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MILITARYMEDICINE,181,8:747, 2016
Dialectical Behavior Therapy Training and Desired Resources
for Implementation: Results From a National Program
Evaluation in the Veterans Health Administration
Sara J. Landes, PhD*; Monica M. Matthieu, PhD, LCSW†‡; Brandy N. Smith, BA*;
Lindsay R. Trent, PhD*; Allison L. Rodriguez, BA*; Janet Kemp, PhD, RN§; Caitlin Thompson, PhD∥
ABSTRACT Context: Little is known about nonresearch training experiences of providers who implement evidence- Downloaded from https://academic.oup.com/milmed/article/181/8/747/4158352 by guest on 26 September 2022
based psychotherapies for suicidal behaviors among veterans. Evidence Acquisition: This national program evaluation
identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans
in a national health care system. This sequential mixed methods national program evaluation used a post-only survey
design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facili-
ties that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support
ongoing use of DBT. Results: While only 33% of clinical sites within VHA facilities reported that staff attended a for-
mal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study
using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health
records to support measurement-based care were desired clinical resources. Conclusion: Results indicate that less-
intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is
requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at
risk for suicide.
INTRODUCTION There are a number of clinical and public health strategies
4
Suicide is a national public health concern representing the to address conditions associated with suicide. Of these, means
10th leading cause of death, occurring at an age-adjusted rate safety, promoting help seeking, access to care among those in
of 12.57 per 100,000 individuals in the U.S. general popula- distress (e.g., hotlines), depression screening, and care man-
tion in 2013.1 Veterans are estimated to comprise 20% of the agement are effective. Among clinical interventions, cogni-
overall suicide rate in the United States, and the prevalence tive therapy, dialectical behavior therapy (DBT),5 medication
rate of suicide is estimated to be higher among veterans than management, continuity of aftercare, and follow-up contact
in the general population.2 A recent Department of Veterans (i.e., caring letters, safety planning) have some data to sup-
Affairs (VA) Suicide Data Report3 indicates that although port reduction in suicide attempts and suicide.
there have been no clear changes in the number of veterans To coalesce current national efforts in suicide preven-
with suicidal behavior, there has been an increase in the tion specific to veteran and military populations, joint VA/
number of younger male VA health care users with suicidal Department of Defense (DoD) Clinical Practice Guidelines
behavior. Given this, national efforts to prevent suicide among (CPG) for the Assessment and Management of Patients at
the general public and veterans seeking VA health care are of Risk for Suicide were released in June 2013. Given the state
paramount concern. of science reviewed at the time, the CPG provides no recom-
mendations with the Strength of Recommendation of strong
[A]orrecommendable[B],leaving the majority of prac-
tices lacking sufficient evidence among veteran and military
*National Center for PTSD, VA Palo Alto Health Care System, 795 populations. One treatment, DBT, is recommended; however,
Willow Road, Menlo Park, CA 94025. with “insufficient” evidence for treating an underlying disor-
†Central Arkansas Health Care System, Mental Health Quality Enrich- der (i.e., borderline personality disorder [BPD] or other per-
ment Research Initiative (QUERI), 2200 Fort Roots Drive, Building 58, North
Little Rock, AR 72114. sonality disorders characterized by emotional dysregulation
‡Saint Louis University, College for Public Health and Social Justice, and a history of suicide attempts and/or self-harm) in patients
School of Social Work, Tegeler Hall, Suite 300, 3550 Lindell Boulevard, whohave suicidal behavior.6
Saint Louis, MO 63103. According to other reviews of the evidence, DBT is
§VISN 2 Center of Excellence for Suicide Prevention, Canandaigua considered as an evidence-based psychotherapy (EBP) for
VA Medical Center, 400 Fort Hill Avenue, Building 37, Canandaigua,
NY14424. emotional dysregulation and suicidal behavior. The Substance
∥Office for Suicide Prevention, Mental Health Service, Department Abuse and Mental Health Services Administration’sNational
of Veterans Affairs, 1575 I Street Northwest, Washington, DC 20420. Registry of Evidence-based Programs and Practices indepen-
The results described are based on data analyzed by the authors and dently rated DBT as a well-researched treatment effective at
does not represent the views of the Department of Veterans Affairs, the reducing suicide attempts, nonsuicidal self-injury, drug use,
Veterans Health Administration, or the U.S. Government.
doi: 10.7205/MILMED-D-15-00267 symptoms of eating disorders, and improving psychosocial
MILITARY MEDICINE, Vol. 181, August 2016 747
Dialectical Behavior Therapy Training and Desired Resources for Implementation
adjustment and treatment retention among civilians.7 DBT understand the current uptake and spread of DBT in VA
has been examined in 11 randomized controlled trials and, health care settings and identify the history of training and
in addition to the above, has been shown to be effective at training needs for implementing DBT, a national program
reducing depression, hopelessness, anger, and impulsiveness evaluation of VHA facilities that have implemented DBT
(see summary in Landes and Linehan).8 was initiated in 2013 in collaboration with VA’sOffice of
DBT has been shown to be effective in the Veterans Suicide Prevention. This article presents results of this national
Health Administration (VHA). Studies indicate that it was program evaluation.
effective in reducing suicidal ideation, hopelessness, depres-
9
sion, and anger expression and helpful in reducing VA health METHODS
care costs.10 VHA program evaluation has shown that DBT
improves veterans’ clinical outcomes. Chiba and colleagues Study Design
examined their DBT program and found a decrease in inpa- The overall study design was a sequential mixed methods Downloaded from https://academic.oup.com/milmed/article/181/8/747/4158352 by guest on 26 September 2022
tient admissions, inpatient days, and cost (presentation at national program evaluation study consisting of a quantita-
the 2009 VA/DoD Evolving Paradigms II OEF/OIF National tive self-report survey and qualitative semi-structured inter-
Conference). Nappi and colleagues piloted a DBT skills group views. The survey was administered first to sites within VHA
15
for depression and found improvement on depression, quality facilities (N =59).Thisquan! QUAL design was selected
of life, and satisfaction (presentation at the 2012 Association so that quantitative results could directly inform design of the
of Behavioral and Cognitive Therapies Conference). Even qualitative interview. The primary objective of the quantita-
though DBT has evidence of effectiveness in VHA settings, tive data was to attain clinic-based needs assessment data and,
it has historically received little attention in comparison to for the qualitative data, to attain in-depth information from
other national EBP dissemination efforts, perhaps because of key stakeholders knowledgeable about implementing DBT
limited information available on providers’ history of train- in VHA settings.
ing, adoption, and current use of DBT within this national The data presented here are a subset of this larger study.
health care system. This article focuses specifically on the training history and
The “gold standard” of DBT training is the DBT Intensive resource preference data. The rationale for selecting this
Training Course,8 provided in two 5-day trainings, separated subset of data is to inform national policy makers and VHA
by 6 months of self-study. Studies on intensive training show clinical managers on the design and development of a national
that in a county-wide implementation, intensive training was DBT training and implementation plan. Ethical approval for
correlated with improvement in therapists’ attitudes toward this study was obtained from the appropriate VA institutional
patients with BPD, greater confidence in DBT’s effective- review boards.
11
ness, and increased self-reported use. Research on a state- Ascertainment and Sample Characteristics
wide implementation using intensive training revealed that
clinicians acquired mastery over the DBT model and the- The ascertainment of the sample used a national program
ory.12 Briefer training (i.e., 2-day workshop) has been found evaluation approach. Considering the need to obtain data
to only increase provider attitudes toward and knowledge from all VHA sites identified with the use of DBT, the VA
about clients with BPD and improve opinions regarding national health care system was our sampling area. We fur-
treatment options for these clients.13 While intensive training ther limited our sampling frame to clinical sites that were
is considered the gold standard to produce the expected identified on an internal VHA DBT resource Web site. The
system-level outcomes of adoption of DBT in health care set- goal was to recruit at least 1 person per site to complete the
tings for research purposes, community-based clinicians are survey on the site’s behalf or complete the survey as a team
propelling the adoption and use of DBT in nonresearch health (either resulting in one submission per site). Characteristics
care settings. of sites included VHA clinical sites implementing DBT. There
There is emerging evidence about DBT training experi- were no exclusion criteria.
ences among community providers (e.g., duration, intensity,
and modality of training). One study examined therapists’ use Sampling Strategy
14 Sites were identified using a two-step, purposive, snowball
of DBT, including the amount and type of training received.
This study, involving therapists (N = 129) trained by a com- sampling process. First, the research team purposively iden-
mercially available DBT training company, found that 64% tified providers who were their site’s point of contact on
of therapists completed a 2-day workshop on skills training, the VHA DBT resource Web site. These individuals were
58%completed a 2-day workshop on individual therapy, and targeted for recruitment using their VA e-mail (N = 60).
39%hadparticipated in intensive training. For the second phase of sampling, the research team
To our knowledge, no other studies have examined thera- focused on sites that had not yet been identified for the
pist training in general health care or community settings, and VHA DBT resource Web site. Using snowball sampling
even less is known about training and implementation of among their professional networks within VHA, the research
DBT in the national veterans’ health care system. To better team requested the DBT points of contact for each site to
748 MILITARY MEDICINE, Vol. 181, August 2016
Dialectical Behavior Therapy Training and Desired Resources for Implementation
share the invitation for study participation by forwarding the on the needs assessment data related to history of training
recruitment e-mail with the survey link to others who might and training needs. Measures of central tendencies were cal-
be implementing DBT in VHA. Given this professional net- culated to obtain rankings of resources. There were a total of
work sampling strategy, data on the resulting nominated sites 67 survey responses. As data were collected about imple-
were not collected. mentation of DBT in each site, when there were multiple
respondents, data were combined, so each site had only one
entry. The 67 responses included eight sites with more than
Data Collection Procedures one respondent. The research team identified each survey by
The research team used the Checklist for Reporting Results site based on facility information provided by respondents.
of Internet E-Surveys16 to guide development and data col- Weekly meetings to review survey information guided team
lection procedures in this Web-based survey. The survey decision making on the combination of data. When there Downloaded from https://academic.oup.com/milmed/article/181/8/747/4158352 by guest on 26 September 2022
was developed using a commercial Web-based platform were discrepancies between respondents at a site, a team of
(i.e., Qualtrics, Provo, Utah). Survey usability and tech- two raters determined the most appropriate answer based
nical functionality was pretested before fielding; testers on a number of rules. Rules included averaging data when
reported no problems, and no changes were made. The appropriate; defaulting to a “yes” answer for yes/no items;
survey was voluntary and not password protected or incen- and, when only one respondent completed an item, using
tivized. Therefore, access was open, and responses were col- that respondent’s data. After the data were cleaned and com-
lected from each unique visitor to the site. No demographic bined so that each site had one entry, there were a total of
data were collected about individuals completing the survey 59 sites. Missing data exist for some variables and were
on behalf of each site. noted accordingly.
RESULTS
Measures
Surveys were collected between July 2013 and May 2014. History of DBT Training Among VHA Clinical
There were two main parts. Part 1 had 6 sections that offered Providers
a skip pattern if the respondent did not endorse at least one Each site was asked to identify from a list which training
component of DBT (e.g., DBT skill groups). This skip pattern activities any DBT provider in their setting had received.
was used to isolate clinical sites that offered any DBT compo- Fifty-seven sites completed these questions. Training activi-
nent, as the remaining questions were tailored to inquire about ties were grouped as high (e.g., intensive training), medium
each component offered. (e.g., 1- to 2-day workshop), and low intensity (e.g., reading
The first section of part 1 allowed sites to describe their DBT books). The average number of high-intensity training
clinic setting (e.g., type of treatment setting, number of DBT activities ranged from 0 to 5 (mean [M] = 1.68, SD = 1.34).
staff). The next section addressed the context for delivering The average number of medium-intensity training activities
DBT, such as the components of DBT and clients’ presenting ranged from 0 to 5 (M = 1.89, SD = 1.26). The average
problems. The remainder gathered more details about each number of low-intensity training activities ranged from 0 to
endorsed primary component of DBT (e.g., frequency, length, 3 (M = 2.60, SD = 0.73). Most sites reported engaging in
and duration). low-intensity training activities. See Table I for a list of all
Part 2 consisted of 4 sections. Section 1 focused on use training activities.
of DBT strategies (e.g., diary cards) while section 2 focused
on the types and amount of DBT training providers in their Training Needs and Desired Resources
setting had received, resources used to implement DBT, and For the needs assessment, the survey assessed use of online-
desired resources to support ongoing use of DBT. Two final or technology-related DBT resources and resources desired.
sections related to barriers, using the DBT barriers to imple- Of the 54 sites responding, the majority indicated use of the
mentation survey (unpublished instrument; Behavioral Tech, VHADBTresource Web site (n = 35; 65%). Other technol-
Seattle, Washington) (α = 0.94), and facilitators to imple- ogy used included online DBT training (n = 14, 26%), DBT
menting DBT (α = 0.82), were administered. The survey con- mobile phone app (n = 9, 17%), and “other” (n = 8, 15%).
cluded with a section related to benefits of implementing DBT Other responses included DBT videos (n = 2, 4%), the inter-
(α = 0.70). Nearly all survey items used multiple choice, Likert national DBT listserv (n = 3, 5%), creating a mindfulness
scaling, or check all that apply as response options; text boxes DVD(n=1,2%),andaWebsite(dbtselfhelp.org; n =1,2%).
were included for some response options for more description. To identify desired resources, sites rank ordered a list of
10 possible resources. The top-rated resource was formal
DBT training, followed by funds for training (see Table II).
Data Analysis Responses entered for other resources (n = 17) were catego-
Data were analyzed using SPSS 21.0 for Windows (Armonk, rized; themes included (a) materials/supplies/tools (n =6),
New York). Analysis included frequencies and descriptives (b) staffing/funding (n = 4), (c) education/training (n =3),
MILITARY MEDICINE, Vol. 181, August 2016 749
Dialectical Behavior Therapy Training and Desired Resources for Implementation
TABLEI Training Activities Endorsed by VHA Clinical Sites (N = 57)
Type of Training n %Endorsed
Low-Intensity Training
5
Read the DBT Skills Manual—Linehan’s Skills Training Manual for Borderline Personality Disorder 55 97
5
Read the DBT Book—Linehan’s Cognitive Behavioral Treatment of Borderline Personality Disorder 50 88
Read Other DBT Books (e.g., Koerner’s Doing Dialectical Behavior Therapy) 43 75
Medium-Intensity Training
One- or 2-Day DBT Workshop 42 74
Seminar or Lectures on DBT in Graduate Training Programs (e.g., Time-limited Brief Seminars or a Lecture-type Presentation) 29 51
Participated in a DBT Study Group 43 30
Online DBT Training Course 13 23
Less than 1 Full Day Attending a DBT Workshop 712 Downloaded from https://academic.oup.com/milmed/article/181/8/747/4158352 by guest on 26 September 2022
High-Intensity Training
DBTSupervision by Clinical Expert 29 51
Practicum or Internship Experience in Using DBT 26 46
Two5-Day DBT Intensive Training with 6 Months of Self-study (with a Team) 19 33
Formal Training Program (e.g., DBT Training Program in Internship Settings) 18 32
Graduate-Level Course as Part of Professional Training Program 4 7
Sites were asked to endorse a training activity if any provider in their setting had completed the training activity. Columns do not add up to 100.
TABLEII Ranking of Desired Resources for Providing DBT by VHA Clinical Sites (N = 57)
Resource Mean Ranking Modal Ranking Range of Ranking
Intensive DBT Training Offered within VHA (e.g., Two 5-Day Trainings Separated 2.24 1 1–8
by 6 Months of Self-study)
Funds for DBT Training (e.g., 2-Day DBT Workshops) 3.06 2 1–9
Videos on Using DBT with Veterans (e.g., DBT Groups, Individual Sessions) 3.83 3 1–8
DBTMonthly Consultation Calls for Clinicians in VHA 5.10 4 1–10
Mentoring Program for Clinicians Using DBT in VHA 5.86 5 1–11
DBTListserv for Clinicians in VHA 6.0 5 2–12
Software to Support Measurement-based Care and Outcomes Integration into the 6.84 7, 8 1–10
Electronic Health Record (e.g., Mental Health Test Assistant)
Mobile Apps for Clients 7.87 9 1–11
Templates in the Electronic Health Record (e.g., Computerized Patient Record System) 7.18 10 1–11
Mobile Apps for Therapists 9.0 10 4–12
Sites completing the survey were asked to rank order a list of 10 desired resources and were given two fill-in-the-blank spaces to enter additional desired
resources. Mean ranking indicates the mean ranking for each resource. The modal ranking indicates the modal ranking for each resource out of 12. The
range indicates the range of all rankings for each resource. Information about text entered in the fill-in-the-blank resources is found in the text.
(d) consultation/supervision (n = 2), (e) release time (n = 1), study may indicate otherwise. In this study, low-intensity
and (f) VHA policy change (n = 1). training of self-study with DBT books may be at an accept-
able level of learning for clinicians “initiating” DBT in VHA
DISCUSSION settings. Nonetheless, results of the training needs assessment
The aims of this article were to identify the history of train- reveal that sites would like additional DBT training, specifi-
ing and training needs for sites implementing DBT in VHA. cally training at higher intensity levels (e.g., intensive train-
While DBT intensive training is considered the gold stan- ing) offered within VHA or in the community. This finding is
dard of training, only one-third of sites reported having any consistent with a previous national survey of clinicians in
staff with a history of this high-intensity training. In terms of VHA, which indicated a desire for training in DBT, among
17
workshop attendance, the most frequently endorsed workshop other therapies. Given what is known about training in EBPs
training was 1- or 2-day workshops, with about three-fourths in general, additional training such as intensive training and
of sites reported having any staff attend this medium-intensity consultation is likely needed for clinicians to become adher-
training. The most frequently endorsed type of low-intensity ent to DBT (as opposed to initiating a DBT program).
training was reading of DBT books. With regard to resources, the most frequently endorsed
While empirical DBT training literature suggests that technology resource was VHA’s internal DBT resource Web
reading manuals and attending brief workshops may not be site developed to create a virtual community of practice. This
13 Web site brings together clinicians and sites engaged in DBT
sufficient for changing provider behavior, results from this
750 MILITARY MEDICINE, Vol. 181, August 2016
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