guidelines for determining the fidelity of a DBT program.

MBHP then defined an enhanced benefit package that would support standard DBT for consumers with borderline personality disorder. To receive the benefit, DBT programs and clinicians had to meet credentialing criteria and report outcome data for each consumer every 90 days. By September 2000, 14 MBHP-credentialed DBT programs had been implemented in the state. At regular intervals, MBHP officials have interacted with authorities in the Department of Mental Health to adjust and refine the benefit package for maximum usefulness.

State mental health authorities in Connecticut, New Hampshire, and Vermont have insisted that agencies wanting to implement DBT form planning teams of clinicians and administrators before entering intensive DBT training. The resulting high level of preparation and commitment has ensured enthusiastic and well-organized statewide dissemination.

Like public mental health authorities, program leaders who are considering DBT need a general introduction to the practice, along with details about structuring the model in an agency, including the optimal use of training funds and judicious selection of DBT team members. Expert DBT consultants can be hired to orient program leaders to DBT, addressing biases about the consumer population, cognitive-behavioral treatments, and feasibility of implementation. One state organized a day-long DBT workshop focused on the needs of administrators. A regional mental health authority in another state offered a day-long introduction to DBT for program leaders and practitioners that included a series of presentations by established DBT program leaders from agencies in other parts of the state. The format allowed the administrators who were unfamiliar with DBT to have detailed discussions about feasibility and implementation strategies with experienced program leaders. Some program leaders have joined practitioners in attending DBT's standard 10-day intensive training workshops, where they have formed collaborative bonds with others in their agency while receiving consultation about program design tailored to their agency and about their case presentations.

Program leaders need to have strategies for retaining skilled DBT clinicians. The DBT consultation team is the mechanism within the treatment model that addresses demoralization and burnout and should therefore be prioritized, protected, and strengthened in each program. One state is considering raising the salaries of clinicians who stay with the agency for more than two years after intensive DBT training. Because some degree of clinician turnover is unavoidable, program leaders should organize focused and effective training materials that can be used repeatedly. Many programs have developed videotaped introductions to their DBT program, have sponsored annual DBT seminars for any interested staff, have sent practitioners to DBT update meetings, and have incorporated updated training materials and exercises in the weekly consultation team meetings.

To evaluate the success of their DBT program, leaders must collect information about consumer outcomes and program fidelity. For the former, a one-page DBT outcome assessment form is available that provides a compact format for the monitoring of all relevant outcomes (54). For the latter, a program adherence measure has been developed and pilot tested and is now undergoing further development.

A variety of strategies have been developed to help clinicians change their therapeutic beliefs and acquire the knowledge and skills they need to implement DBT. Typically clinicians are first introduced to DBT in grand rounds, seminars, and professional literature or on Web sites. They can then learn it in sufficient depth to deliver the therapy from treatment manuals (26,34) and videotapes (55,56,57) for self-guided study. Clinicians can also attend standardized one- and two-day introductory workshops that are designed to teach DBT and to shift attitudes toward consumers with borderline personality disorder in a compassionate direction. For clinicians without training in behavioral principles and protocols, behavioral treatment manuals for self-guided study and continuing education workshops are also available. Specialty workshops focus on DBT skills training and DBT as adapted for substance abusers and adolescents. Opportunities to update skills and knowledge and to learn how to implement modifications in DBT, such as those for substance abusers, can be found at regional advanced two-day workshops and at the annual meeting of the International Society for the Improvement and Teaching of DBT, where research presentations, symposia, and poster presentations keep practitioners up-to-date.

However, the most inclusive training format is the ten-day intensive DBT workshop for practitioners and program leaders, which is designed to get DBT programs up and running. In one statewide intervention, some evidence suggested that this format helps frontline clinicians master DBT's knowledge base (42).

The process starts in a pretraining commitment phase during which teams apply and are selected and during which role induction takes place. Teams are accepted only if a successful DBT implementation seems possible. Solo practitioners are not accepted into the training. Trainers serve as consultants to applicants for intensive training, sometimes suggesting preparation work before the training. All participants are expected to commit to attending all ten days and to have read Linehan's manuals before the training begins.

The training itself includes team exercises and consultations that address existing team problems, enhance team cohesion, and reduce some potential barriers to implementation. During the initial five days—part 1—the treatment is taught through didactic methods, experiential exercises, role playing, and videotaped DBT sessions. The training team highlights DBT principles and strategies in the management of the workshop. After part 1, there is a six-month interval during which teams and individuals practice the treatment in extensive homework assignments, complete a difficult examination first with a closed book and then with an open book, and prepare for part 2, during which they present their programs and cases for consultation.

Part 2, the second five-day period, is centered on the consultations about programs and cases. Anxiety about the presentations fosters participants' intense preparation and more practice of DBT with coaching from the trainers. Daily evaluations of the workshop have affirmed that the five-day format allows participants to separate themselves from the usual burdens and routines of work, facilitates team bonding, and provides a momentum and intensity that are unavailable in most training formats.

The consultation team in DBT is the component responsible for ongoing enhancement of the capabilities and motivation of practitioners. It is structured to do so with particular guidelines and formats. The team is used to review individual therapy cases as well as the functioning and content of the skills group and to offer encapsulated training experiences. Intense emotions and strong opinions are typical among clinicians who work with this population, and the team serves to validate painful feelings, offer alternative solutions to impasses, and search for syntheses among conflicting and rigidly held positions.

Strategies for overcoming barriers to consumers' participation in DBT are intrinsic to the treatment. Behaviors on the part of the consumer or the therapist that interfere with treatment are targeted in treatment sessions. Targeting these behaviors is second in priority only to targeting suicidal behaviors.

The first stage of treatment in DBT is the precommitment stage, during which the consumer and the therapist collaboratively identify the consumer's goals and convert those goals into a prioritized list of behaviors to target. They also consider and agree on methods by which DBT will help achieve the goals. They specifically discuss factors that may interfere with the consumer's participation. Some myths about cognitive-behavioral treatment, about a treatment that uses a manual, and about DBT in particular can be addressed to correct distortions and alleviate some fears. If a consumer expresses the concern that DBT will not address underlying responses to childhood trauma, the therapist emphasizes that the symptoms of posttraumatic stress disorder will be targeted from the beginning, that information will gradually emerge about traumatic circumstances, and that after the consumer achieves some stability, the painful memories and affects will be systematically processed.

If the consumer is having difficulty moving on from a previous non-DBT therapist or entering the skills group, time is allowed for a transition. DBT therapists tell consumers about non-DBT alternatives so that their commitment to DBT is voluntary. Consumers' concerns about how DBT can be modified to suit their situation are addressed. DBT is a theory-driven treatment, rather than protocol-driven, and it can be adjusted. For instance, DBT has been adapted to address treatment barriers common among substance abusers by adding attachment strategies, modifying the priorities of target behaviors, adding case management, incorporating several substance abuse-specific skills, and defining a protocol for drug testing.