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Table 1 Discussion papers

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

Reference Country & service context Key points/ recommendations made
Chugani, 2015 [16] America. College counselling centres -Important to collect service-relevant outcome data as DBT is often adapted to fit the service
-Important to adapt DBT so appropriate for the service
-Can mitigate costs by hosting training or offering partial programmes
Borroughs & Somerville, 2013 [15] America. Assertive Community Treatment teams -There may be resource and financial barriers, especially in the US healthcare system where services cannot recoup costs for training, consultation team meetings or data collection
-It is important to determine if DBT ‘fits’ the service’s client group and theoretical stance
-Recommended adapting DBT and offsetting costs by using existing infrastructure and demonstrating cost-effectiveness
Koener, 2013 [18] N/A -DBT clinicians need a good conceptualisation of the therapy, including the treatment hierarchy and biosocial theory
-Important that therapists are dialectical, cognitively flexible and validating
-Recursive culture important; a community of therapists working with a community of patients, with everyone in the same boat
-Services need to see patients as motivated to change and that services want to improve patient capability
-Therapists should access the consultation team and mindfulness practice
-Ensuring fidelity to manualised DBT ignores the contextual factors that moderate success
McHugh & Barlow, 2010 [19] Worldwide; Reviews and describes a range of implementation efforts -In America, Behavior Tech acts as a champion for DBT
--Ongoing outcome monitoring important to sustain fidelity and quality improvement
-Implementation issues have informed DBT training. For instance, teams implement DBT before completing final training so that they can access consultation after their first attempts
Swales, 2010a [11] UK -Larger DBT teams with less time will be slower at learning DBT than smaller teams who have greater allocated time
-Important to gain staff commitment to implement DBT and to select staff with knowledge about DBT and implementation, who are willing to apply DBT skills themselves
-Beneficial to recruit so that DBT teams encompass a range of skills
-Important to have a DBT ‘champion’ and the team leader should be in a senior position
-Consultation teams have an important role and the consultation agreement establishes the team climate
-A minimum of two hours per work is necessary for supervision and consultation team meetings
Swales, 2010b [12] UK -Description of an organisational pre-treatment approach where the DBT team leader or champion:
-Identifies the appropriateness of DBT, weighing the evidence, policy aims and organisation suitability, culture and climate
-Considers the organisations experience in implementing other new therapies
-Resolves competing goals and if synthesis is impossible undertakes a pros and cons analysis
-Forms an advisory or steering group to address factors likely to interfere with implementation
Berzins & Trestman, 2004 [14] America. Prison/correctional services. Non-systematic review and information collected from services -All the programmes described had adapted DBT. There is currently no manual for DBT in correctional settings
-Programmes were driven by clinical need (DBT had ‘goal fit’)
-To implement and evaluate a proposed modified DBT programme for correctional settings, a coalition had been formed between the university, state and health departments
Huffman et al., 2003 [17] N/A -Champion/consultant should be willing to model DBT skills
-To accommodate time limitations, single components of DBT can be applied rather than the comprehensive intervention
-Need to provide psychoeducation about BPD and validate staff experience of difficulties
-Use contingency management; frame behaviour modification as the most effective approach
Swenson et al., 2002 [21] America. Public mental health authorities. Recommendations based on observations, a survey and literature review -Barriers listed included therapist view of DBT suitability and staff turnover. Discussed therapist selection issues
-Also discussed the barriers patients may face when starting DBT- e.g. it is a high time commitment and they might need to terminate current treatment contracts
-Facilitators endorsed leadership from public mental health authorities, training, a positive attitude towards BPD and monitoring outcomes
-Recommended forming coalitions between organisations providing DBT and those planning to implement DBT
-Recommended providing training (psychoeducation) for public mental health authorities about DBT and BPD
-Recommended highlighting to patients that DBT participation is voluntary
Scheel, 2000 [20] N/A. Overview and literature critique -Suggested inpatient settings might transition most easily to DBT, as there is fit in terms of time availability and goals
-Need access to training, supervision and consultation
-Implementing DBT in a manner consistent with the evidence base requires a considerable staff team: resources may threaten viability
-Outpatient DBT requires inter-agency support (a need for coalitions)
Swenson, 2000 [22] America -Should use DBT skills to help implementation
-The design of DBT contributes to its appeal to therapists. For instance, it integrates different orientations meaning it has a wide support base and therapists from various orientations automatically have ‘buy-in’
-DBT can be both pragmatic and very sophisticated