Implementing Dialectical Behavior Therapy

Borderline personality disorder is a formidable public health problem. The estimated prevalence in the general population is 2 to 3 percent (1,2,3). Fifteen percent of persons seen in outpatient clinics and about 25 percent of psychiatric inpatients have the disorder (4,5,6).

People with borderline personality disorder present special difficulties to public-sector providers. Up to 80 percent have a history of parasuicide (7,8,9,10,11,12), up to 67 percent have comorbid substance use disorders (13), and 8 to 10 percent eventually commit suicide (14,15,16,17,18,19). Individuals with the disorder constitute up to 40 percent of frequent recidivists in psychiatric hospitals (20,21). When borderline personality disorder co-occurs with other major disorders, such as affective illness and eating disorders, standard treatment approaches for the other conditions are less effective (22,23,24,25,26). Providers often have trouble sustaining the effort of caring for people who experience repeated suicidal crises and frequent hospitalizations and whose mood is highly reactive. Consumers with the disorder often lose hope and resign themselves to chronic illness and palliative care.

Despite an extensive literature on the psychotherapeutic treatment of people with borderline personality disorder, few approaches are supported by research. Dialectical behavior therapy (DBT) is the only psychosocial treatment with demonstrated success in several controlled treatment trials and is thus a promising development. Since DBT was introduced, the demand for it has been steady. The purpose of this article is to briefly describe DBT, review and critique its research base, speculate on the reasons for the appeal of DBT to practitioners, identify barriers to implementing DBT, and describe strategies for overcoming those barriers.

Description of DBT

Dialectical behavior therapy is a cognitive-behavioral therapy for the treatment of borderline personality disorder in which an ongoing focus on behavioral change is balanced with acceptance, compassion, and validation of the consumer. DBT's biosocial theory holds that individuals with borderline personality disorder have a pervasive deficit in their capacity to regulate emotions. The deficit originates in and is maintained by an ongoing transaction between the individual's emotional vulnerability and the environment's pervasive pattern of invalidating the individual. As defined in this treatment approach, invalidation is a complex construct that includes the indiscriminate rejection of the communication of private experiences, the punishment of emotional displays but with intermittent reinforcement of emotional escalation, and the consistent communication that emotional problems are easier to solve than they really are. DBT's biosocial theory explicitly supports a nonpejorative stance toward individuals with borderline personality disorder, which helps correct a common tendency to blame them for their maladaptive behaviors.

At the beginning of treatment, the consumer and the therapist collaboratively generate a prioritized list of specific behavioral targets for change, which then guides the content of therapy sessions. After gaining the consumer's commitment to the treatment program, the therapist helps the consumer in stage 1 to establish behavioral control and to master skills, in stage 2 to resolve posttraumatic stress disorder, in stage 3 to address issues of self-respect and individual goals, and in stage 4 to increase the capacity for sustained joy. Each stage has its own prioritized list of targets. For instance, in stage 1 the therapist tries to reduce life-threatening behaviors, then behaviors that interfere with therapy, and then behaviors that interfere with quality of life. The final step in stage 1 is to help the consumer increase the use of his or her skills.

The therapist works directly with the consumer to address problems connected with his or her environment, or social-professional network, rather than consulting with persons in the network about the consumer. The therapist uses a variety of techniques, including behavioral chain analyses to understand behaviors targeted for change, problem solving with cognitive restructuring, exposure procedures, skills training, and contingency management. Progress in changing the targeted behaviors is monitored daily by the consumer, who completes a diary card for review with the therapist.

DBT's comprehensive treatment package orchestrates the delivery of five essential functions through five typical DBT treatment modes. First, a weekly 2.25-hour skills training group, which uses a DBT skills training manual, helps enhance consumers' capabilities. Second, weekly individual psychotherapy—under some circumstances twice weekly—works to improve motivation for treatment and behavioral change. Third, consumers telephone their therapists between sessions for skills coaching as a way to generalize the skills to their natural environments. Fourth, individual therapists and group skills trainers meet in weekly consultation team meetings—considered mandatory in DBT—to enhance their therapeutic skills and to maintain or improve their motivation. Finally, DBT program directors structure the treatment environment, and case managers help consumers structure their environments.

Research findings

The strongest level of evidence for a given treatment is the support of numerous randomized clinical trials, conducted by different investigators, that compare the treatment with alternative treatments or with no intervention (27). To date, five randomized clinical trials of DBT can be found in the literature—two of standard DBT, one of an adaptation of DBT for women with borderline personality disorder and substance use disorders, one of an adaptation of DBT for women with bulimia nervosa, and one in which DBT-oriented treatment is compared with client-centered treatment.

The original study by Linehan and associates (28,29,30) was of women who met criteria for borderline personality disorder and who had both a history of suicide attempts and a recent attempt. Some of the women received one year of standard comprehensive DBT. Women in the treatment-as-usual condition were referred to substance abuse or mental health treatment programs in the community, or, if they were receiving treatment when they entered the study, they were allowed to continue with individual psychotherapy. They also received case management as needed.

After one year of treatment, women who received DBT reported less anger and better global social adjustment than those in the comparison group, and interviewers' ratings of their global adjustment were better. The two approaches were equally effective in producing clinically significant improvement in depression. At the six-month posttreatment follow-up, those who received DBT reported significantly fewer parasuicide episodes, fewer episodes of medical treatment for parasucidal behavior, fewer days of psychiatric hospitalization, and less anger than those in the comparison group, and interviewers' ratings of their social adjustment and employment performance were better. They were also more likely to have stayed in treatment. One year after treatment, those who had received DBT continued to have fewer days of psychiatric hospitalization, better global adjustment, and better interviewer-rated social adjustment and employment performance. However, although DBT reduced parasuicide more quickly, by 12 months after treatment the women in the comparison group had a similarly lower rate of parasuicide.

Koons and associates (31) replicated these findings at a Veterans Affairs clinic by comparing a six-month course of standard comprehensive DBT with treatment as usual. Treatment as usual was delivered by self-identified cognitive-behavioral therapists. Participants were women veterans who met criteria for borderline personality disorder. Unlike the women in the study by Linehan and her group, those in the VA sample were not required to have a history of parasuicide or a recent suicide attempt. Thus the VA sample was less parasuicidal and had a lower rate of previous hospitalization. At the end of the six-month treatment period, Koons and associates found that treatment retention was good for both groups and that those who received DBT experienced less suicidal ideation, depression, hopelessness, and anger than those in the comparison group.

Linehan and colleagues (32) reported on a randomized clinical trial of an adaptation of DBT for women with a dual diagnosis of a substance use disorder and borderline personality disorder. The adapted treatment entailed four major modifications to standard DBT: the addition of specific targets relevant to drug use; a set of attachment strategies intended to enhance patients' connection to therapy and the treatment team; an optional, tapered drug-replacement program; and case management. Women in the treatment-as-usual group received multiple referrals for treatment in the community. Both during treatment and four months after treatment, the women who received DBT had significantly less drug abuse than those in the comparison group as measured by both structured interviews and urinalyses. In addition, the women who received DBT were more likely to stay in treatment. However, no significant differences were found in the amount of medical or psychiatric inpatient treatment received during the course of treatment. Four months after treatment, those in DBT showed significantly more gains in global and social adjustment and in state and trait anger.

Safer and colleagues (33) conducted a randomized controlled trial comparing outcomes for 31 women with bulimia nervosa who either received 20 weeks of individual DBT psychotherapy sessions or were assigned to a waiting list. The major modifications to standard DBT included a shorter treatment period, specific targets relevant to binge eating and purging, and inclusion of systematic skills training, with use of a manual, in individual psychotherapy sessions. The manual-based DBT focused on training in mindfulness, tolerance of distress, and skills to regulate emotions, all of which were drawn from Linehan's skills training manual (34). Using an intent-to-treat design, Safer and colleagues found that the women who received DBT experienced highly significant decreases in binge-purge behavior compared with the women on the waiting list. None of the women who received DBT dropped out of treatment.

Turner (35) compared a DBT-oriented treatment with client-centered treatment by using an intent-to-treat design with a racially diverse sample of men and women in a community mental health clinic. The two treatments were delivered by the same experienced therapists over one year. The DBT-oriented treatment condition modified standard DBT with psychodynamic case conceptualization and incorporated skills training into individual DBT psychotherapy sessions so that the number of hours of clinical contact was equivalent to that in client-centered therapy. In both approaches, six group sessions that focused on significant interpersonal relationships were offered to participants. When treatment ended, participants who received DBT-oriented treatment had clinically significant reductions on measures of suicide and self-harm behaviors. They also showed improvement on measures of suicidal ideation, were more likely to have remained in treatment, and had experienced fewer days of psychiatric hospitalization. Those in DBT also showed greater improvement on measures of depression, impulsiveness, anger, and global psychological functioning.

In addition to these randomized clinical trials, a number of other experiments and quasi-experiments add support to the use of standard and modified versions of DBT (36,37,38).

The literature on DBT has recently been reviewed (39,40) and critiqued (41). The findings most common across studies suggest that DBT reduces severe dysfunctional behaviors that are targeted for intervention, increases treatment retention, and reduces psychiatric hospitalization. Although published follow-up data are limited, the available data indicate that improvements may remain up to one year after treatment (29).

Overall, these published reports show that DBT is a promising treatment for a population in great need of effective services. It should be noted that three of the five randomized controlled trials (31,33,35) and all three of the experimental and quasi-experimental studies (36,37,38) were conducted by investigators who were not associated with Linehan's group. Nevertheless, additional studies by different groups of investigators in a variety of outpatient settings would deepen our overall understanding of DBT and could answer specific questions about the transferability of the practice to typical public mental health outpatient settings.

One question is about the level of training required. DBT therapists in the randomized clinical trials were described as having years of experience conducting therapy, and most had doctoral-level training. However, in typical mental health settings, therapy is usually conducted by master's-level therapists whose experience varies. Although one study showed that people with different levels of training can master the conceptual complexity of DBT, as measured by a test (42), effectiveness studies of DBT delivered by typical outpatient therapists would provide considerably stronger evidence.

The appeal of DBT

Despite the lack of effectiveness trials supporting the transfer of DBT to routine community settings, mental health authorities, program leaders, and practitioners have embraced DBT with enthusiasm, and many have implemented programs. The foremost factor contributing to the demand for DBT appears to be the intense need experienced by mental health providers for a treatment that is clear, "do-able," and effective.

DBT is an integrative approach that resonates with the current zeitgeist in mental health care. It weaves together neurobiology, cognitive science, behaviorism, a focus on trauma, and spirituality (43), which is appealing to practitioners of any of these orientations, who find in DBT an avenue to expand and integrate their areas of expertise. In its emphasis on skills development, self-care, a nonpejorative attitude, a staged treatment leading to full recovery, and consultation with the consumer rather than consultation with those in the consumer's environment about the consumer, DBT is also compatible with the recovery and consumer empowerment movements. The specific behavioral targets, staged treatment, ongoing documentation of outcomes, and cost-effectiveness (44) make DBT attractive to managed care companies.

DBT is simple and coherent enough to be understood by new practitioners and sophisticated and complex enough to appeal to experienced therapists. The skills and strategies offer concrete pragmatic help almost immediately, yet the comprehensive model and treatment stages provide a road map for long-term, recovery-oriented treatment. The implementation program takes clinicians through a graduated learning process that leads to competence in DBT practice and adherence to the model. Finally, DBT's requirement that skills trainers and individual clinicians form a consultation team provides a mechanism for ongoing education, support, supervision, and renewal for practitioners.

Barriers to implementation

Public mental health authorities, program leaders, practitioners and their clinical supervisors, and consumers all play important roles and face different barriers in implementing practices in the public sector (45).

Public mental health authorities

Public mental health authorities, sometimes working through public-sector managed care companies, powerfully influence the allocation of finite public dollars among the range of treatment options. To facilitate the implementation of DBT, these authorities must be aware of the practice, give it high priority, and then support it through effective policies and financing. Several factors keep public mental health authorities from learning about DBT and giving it priority. Adults with borderline personality disorder do not have the backing of any powerful advocacy group, so political pressure to provide disorder-specific services is lacking. Pressures to invest in DBT typically arise from clinicians and program leaders who are disenchanted with current approaches, and occasionally from managed care companies in search of more cost-effective treatments. Nevertheless, some public mental health authorities who appreciate the potential benefits of DBT balk at giving priority to a practice whose effectiveness in typical community health care settings has yet to be firmly established.

For public mental health authorities who do give DBT high priority, further barriers arise in the process of guiding and funding the implementation. Promoting DBT successfully is not simply a matter of contracting for clinician training. Several states have found that when intensive training for clinicians was arranged before mental health program leaders had had a chance to prepare for DBT administratively, the clinicians' lack of orientation, preparation, and commitment has seriously impeded the training effort and start-up. The promotion of DBT can also fail if expectations for program fidelity are not clearly articulated and reinforced. Because no validated fidelity measure for DBT programs has been formulated, mental health authorities and program leaders must rely on DBT experts to determine adherence. In several cases, DBT teams have been funded but then allowed to drift, resulting in such extensive modifications that the treatment no longer resembled DBT.

Finally, implementation can fail if mental health authorities cannot work out funding mechanisms to cover ongoing costs. Some programs have enthusiastically implemented all five standard DBT treatment modes only to discover that available benefit packages cannot easily be adjusted to cover even the first year of costs. In particular, standard benefit packages fail to reimburse fully for a 2.25-hour group, for two group therapists, for telephone consultation outside weekly individual therapy, and for attendance at consultation team meetings.

Mental health program leaders

Mental health program leaders set priorities for care, seek resources, and structure the operational details of practice. Given the challenge of transitioning current clinicians and vulnerable consumers to a new team-oriented model, program leaders must understand and clearly assign priority to DBT to avoid getting sidetracked by crisis situations. The work of program leaders is slowed if they do not strongly believe that individuals with borderline personality disorder are truly suffering, want treatment, and can get better. Some program leaders show a premature readiness to modify the treatment package in response to financial, political, or philosophical pressures, not appreciating that high-fidelity programming may be more effective.

Program leaders face staffing challenges. Recruiting and retaining staff to work with high-risk consumers can be difficult, particularly before the team has developed a track record of providing adequate support to therapists. Even when a team is staffed and going well, losing a trained, skilled staff member can be a demoralizing setback. With the high turnover rates in many community mental health settings, staff recruiting and training is an ongoing process.

Operational barriers can arise as the program leader defines and structures the DBT program within the agency. Some leaders, hoping to maximize the impact of DBT, have made the mistake of modifying DBT for nonstandard populations and contexts before establishing a viable standard program. In a radical departure from the general culture of a community mental health center, DBT practitioners deliberately refrain from consulting with other professionals who are working with the consumer unless it is absolutely necessary, and instead coach the consumer to interact skillfully with other treatment providers. Unless those providers, including psychiatrists, inpatient staff, and emergency services staff, are adequately oriented by DBT practitioners to this policy, they may come to regard the DBT program as noncollaborative. Given the intensity of conflicts that can arise about the care of people with borderline personality disorder, fault lines can consolidate to the detriment of the treatment environment as a whole. Finally, to argue for the ongoing support of the DBT program, leaders must demonstrate the success of the program by tracking important outcomes over time, such as rates of suicidal behavior or days of hospitalization.

Clinicians

Clinicians face barriers in becoming effective DBT therapists. For many clinicians, the shift requires a dramatic reworking of therapeutic belief, a significant role redefinition, and the acquisition of new skills. For some, repeated and painful treatment failures with consumers who have borderline personality disorder have led to pessimism and burnout. Competing demands in a practitioner's work can interfere with the time and focus necessary to learn to practice DBT.

DBT is a behavioral therapy that involves active and directive work to analyze and change target behaviors through cognitive restructuring, skills training, exposure procedures, and contingency management. Access to training in these component protocols is limited during both professional and postgraduate training. Difficulty obtaining DBT supervision can interfere with on-the-job learning. Psychodynamically trained clinicians are sometimes concerned that what they see as the root causes of the problems are being neglected. Those trained to see borderline personality disorder as a manifestation of poorly integrated aggression are likely to see DBT therapy as relatively blind to aggression and its vicissitudes, and therapists trained to be concerned about therapeutic neutrality may have trouble offering the extensive teaching and strategic self-disclosure required in DBT. Some therapists object to DBT's staged approach to posttraumatic stress disorder, in which the systematic processing of memories and affects is attempted only after stability and safety have been established, although this staged approach is normative in current trauma treatment models (46,47,48).

To practice DBT, therapists must do things that many are not accustomed to doing, such as following a treatment manual, giving homework, reviewing a consumer's self-ratings of behaviors, and serving as the coordinator of the consumer's treatment team. The active role of DBT therapists, which includes teaching skills groups, encouraging and coaching consumers in the use of skills, and taking crisis calls, is new to many clinicians. For DBT to work, therapists must also learn to rely on the consultation team for advice, balance, and support rather than trusting only their own judgment or the help of a one-on-one supervisor.

Consumers

Common barriers that consumers must overcome include changing their expectations of what constitutes treatment, arranging their lives to facilitate DBT treatment, and managing the emotions prompted by entering yet another form of therapy after repeated treatment failures. Having learned in previous treatment that change will come about through processing memories of trauma or through gaining psychodynamic insights, some consumers find DBT's focus on immediate behavioral change to be jarring. For these consumers, the DBT therapist's emphasis on behavioral assessment, behavioral change, self-monitoring of target behaviors, skills training, and homework assignments can seem superficial or off the mark. Even when consumers understand the general goals and logic of DBT, they sometimes cannot link that logic with their own problems to see how the treatment could help them.

DBT requires a considerable commitment from the consumer. To enter DBT, most consumers must terminate treatment with their current clinician or clinical team, to whom they are often very attached. Shifting allegiances to DBT team members who are trained to avoid reinforcing crisis behavior can be difficult for consumers when these same behaviors may have been reinforced for years by the case managers, residential outreach workers, inpatient staff, and emergency services personnel who have cared for them. The time commitment—a session and a lengthy skills group each week for a minimum of one year—can be daunting to consumers, especially if their lives have been too chaotic to make long-term planning possible in the past. The explicit commitment to change behaviors can frighten consumers who cannot envision a life without self-harm or suicidal preoccupation. Finally, the prospect of entering a treatment that explicitly identifies the goal of developing a life worth living can set off consumers' fears that with improvement will come the loss of supports that are in place because of their severe behavioral problems.

Strategies for implementation

Although many factors favor the implementation of DBT, powerful barriers limit its widespread high-fidelity implementation. Over more than a decade, those involved in the dissemination of DBT have developed a number of strategies to overcome these barriers. The strategies described below were derived from the authors' observations and from the responses to a questionnaire that we developed to administer to people who have been involved in DBT implementation. Twenty-five people responded to our survey. Participants included mental health authorities, program leaders, clinicians, consumers, and DBT trainers and consultants. We also reviewed published descriptions of strategies for implementing DBT in several settings, including inpatient settings (49,50), a partial hospital (51), a community mental health center (52), and a forensic setting (53).

Public mental health authorities

Public mental health authorities considering whether to invest in DBT need a primer on the nature and scope of the problem of caring for individuals with borderline personality disorder, a clear description of DBT, a summary of the research on outcomes for consumers in DBT, tips on implementing DBT, an estimate of the nature and costs of a DBT training sequence that would result in functioning DBT programs, a tool that can be used to measure program fidelity, and a list of other public mental health authorities that have undertaken implementation and that can provide consultation.

In an example of a successful process, one of the authors (CRS), acting as director of training for DBT and as regional medical director in the Massachusetts Department of Mental Health, provided consultation to the Massachusetts Behavioral Health Partnership (MBHP), the statewide managed care company for behavioral health in the public sector, on the development of DBT resources for public-sector consumers. MBHP clinical managers reviewed the research and clinical literature in advance of an orientation meeting in November 1997. At the meeting, special attention was paid to research outcomes, qualifications of DBT practitioners, and guidelines for determining the fidelity of a DBT program.

MBHP then defined an enhanced benefit package that would support standard DBT for consumers with borderline personality disorder. To receive the benefit, DBT programs and clinicians had to meet credentialing criteria and report outcome data for each consumer every 90 days. By September 2000, 14 MBHP-credentialed DBT programs had been implemented in the state. At regular intervals, MBHP officials have interacted with authorities in the Department of Mental Health to adjust and refine the benefit package for maximum usefulness.

State mental health authorities in Connecticut, New Hampshire, and Vermont have insisted that agencies wanting to implement DBT form planning teams of clinicians and administrators before entering intensive DBT training. The resulting high level of preparation and commitment has ensured enthusiastic and well-organized statewide dissemination.

Mental health program leaders

Like public mental health authorities, program leaders who are considering DBT need a general introduction to the practice, along with details about structuring the model in an agency, including the optimal use of training funds and judicious selection of DBT team members. Expert DBT consultants can be hired to orient program leaders to DBT, addressing biases about the consumer population, cognitive-behavioral treatments, and feasibility of implementation. One state organized a day-long DBT workshop focused on the needs of administrators. A regional mental health authority in another state offered a day-long introduction to DBT for program leaders and practitioners that included a series of presentations by established DBT program leaders from agencies in other parts of the state. The format allowed the administrators who were unfamiliar with DBT to have detailed discussions about feasibility and implementation strategies with experienced program leaders. Some program leaders have joined practitioners in attending DBT's standard 10-day intensive training workshops, where they have formed collaborative bonds with others in their agency while receiving consultation about program design tailored to their agency and about their case presentations.

Program leaders need to have strategies for retaining skilled DBT clinicians. The DBT consultation team is the mechanism within the treatment model that addresses demoralization and burnout and should therefore be prioritized, protected, and strengthened in each program. One state is considering raising the salaries of clinicians who stay with the agency for more than two years after intensive DBT training. Because some degree of clinician turnover is unavoidable, program leaders should organize focused and effective training materials that can be used repeatedly. Many programs have developed videotaped introductions to their DBT program, have sponsored annual DBT seminars for any interested staff, have sent practitioners to DBT update meetings, and have incorporated updated training materials and exercises in the weekly consultation team meetings.

To evaluate the success of their DBT program, leaders must collect information about consumer outcomes and program fidelity. For the former, a one-page DBT outcome assessment form is available that provides a compact format for the monitoring of all relevant outcomes (54). For the latter, a program adherence measure has been developed and pilot tested and is now undergoing further development.

Clinicians

A variety of strategies have been developed to help clinicians change their therapeutic beliefs and acquire the knowledge and skills they need to implement DBT. Typically clinicians are first introduced to DBT in grand rounds, seminars, and professional literature or on Web sites. They can then learn it in sufficient depth to deliver the therapy from treatment manuals (26,34) and videotapes (55,56,57) for self-guided study. Clinicians can also attend standardized one- and two-day introductory workshops that are designed to teach DBT and to shift attitudes toward consumers with borderline personality disorder in a compassionate direction. For clinicians without training in behavioral principles and protocols, behavioral treatment manuals for self-guided study and continuing education workshops are also available. Specialty workshops focus on DBT skills training and DBT as adapted for substance abusers and adolescents. Opportunities to update skills and knowledge and to learn how to implement modifications in DBT, such as those for substance abusers, can be found at regional advanced two-day workshops and at the annual meeting of the International Society for the Improvement and Teaching of DBT, where research presentations, symposia, and poster presentations keep practitioners up-to-date.

However, the most inclusive training format is the ten-day intensive DBT workshop for practitioners and program leaders, which is designed to get DBT programs up and running. In one statewide intervention, some evidence suggested that this format helps frontline clinicians master DBT's knowledge base (42).

The process starts in a pretraining commitment phase during which teams apply and are selected and during which role induction takes place. Teams are accepted only if a successful DBT implementation seems possible. Solo practitioners are not accepted into the training. Trainers serve as consultants to applicants for intensive training, sometimes suggesting preparation work before the training. All participants are expected to commit to attending all ten days and to have read Linehan's manuals before the training begins.

The training itself includes team exercises and consultations that address existing team problems, enhance team cohesion, and reduce some potential barriers to implementation. During the initial five days—part 1—the treatment is taught through didactic methods, experiential exercises, role playing, and videotaped DBT sessions. The training team highlights DBT principles and strategies in the management of the workshop. After part 1, there is a six-month interval during which teams and individuals practice the treatment in extensive homework assignments, complete a difficult examination first with a closed book and then with an open book, and prepare for part 2, during which they present their programs and cases for consultation.

Part 2, the second five-day period, is centered on the consultations about programs and cases. Anxiety about the presentations fosters participants' intense preparation and more practice of DBT with coaching from the trainers. Daily evaluations of the workshop have affirmed that the five-day format allows participants to separate themselves from the usual burdens and routines of work, facilitates team bonding, and provides a momentum and intensity that are unavailable in most training formats.

The consultation team in DBT is the component responsible for ongoing enhancement of the capabilities and motivation of practitioners. It is structured to do so with particular guidelines and formats. The team is used to review individual therapy cases as well as the functioning and content of the skills group and to offer encapsulated training experiences. Intense emotions and strong opinions are typical among clinicians who work with this population, and the team serves to validate painful feelings, offer alternative solutions to impasses, and search for syntheses among conflicting and rigidly held positions.

Consumers

Strategies for overcoming barriers to consumers' participation in DBT are intrinsic to the treatment. Behaviors on the part of the consumer or the therapist that interfere with treatment are targeted in treatment sessions. Targeting these behaviors is second in priority only to targeting suicidal behaviors.

The first stage of treatment in DBT is the precommitment stage, during which the consumer and the therapist collaboratively identify the consumer's goals and convert those goals into a prioritized list of behaviors to target. They also consider and agree on methods by which DBT will help achieve the goals. They specifically discuss factors that may interfere with the consumer's participation. Some myths about cognitive-behavioral treatment, about a treatment that uses a manual, and about DBT in particular can be addressed to correct distortions and alleviate some fears. If a consumer expresses the concern that DBT will not address underlying responses to childhood trauma, the therapist emphasizes that the symptoms of posttraumatic stress disorder will be targeted from the beginning, that information will gradually emerge about traumatic circumstances, and that after the consumer achieves some stability, the painful memories and affects will be systematically processed.

If the consumer is having difficulty moving on from a previous non-DBT therapist or entering the skills group, time is allowed for a transition. DBT therapists tell consumers about non-DBT alternatives so that their commitment to DBT is voluntary. Consumers' concerns about how DBT can be modified to suit their situation are addressed. DBT is a theory-driven treatment, rather than protocol-driven, and it can be adjusted. For instance, DBT has been adapted to address treatment barriers common among substance abusers by adding attachment strategies, modifying the priorities of target behaviors, adding case management, incorporating several substance abuse-specific skills, and defining a protocol for drug testing.

Conclusions

Numerous public mental health programs have implemented DBT programs over the past ten years. Although the dissemination process has not yet been formally studied, DBT trainers and consultants have identified common barriers to the implementation of DBT and have developed strategies to overcome them. The lessons learned from disseminating DBT may be helpful to others who are promoting the implementation of other practices.

Acknowledgments

Work on this paper was supported by the West Family Foundation through the West Institute at Dartmouth and by West Central Behavioral Health in Lebanon, New Hampshire. The authors thank Kim Mueser, Ph.D., for his helpful comments.

Dr. Swenson is associate clinical professor of psychiatry at the University of Massachusetts Medical School in Worcester. Dr. Torrey is associate professor of psychiatry at Dartmouth Medical School in Lebanon, New Hampshire. Dr. Koerner is president of the Behavioral Technology Transfer Group in Seattle. Address correspondence to Dr. Swenson at 695 Kennedy Road, Leeds, Massachusetts 01053 (e-mail, [email protected]).