Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: a mixed methods approach

Daniel Flynn, Mary Joyce, Conall Gillespie, Mary Kells, Michaela Swales, Ailbhe Spillane, Justina Hurley, Aoife Hayes, Edel Gallagher, Ella Arensman, Mareike Weihrauch, Daniel Flynn, Mary Joyce, Conall Gillespie, Mary Kells, Michaela Swales, Ailbhe Spillane, Justina Hurley, Aoife Hayes, Edel Gallagher, Ella Arensman, Mareike Weihrauch

Abstract

Background: The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., Implementation Sci. 4:50, 2009) provided structural guidance for this national level coordinated implementation.

Methods: A mixed methods approach was utilised to explore the national multisite implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders (n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists (n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis.

Results: Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management.

Conclusions: The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework (Toms et al., Borderline Personal Disord Emot Dysregul. 6: 2, 2019). Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service.

Trial registration: ClinicalTrials.gov ID: NCT03180541; Registered June 7th 2017 'retrospectively registered'.

Keywords: Borderline personality disorder; Community settings; DBT therapists; Dialectical behaviour therapy; Evaluation; Implementation; Public health service; Team leaders.

Conflict of interest statement

Michaela Swales is the Director of Training for British Isles DBT Training Team that trains practitioners in DBT with a licensed training programmme. She receives income from training and royalties from books on DBT. She is married to the Managing Director of Integral Business Support Ltd. that delivers licensed training in DBT. The remaining authors declare that they have no competing interests.

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