Abstract
Delivering Dialectical Behavior Therapy (DBT) with adherence to the manual is a critical aspect of quality assurance and leads to better outcomes for clients. However, DBT is a challenging treatment to deliver adherently as it requires therapists to learn many strategies and to know when and how to apply them effectively. To date, little is known about the degree to which therapists in routine care deliver DBT adherently or what adherence challenges may be most common in these settings. This paper presents data from two studies in which the DBT Adherence Coding Scale (Linehan, M. M., & Korslund, K. E. (2003). Dialectical behavior therapy adherence coding scale manual. University of Washington.) was used to evaluate 158 DBT individual therapy sessions delivered by 63 therapists to 78 clients in routine practice (non-academic or research) settings. Nearly all therapists (98.4%) had read the DBT manual and attended DBT workshops (M = 17.9 days). Across studies, therapists delivered DBT individual therapy slightly below adherence on average (M = 3.96, SD = 0.18; cut-off for adherence = 4.00). Overall, 54.4% of sessions were adherent and 45.6% of sessions were non-adherent. On average, therapists exhibited highest adherence for acceptance-oriented strategies, moderate adherence for structural strategies, and lowest adherence for change-oriented and dialectical strategies. Informed by these results, we provide recommendations for how to improve adherence for the strategies most frequently delivered non-adherently as well as how to increase use of underutilized strategies.
Similar content being viewed by others
References
Beidas, R. S., & Kendall, P. C. (2010). Training therapists in evidence-based practice: A critical review of studies from a systems-contextual perspective. Clinical Psychology, 17, 1–30. https://doi.org/10.1111/j.1468-2850.2009.01187.x.
Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In E. Storch, & D. McKay (Eds.), Handbook of treating variants and Complications in anxiety disorders (pp. 363–373). Springer. https://doi.org/10.1007/978-1-4614-6458-7_23.
DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50, 60–72. https://doi.org/10.1016/j.beth.2018.03.009.
DiGiorgio, K. E., Glass, C. R., & Arnkoff, D. B. (2010). Therapists’ use of DBT: A survey study of clinical practice. Cognitive and Behavioral Practice, 17(2), 213–221. https://doi.org/10.1016/j.cbpra.2009.06.003.
Dubose, A. P., Botanov, Y., Navarro-Haro, M. V., & Linehan, M. M. (2019). Evidence-based training: The intensive model of training in Dialectical Behaviour Therapy. In M. A. Swales (Ed.), The Oxford Handbook of Dialectical Behaviour Therapy (pp. 965–980). Oxford University Press.
Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7–17. https://doi.org/10.1016/j.brat.2014.01.008.
Harned, M. S., Schmidt, S. C., & Korslund, K. E. (2021a). Does adding the Dialectical Behavior Therapy prolonged exposure (DBT PE) protocol for PTSD to DBT improve outcomes in public mental health agencies? A pilot nonrandomized effectiveness trial with benchmarking. Behavior Therapy, 52, 639–655. https://doi.org/10.1016/j.beth.2020.08.003.
Harned, M. S., Schmidt, S. C., & Korslund, K. E. (2021b). The Dialectical Behavior Therapy Adherence Checklist for Individual Therapy (DBT AC-I)https://www.dbtadherence.com.
Harned, M. S., Gallop, R. J., Schmidt, S. C., & Korslund, K. E. (2022). The temporal relationships between therapist adherence and client outcomes in Dialectical Behavior Therapy. Journal of Consulting and Clinical Psychology, 90, 272–281. https://doi.org/10.1037/ccp0000714.
Harned, M. S., Schmidt, S. C., Korslund, K. E., & Gallop, R. J. (2023). Development and evaluation of a pragmatic measure of adherence to Dialectical Behavior Therapy: The DBT Adherence Checklist for Individual Therapy. Administration and Policy in Mental Health and Mental Health Services Research, 50, 734–749. https://doi.org/10.1007/s10488-023-01274-x.
Kothgassner, O. D., Goreis, A., Robinson, K., Huscsava, M. M., Schmahl, C., & Plener, P. L. (2021). Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: A systematic review and meta-analysis. Psychological Medicine, 51, 1057–1067. https://doi.org/10.1017/S0033291721001355.
Landes, S. J., Matthieu, M. M., Smith, B. N., Trent, L. R., & Thompson, C. (2016). Dialectical behavior therapy training and desired resources for implementation: Results from a national program evaluation in the Veterans Health Administration. Military Medicine, 181, 747–752. https://doi.org/10.7205/MILMED-D-15-00267.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
Linehan, M. M. (2015). DBT skills training manual (2nd ed).). Guilford Press.
Linehan, M. M., & Korslund, K. E. (2003). Dialectical behavior therapy adherence coding scale manual. University of Washington.
Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal of Addictions, 8, 279–292. https://doi.org/10.1080/105504999305686.
Miga, E. M., Neacsiu, A. D., Lungu, A., Heard, H. L., & Dimeff, L. A. (2019). Dialectical Behaviour Therapy from 1991–2015: What do we know about clinical efficacy and research quality? In M. A. Swales (Ed.), The Oxford Handbook of Dialectical Behaviour Therapy (pp. 467–496). Oxford University Press.
Navarro-Haro, M. V., Harned, M. S., Korslund, K. E., DuBose, A., Chen, T., Ivanoff, A., & Linehan, M. M. (2019). Predictors of adoption and reach following Dialectical Behavior Therapy Intensive Training™. Community Mental Health Journal, 55, 100–111. https://doi.org/10.1007/s10597-018-0254-8.
Perepletchikova, F., Treat, T. A., & Kazdin, A. E. (2007). Treatment integrity in psychotherapy research: Analysis of the studies and examination of the associated factors. Journal of Consulting and Clinical Psychology, 75, 829–841. https://doi.org/10.1037/0022-006X.75.6.829.
Priebe, S., Bhatti, N., Barnicot, K., Bremner, S., Gaglia, A., Katsakou, C., & Zinkler, M. (2012). Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: A pragmatic randomised controlled trial. Psychotherapy and Psychosomatics, 81, 356–365. https://doi.org/10.1159/000338897.
Stiglmayr, C., Stecher-Mohr, J., Wagner, T., Meiβner, J., & Renneberg, B. (2014). Effectiveness of dialectic behavioral therapy in routine outpatient care: The Berlin Borderline Study. Borderline Personality Disorder and Emotion Dysregulation, 1, 20. https://doi.org/10.1186/2051-6673-1-20.
Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD012955. https://doi.org/10.1002/14651858.CD012955.pub2.
Walton, C. J., & Comtois, K. A. (2019). Dialectical behaviour therapy in routine clinical settings. In M. A. Swales (Ed.), The Oxford Handbook of Dialectical Behaviour Therapy (pp. 467–496). Oxford University Press.
Funding
This research was supported by grants from the National Institute of Mental Health awarded to the first author [R56MH117085 and R34MH106598]. All authors are paid to provide training and consultation in DBT.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Harned, M.S., Schmidt, S.C., Korslund, K.E. et al. Therapist Adherence to Dialectical Behavior Therapy in Routine Practice: Common Challenges and Recommendations for Improvement. J Contemp Psychother 54, 87–98 (2024). https://doi.org/10.1007/s10879-023-09601-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10879-023-09601-x