1. © 2012 Behavioral Tech KEY COMPONENTS IN DBT IMPLEMENTATION: A SURVEY FROM THE GROUND UP Linda A. Dimeff, Ph.D. 1, Andre Ivanoff, Ph.D. 2, 3, & Erin Miga, Ph.D. 2 BEHAVIORAL TECH RESEARCH, INC. 1 BEHAVIORAL TECH, L.L.C. 2 SEATTLE, USA COLUMBIA UNIVERSITY, NEW YORK 3 2 ND International Congress on Borderline Personality Disorder & Allied Disorders Amsterdam 28 September 2012

2. ©2012 Behavioral Tech, LLC Our Overarching Question What actually happens to DBT Teams once the Intensive Training is over?

3. ©2012 Behavioral Tech, LLC Specifically… 1.Are they alive and still doing DBT? To fidelity? 2.Did they achieve goals they set for themselves? 3.What barriers interfere with their ability to achieve their primary objectives? 4.What one thing would they do over with the benefit of hindsight?

4. ©2012 Behavioral Tech, LLC Methods Mixed methods approach: A.Online DBT Program Elements of Treatment Questionnaire (PETQ: Schmidt, Ivanoff, Linehan, 2009) B. Telephone follow-up interview Sample: A. Randomly drew 50% of all teams who completed BTECH Intensive Training 2008-2011 B. Addressed to DBT Team Leaders

5. ©2012 Behavioral Tech, LLC Procedures EMAIL: Invitation email & to each DBT team leader. PHONE CALL: Evaluation efforty + opportunity for self-assessment + appt. for follow-up discussion. (assertive tracking) ONLINE SURVEY COMPLETION FOLLOW UP PHONE DISCUSSION

6. ©2012 Behavioral Tech, LLC Sample 154 teams trained 2008-2011 77 randomly selected; N=78. –66 (85%) contacted –8 (10%) DBT Program defunct –54 (69%) agreed to participate Of 54 who agreed to participate – 4 (7%) did not complete the survey –47 (87 %) completed survey & interview

7. ©2012 Behavioral Tech, LLC Clients Treated in DBT Settings

8. ©2012 Behavioral Tech, LLC Survival of DBT Programs Of the total sample (N=78), 74% (n=58) DBT program continues 10% (n=8) DBT program defunct 16% (n=12) DBT program unknown.

9. ©2012 Behavioral Tech, LLC Fidelity Snapshot Are the DBT teams meeting the five functions of DBT?

10. ©2012 Behavioral Tech DBT Functions & Modes Enhance capabilities - Skills training Improve motivation - One-to-one intervention Assure generalization to natural environment - One-to-one intervention - Phone coaching Structure the environment - One-to-one intervention - Phone coaching - Skills training Enhance therapist capabilities and motivation to treat effectively - Therapists’ Consultation Team

11. ©2002-2012 Marsha M. Linehan, Ph.D., ABPP Modes of Treatment Help Reach Goals Brief Review of Modes Individual Session_____  Increasing motivation for goals  Analyzing behavior  Learning skills and applying them to life Skills Group__________  Acquiring new skills & capabilities Milieu_______________  Strengthening and generalizing new skills  Contingency management Team_______________  Increase staff skills and motivation

12. ©2012 Behavioral Tech, LLC DBT Modes Provided (N=50)

13. ©2012 Behavioral Tech, LLC Enhancing Therapist Motivation & Capabilities: Consultation Team YesSomePlannedNo Do you have a consultation team? 90.2 %(46) 3.9%(2)2.0%(1)3.9 %(2) Does your team meet weekly? 73.5%(36) 6.1 %(3)4.1%(2)16.3% (8) Do you have a designated team leader? 79.6%(39) 14.3 %(7)2.0%(1)4.1% (2)

14. ©2012 Behavioral Tech, LLC Administrative Support Does your admin provide: YesSomePlannedNo Ongoing financial support for DBT leaders to obtain consultation & training 38.0%(19)28.0%(14)6.0%(3)22.0%(11) DBT manual for trainees 70.0%(35)14.0%(7)4.0%(2)10.0%(5) Time for training as a basic job expectation 62.0%(31) 24.0%(12) 0%12.0% (6)

15. ©2012 Behavioral Tech, LLC Are programs closely tracking the treatment they are delivering? DBT Adherence & Fidelity Assessment

16. ©2012 Behavioral Tech, LLC DBT TEAMS –40% conduct self-assessment of DBT program adherence to manual –16% of DBT team leaders and consultants review fidelity performance data. –When individual DBT adherence data is collected, 20% of programs give adherence data to teams & supervisors for quality improvement purposes Ongoing Assessment of Adherence & Fidelity

17. ©2012 Behavioral Tech, LLC At the Bottom Tracking treatment outcomes: –Only 34% consistently use nationally recognized outcome measures that have documented reliability/validity –Only 28% of DBT team leaders consistently monitor treatment completion rates Consultation team: –Only 29% of DBT teams implement clear contingencies for any DBT provider failing to gain knowledge, skills and/or attend consultation teams

18. ©2012 Behavioral Tech, LLC DBT Intensive Objectives: Did DBT Teams Achieve Top Goals? Main goal in implementing DBT: 100% achieved: 19% (n=9) 80-99% achieved: 39% (n=17) 60-79% achieved: 28% (n=13) Less than 60%:14% (n=6)

19. ©2012 Behavioral Tech, LLC Qualitative Analyses Questions 1.What were your organization’s primary objectives/goals for doing DBT? 2.What were your team’s most significant accomplishments? 3.What barriers interfered with implementation of DBT? 4.If you could do one thing over/differently, what would it be?

20. ©2012 Behavioral Tech, LLC 1.Reduce Stage 1 Target Behaviors (n=19) 2. Provide Comprehensive Adherent DBT (n=10) 3. Provide an evidence-based treatment effective for BPD and others with emotion regulation problems (n=8) Primary Goals & Objectives of DBT Implementation

21. ©2012 Behavioral Tech, LLC 1.Lives of patients have significantly improved – reductions in suicidal behavior & hospitalizations (n=12) 2.Built a DBT program despite high obstacles (n=7) 3.Built a comprehensive and adherent program (n=5) 4.Trained a large number of staff in DBT (n=3) 5.Consultation team function ( n=3) 6.First in locale to successfully implement (n=3) Primary Implementation Accomplishment

22. ©2012 Behavioral Tech, LLC Funding constraints*: 12 % (n=14) Staff turnover: 10% (n=12) Time constraints: 9% (n=10) Lack of true understanding of DBT/resistance to DBT amongst staff or administration: 7% (n=8) *lack of funding for ongoing training, lack of financial support for after hours coaching Barriers to Implementing DBT?

23. ©2012 Behavioral Tech, LLC 1.Better overall planning for the intensive (n=9), including selection & level of attendees 2.Get more clinicians intensively trained (n=8) 3.Get commitment from administration at outset to do DBT to fidelity and devote sufficient time to strategic planning (n=6) 4.Ongoing consultation with DBT experts after intensive training (n=3) 5.Nothing (n=4) What Would You Like to Do Over?

24. ©2012 Behavioral Tech, LLC Summary 1.Almost 75% of DBT programs are still functioning 1-3 years beyond intensive training. 2.DBT programs report high rates (75%) of fidelity across modes and functions of DBT. 3. Program objectives map squarely onto intensive training objectives: Reduce Stage 1 behaviors; Create/maintain DBT program to fidelity; Improve by enhancing capabilities.

25. ©2012 Behavioral Tech, LLC Summary -continued 4.Greatest challenges: financial and other administrative support toward fidelity implementation 5. In hindsight, place greater emphasis on: selection of team members ensuring decision-makers are committed to ongoing implementation support 6. DBT programs are resilient.

26. ©2012 Behavioral Tech, LLC Future Directions of BTECH Training Ongoing evaluation of training that begins at initial application proceeding through outcomes Involvement & contribution to general implementation science efforts Inclusion of new findings from Behavior Therapy & Research Clinics’ experimental training unit.