Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration

Abstract

National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.

Barriers and facilitators affecting the sustainability of dialectical behaviour therapy programmes: A qualitative study of clinician perspectives

“…into one's professional identity) and is associated with intent to provide a treatment long term (Powell et al, ). This theme is consistent with findings in the literature supporting that clinicians' interest and expertise in DBT is a facilitator in its implementation (Landes et al, ) and that confidence in the effectiveness of DBT is associated with its increased use (Herschell, Lindhiem, Kogan, Celedonia, & Stein, ). The selection of staff that demonstrate this “buy in” may increase programme sustainability as these clinicians may be more likely to commit to the provision of DBT long term.…”

“…A number of studies have investigated barriers and facilitators associated with the implementation of DBT in a variety of service contexts (Ben‐Porath, Peterson, & Smee, ; Carmel, Rose, & Fruzzetti, ; Chugani & Landes, ; Ditty, Landes, Doyle, & Beidas, ; Herschell, Kogan, Celedonia, Gavin & Stein, ; King, Hibbs, Saville, & Swales, ; Landes et al, ; Swales, Taylor, & Hibbs, ). Most employed qualitative research methods to explore clinicians' and/or administrators' opinions about DBT.…”

“…Facilitators were identified in a few of the studies and seemed to mirror the identified barriers. For example, facilitators included systemic support (Carmel et al, ), staff interest and expertise (Landes et al, ) and positive team dynamics (Ditty et al, ).…”

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

“…If the structural components are not present, even a motivated clinical staff may not be able to sustain an EBP over time. If the structural components have been appropriately attended to, then key factors to enhance DBT success include interpersonal variables within organizations such as supervision, team cohesion, team communication, and team climate [6] as well as staff interest and expertise [8]. While the involved agencies in the present study communicated their interest in adopting DBT early on [23], some agencies were unable to start or maintain DBT implementation due to various organizational barriers.…”

“…Researchers concerned about getting EBPs from research laboratories to real-world community settings have recently focused on understanding community-based behavioral health (CBBH) agency leadership [2,5] and how leadership factors (e.g., attitudes) or organizational level constructs (e.g., culture/climate) can influence the successful implementation of EBPs [6]. Even with a greater concern for understanding the unique challenges of CBBH agencies [7,8], little information has been gathered directly from organizational leaders to inform implementation and sustainability efforts [9,10]. Collecting data from these community-based leaders/experts about the challenges and successes of EBP implementation may likely increase the opportunity for an EBP to be sustained within practicing CBBH agencies [11].…”