The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review

Abstract

BackgroundDialectical behaviour therapy (DBT) is a third wave behaviour therapy combining behaviour based components with elements of mindfulness. Although DBT effectiveness has been explored, relatively little attention has been given to its implementation. Frameworks are often the basis for gathering information about implementation and can also direct how the implementation of an intervention is conducted. Using existing implementation frameworks, this critical literature review scoped the DBT implementation literature to develop and refine a bespoke DBT implementation framework.Method and resultsThe initial framework was developed by consolidating existing implementation frameworks and published guidance on DBT implementation. The critical literature review retrieved papers from Medline, CINAHL, PsycInfo, PubMed, and the reference lists of included papers. Framework elements were used as codes which were applied to the literature and guided the synthesis. Findings from the synthesis refined the framework.The critical literature review retrieved 60 papers but only 14 of these explicitly focused on implementation. The DBT implementation framework captured all the execution barriers and facilitators described in the literature. However, the evidence synthesis led to a more parsimonious framework as some elements (e.g., research and published guidance) were seldom discussed in DBT implementation.ConclusionTo our knowledge this is the first published review exploring DBT implementation. The literature synthesis suggests some tentative recommendations which warrant further exploration. For instance, if DBT implementation is not pre-planned, having someone in the organisation who champions DBT can be advantageous. However, as the literature is limited and has methodological limitations, further prospective studies of DBT implementation are needed.Electronic supplementary materialThe online version of this article (10.1186/s40479-019-0102-7) contains supplementary material, which is available to authorized users.

Initiating a DBT consultation team: Conceptual and practical considerations for training clinics.

“…According to the original DBT text (Linehan, 1993), extant handbooks and training guidelines (e.g., Heard & Swales, 2016;Koerner, 2012;Koerner et al, 2007;Sayrs, 2018;Swales, 2010;Lungu, Rodriguez-Gonzales, & Linehan, 2012), and recent reviews (e.g., Prada, Perroud, Rufenacht, & Nicastro, 2018), therapist participation in a consultation team is viewed as integral to the DBT treatment model. Moreover, lacking access to DBT consultation is a known barrier to effective implementation of the DBT (Toms et al, 2019). The rationale for consultation team is that individuals with a BPD diagnosis or other persons experiencing severe emotional dysregulation are often difficult to treat, engaging in behaviors that are endorsed as highly stressful to therapists, such as suicide threats/attempts, therapy interfering behaviors, and hostile communication (Hellman, Morrison, & Abramowitz, 1986;Linehan, 1993).…”

“…Although many trainees who self-select into DBT training have a strong interest in working with high-risk populations (as was the case for everyone on our team), it is not uncommon for trainee therapists to have some uncertainty about what population(s) they would most like to work with after they complete their training and, similarly, whether specializing with high-risk clients is a good fit for their desired career trajectory. This uncertainty may pose a challenge for trainees insofar as it may not always be clear to the trainee therapist whether their experience of difficulty in treating high-risk clients is a function of solvable problems that can be fully addressed through better application of the DBT model to themselves or, conversely, that they applied DBT effectively but the therapy itself was not a good fit for the client, or, conversely, a function of a lack of fit between the theoretical underpinnings of DBT and the trainee therapist's emerging theoretical orientation or personal qualities (Toms et al, 2019). Working with individuals with severe or high-risk symptoms of psychopathology, including suicidal ideation or self-harm behaviors, can be emotionally taxing for all clinicians, even under the best circumstances (Perseius, Kåver, Ekdahl, Åsberg, & Samuelsson, 2007).…”

Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: A mixed methods approach

“…had at least 6 months of a standard DBT programme delivered) while participants in CAMHS had implemented at least one full 16-week DBT-A programme. Interviews were conducted with a member of the research team [2] and lasted approximately one hour. All interviews were audio-recorded and transcribed in preparation for analysis.…”

“…Optimised DBT programmes require implementation planning where the intervention is aligned with organisational goals, and staff are carefully selected and supported to train in and provide the intervention on a sustained basis. Supervision, ongoing training, monitoring of outcomes, and clear communication to stakeholders across all levels of an organisation are required to maximise the likelihood of successful implementation in a public mental health system [2,34,[36][37]. The current study considered all of these factors under the CFIR framework for the coordinated implementation with a particular emphasis on the 'Process' domain (see Additional file 1).…”

Community-based behavioral health administrator perspectives on sustainability of Dialectical Behavior Therapy: a qualitative evaluation

“…In an effort to enhance existing services, some behavioral health leaders have implemented evidence-based practices (EBPs) in community settings. Although agencies may be interested in adopting EBPs into their service line, implementation science is a relatively new field, and successful implementation strategies are not regularly reported in many EBP studies [1] thus limiting interested agencies' capacities to recreate successful models or avoid implementation failures. Moreover, implementation efforts reportedly have been complex and sometimes difficult processes [2].…”