Table 2 Implementation papers, programme descriptions and trial process analysis papers

Chwalek & McKinney, 2015 [24]

America (and Germany). Range of mental health services

Retrospective data collection

Survey and interviews of music therapists

N/A

38.3% of respondents endorsed implementing DBT in music therapy practice

Ditty et al., 2015 [26]

America. Mental health services

Retrospective data collection

Survey and interviews with therapists trained in DBT exploring inner setting constructs of CFIR framework

N/A

96% of respondents provided individual therapy, 99% provided skills groups, 97% attended a consultation team and 87% provided phone skills coaching

Carmel et al., 2014 [23]

America. Public behaviour health system

Retrospective data collection

Telephone interviews with therapists

N/A

Therapists received ten days (80 h) of DBT training over 13 months

Herschell et al., 2014 [35]

America

Prospective data collection

Quantitative survey of therapists pre and post implementation

Therapists reported trend reduction in patient A&E visits and hospitalisations

Therapist training ranged from 32 to 96 h (maximum 96 h) and received on average 25.67 h of phone consultation

Swales et al., 2012 [31]

UK. Range of inpatient, outpatient and forensic services

Retrospective data collection

Telephone interviews with DBT team members

7.1% said improved patient outcomes were an implementation facilitator

62.8% of programmes remained active at five years. 57% of programmes provided all DBT components

Dimeff et al., 2011 [32]

America.

Prospective data collection

Randomised controlled trial with DBT naïve therapists

N/A

E-learning resulted in best knowledge retention at 15 week follow-up

Dimeff et al., 2009 [33]

America.

Prospective data collection

Randomised controlled trial with DBT naïve therapists

N/A

80% of therapists completed training. Online training best at improving knowledge. Instructor led training better than reading the training manual at increasing self-efficacy and satisfaction

Herschell et al., 2009 [36]

America. Community mental health services

Prospective data collection

Qualitative interviews pre implementation with county level mental health administrators

N/A

N/A

Perseuis et al., 2007 [28]

Sweden. Outpatient services

Retrospective data collection

Survey and interviews with DBT trained therapists

N/A

Therapists worked part-time in the DBT team. Tendency for greater staff burnout over time, but not statistically significant. Reduced occupational stress

Sharma et al., 2007 [30]

America. Psychiatric residency

Retrospective data collection

Survey of residency directors and senior residents. Also presented a case study

Patient hospitalised then discontinued DBT therapy

56% of residency programmes had no lectures on DBT and 32% provided no DBT supervision

Frederick & Comtois, 2006 [27]

America

Retrospective data collection

Survey of psychiatry residency graduates who had attended at least one DBT workshop

N/A

23% of respondents practiced all DBT components. Most practiced at least one DBT component

Cunningham et al., 2004 [25]

America

Retrospective data collection

Interviews with BPD patients who had received DBT therapy

Reduced hospitalisations and increased vocational work

N/A

Perseius et al., 2003 [29]

Sweden

Retrospective data collection

Interviews with DBT therapists and patients

Patients reported positive outcomes. Patients had been in therapy for at least 12 months

Therapists gained a new perspective and DBT influenced how therapists solved problems in their own lives

Hawkins & Sinha, 1998 [34]

America. Department of mental health and addiction services

Prospective data collection

Correlated therapist DBT knowledge to demographics and training through repeated measures and naturalistic service outcome data

Archival data suggested DBT training led to better patient outcomes: less A&E, inpatient, seclusion and restraint use

Training and the amount of time practiced DBT had a moderate correlation with DBT knowledge

James et al., 2015 [60]

America. Psychiatric facility

Trial process analysis

Service embedded repeated measures evaluation

Good outcomes

Grant funded participants had higher attrition

Kinsey & Reed, 2015 [43]

America. Native American tribe outpatient mental health and substance use service

Programme description

N/A

N/A

Programme had run for 14 years and had a good relationship with the tribal community

Baillie & Slater, 2014 [39]

UK. Community intellectual disability service

Programme description

Mostly discussion

Some evidence that patients developed emotion regulation and distress tolerance skills

DBT service had been in operation for four years

Engle et al., 2013 [42]

America. College counselling service

Programme description

Between groups

Reduced psychiatric and substance use hospitalisations. Reduced college absence due to mental health problems

Team received intensive training. Carried caseloads of up to seven patients plus one skills group

Arroyo et al., 2012 [38]

America. Mount Sinai East Harlem health outreach project

Programme description

N/A

Anecdotal evidence of patient improvement

Implemented skills group only. Therapists received fortnightly supervision

Lajoie et al., 2011 [44]

America. Residency run clinic

Programme description

N/A

N/A

Implemented all core DBT components

Morrissey & Ingamells, 2011 [47]

UK. Learning disability forensic secure service

Programme description

Naturalistic outcomes reported

Reduced symptoms and distress. Reduced perceived risk

Implemented programme over six years

Pasieczny & Connor, 2011 [66]

Australia. Adolescent mental health service

Trial process analysis

Between groups

Patients of intensively trained therapists had better outcomes in terms of DSH and suicide attempts

Therapists worked in DBT team part-time. Therapist adherence ranged nine-to-12 (maximum achievable = 12)

Little et al., 2010 [46]

America. Residential service

Programme description

N/A

Self-reported patient improvement and positive feedback

DBT was the best implemented treatment in the service; had furthest reach, most staff support and needed less senior administrative support. Minimal attrition

Sampl et al., 2010 [48]

America. Correctional setting

Programme description

N/A

N/A

Primarily just implemented skills group

Blennerhassett et al., 2009 [54]

Ireland. Community mental health team

Trial process paper

Repeated measures

Improved risks, symptoms, functioning and subjective wellbeing. Reduced hospitalisations and reduced costs

Therapists completed intensive training but DBT team not established in the service

Kerr et al., 2009 [62]

America. Low resourced rural training clinic

Trial process analysis

Case study

There were “meaningful” changes in suicidality and misery ratings

The therapist received DBT training and supervision. Could not access DBT skills group, so provided skills training in individual therapy sessions. Also provided adapted phone skills coaching

Hjalmarsson et al., 2008 [59]

Sweden. Outpatient services

Trial process analysis

Repeated measures

Patients had reduced para-suicidal behaviours and psychological distress

18 therapists trained and worked part-time on DBT team. DBT now provided by the service as a routine treatment. Attrition low

Woodberry & Popenoe, 2008 [71]

America. Adolescent and family outpatient clinic

Trial process analysis

Repeated measures

Good outcomes reported

Five therapists received intensive training, the rest received less intensive or in-service training. The hospital provided some money to support staff training

Comtois et al., 2007 [57]

America. Harbour view mental health services- community mental health centre

Trial process analysis

Repeated measures

Reduced DSH, A&E visits and inpatient admissions

Noted DBT staff were highly trained. Implemented all DBT components and incorporated access to DBT relevant services

Prendergast & McCausland, 2007 [67]

Australia, Adult mental health outpatient service

Trial process analysis

Between groups

Reduced depression and frequency of suicide attempts and hospitalisations. Improved patient functioning and reduced intervention duration

The team comprised 12 therapists. Attrition was 31%

Zinkler et al., 2007 [52]

UK. Newham project for BPD

Programme description

N/A

Reduced hospitalisation and DSH frequency

Annual service cost £92,000. Therapists worked part-time on DBT team. Staff satisfaction and retention high

Brassington & Krawitz, 2006 [56]

New Zealand. Mental health service

Pilot trial process analysis

Repeated measures

Good outcomes reported

Implementation reportedly successful. Team staffed by part-time therapists and at the end of the trial team had a dedicated budget

Koons et al., 2006 [65]

America. Division of vocational rehabilitation

Trial process analysis

Repeated measures

At six months improved depression, hopelessness, anger expression, work role satisfaction and number of hours worked

Provided just DBT skills group

Lew et al., 2006 [45]

America. Intellectual disability service

Programme description

Provided service outcome data

Eight learning disability patients completed the programme. DSH gradually reduced

Staff carried caseloads of eight. Parents and staff also attended the skills groups

Nelson-Gray et al., 2006 [64]

America. Outpatient adolescent clinic

Trial process analysis

Repeated measures

Reduced negative behaviours, externalising and internalising symptoms, and depression. Increased positive behaviours

Trained a high number of graduate students and these students achieved 88% intervention delivery fidelity over eight groups

Vitacco & Van Rybroek, 2006 [50]

America. Forensic hospitals

Programme description

Primarily a discussion paper

N/A

N/A

Nee & Farman, 2005 [63]

UK. Female prisons

Trial process analysis

Between groups (with a waiting list control)

The majority of completers showed overall improvement with notable effect sizes

Implementation problems believed to contribute to high attrition

APA Gold Award, 2004 [37]

America. Grove street adolescence residence- residential care service

Programme description

N/A

Outcome data indicated the programme was effective

Provided all DBT components and had 18.7 full time equivalent staff members

Ben-Porath et al., 2004 [53]

America. Urban community mental health centre

Trial process analysis

Repeated measures

Reduced life threatening, therapy interfering and QOL interfering behaviours

Implemented all core DBT components. Three of the eight DBT team members left within six months

Katz et al., 2004 [61]

Canada. Adolescent inpatient service

Pilot trial process analysis

Between groups

Reduced behavioural incidents on ward. Equivalent to TAU in reducing para-suicidal behaviour, depression symptoms and suicidal ideation at one year follow-up

Provided skills group, individual therapy and milieu therapy

Sunseri, 2004 [49]

America. Residential centre for adolescents

Programme description

Naturalistic outcomes reported

Reduced attrition, inpatient days and duration of restraint and seclusion

Staff confidence grew with DBT implementation

Eccleston & Sobello, 2002 [58]

Australia. Prison service

Pilot trial process analysis

Repeated measures

Trend improvement supported by patient feedback

Anecdotally, a range of staff saw programme benefits

Rathus & Miller, 2002 [68]

America. Adolescent outpatient clinic

Trial process analysis

Between groups

Reduced hospitalisations and increased retention but did not reduce suicide attempts

DBT transportable to real-world settings: provided in a hospital, not a university-based clinic

Trupin et al., 2002 [69]

America. Incarceration centre for female juvenile offenders

Trial process analysis

Between groups

Only one unit showed reduced behaviour problems

Only one unit showed less staff use of punitive responses. Not all staff adherent to DBT

van den Bosch et al., 2002 [70]

Netherlands. Addiction treatment centre

Trial process analysis

Randomised controlled trial

Reduced DSH but did not improve substance use

Over time therapists said they felt less isolated, more competent and experienced more work satisfaction. Consultation team attendance 100%. Attrition 37%

Bohus et al., 2000 [55]

Germany. Inpatient service

Pilot trial process analysis

Repeated measures

Reduced DSH, disassociation phenomena and depressive symptoms

Intervention was rated positively by staff and patients and this was an impetus to conduct the trial

Wolpow et al., 2000 [51]

America. Residential programme

Programme description

Included a service evaluation

Patients gave positive feedback and observations were positive

Residential staff became more positive about DBT

Gold Award, 1998 [41]

America. Mental health centre

Programme description

N/A

Positive patient outcomes and reduced costs reported

13 staff in DBT team. Provided all DBT components plus additional DBT related services. Team funding the equivalent of £520,000 per annum

Barley et al., 1993 [40]

America. Inpatient psychiatric hospital

Programme description

Naturalistic outcome evaluation

Reduced para-suicidal behaviour

Transitioned to a DBT model over a two year period