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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

  • Original Research
  • Published:
Translational Behavioral Medicine

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.

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Acknowledgements

The results described are based on data analyzed by the authors and do not represent the views of the Department of Veterans Affairs (VA), Veterans Health Administration (VHA), or the US Government.

Author information

Authors and Affiliations

  1. National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA

    Sara J. Landes PhD, Allison L. Rodriguez BA, Brandy N. Smith BA & Lindsay R. Trent PhD

  2. University of Arkansas for Medical Sciences, 4301 W. Markham St., #755, Little Rock, AR, 72205, USA

    Sara J. Landes PhD

  3. Central Arkansas VA Health Care System, VISN 16 South Central Mental Illness Research Education and Clinical Center (MIRECC), NW, Washington, DC, USA

    Sara J. Landes PhD

  4. Central Arkansas VA Health Care System, 2200 Fort Roots Drive, Building 58, North Little Rock, AR, 72114, USA

    Monica M. Matthieu PhD, LCSW

  5. College for Public Health and Social Justice, School of Social Work, Saint Louis University, Tegeler Hall, Suite 300, 3550 Lindell Blvd., Saint Louis, MO, 63103, USA

    Monica M. Matthieu PhD, LCSW

  6. Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road Suite 3217, Stanford, 94305-5719, USA

    Lindsay R. Trent PhD

  7. VISN 2 Center of Excellence for Suicide Prevention, NW, Washington, DC, USA

    Janet Kemp PhD, RN

  8. Office for Suicide Prevention, Mental Health Service, US Department of Veterans Affairs, NW, Washington, DC, 20420, USA

    Caitlin Thompson PhD

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  1. Sara J. Landes PhD
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Corresponding author

Correspondence to Sara J. Landes PhD.

Ethics declarations

Funding

This study was funded by the Department of Veterans Affairs (VA), Mental Health Quality Enhancement Research Initiative (MH QUERI) QLP 55-055 awarded to the first author.

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study. The findings reported in this manuscript have not been previously published and the manuscript is not being simultaneously submitted elsewhere during the Translational Behavioral Medicine review process. Portions of the data reported in this manuscript have previously been presented at conferences for the Society for Implementation Research Collaboration in September 2015 and the Association of Behavioral and Cognitive Therapies in November 2015. The authors have full control of all primary data and agree to allow the journal to review their data if requested and will do so in accordance with data sharing guidelines within the Department of Veterans Affairs.

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Implications

Policy: Mental health leaders who have the ability to impact and inform policy should consider policy changes that would help address the barriers rated as difficult to overcome by clinical sites.

Research: Additional work is needed to systematically identify implementation strategies best suited to address the barriers identified, especially those rated as difficult to overcome.

Practice: Clinic administrators and clinical providers can use the barriers and facilitators described here to plan for implementing dialectical behavior therapy in their setting.

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Landes, S.J., Rodriguez, A.L., Smith, B.N. et al. 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. Behav. Med. Pract. Policy Res. 7, 832–844 (2017). https://doi.org/10.1007/s13142-017-0465-5

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  • DOI: https://doi.org/10.1007/s13142-017-0465-5

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