Sara J. Landes, PhD National Center for PTSD, VA Palo Alto Health Care System Matthew S. Ditty, DSW University of Pennsylvania School of Social Policy and Practice
11 RCTs, 7 independent sites 5 controlled trials SAMHSA’s National Registry of Evidence- based Programs and Practices
• Suicidal behavior • Non-suicidal self-injury • Depression • Hopelessness • Anger • Symptoms of eating disorders • Substance dependence • Impulsiveness • General adjustment • Social adjustment • Treatment retention • Positive self esteem
Improve client motivation Improve Enhance client therapist skills capabilities & motivation Structure Assure skill environment generalization
Improve client Individual motivation Therapy Improve Enhance client Therapist therapist skills Group Skills capabilities & motivation Consultation Training Team Structure Assure skill Case Phone environment generalization Management Consultation & Outreach
Self study • 5 days • 5 days • Main content, structure, • Self study presentations • 6 months & elements of DBT • Consultation: barriers to • Homework • Barriers to implementation • Implement program implementation • Others areas as needed • Consultation to teams Part I Part II
What do practice settings require to implement DBT well?
All participants were intensively trained > 1 year ago n = 79 n = 20
22 CFIR “Inner Setting” DBT Implementation Variables Outcomes Program Elements of Organizational Readiness Treatment for Change (ORC) Questionnaire (PETQ) (Communication and Cohesion subscales) 8 questions on modes Team Climate Inventory, Short Version (TCI-14) CFIR-generated questions
% of Respondents Mode Who Implemented it Individual Therapy 96.2 Group Skills Training 98.7 Coaching 87.3 Consult Team 97.5 Individual Skills Training 60.8 DBT Pharmocotherapy 26.6 DBT Case Management 31.7 Support/ Group Process 32.9
0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
It’s still probably the most challenging part in all of this. Barriers: Logistical concerns (time, cost) Don’t know how or why to track
0.9 * 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 * compared to IVs
> Stand-alone programs. Nested within an organization. Moderate significance. * Some qualitative support.
Large team size? Moderate significance. Conflicting qualitative support.
Team Cohesion Strong significance. Clear qualitative support.
Team Communication Strong significance. Clear qualitative support.
Culture/ Climate Strong significance. Clear qualitative support.
Supervision Strong significance. Clear qualitative support.
Higher % of team members with a doctoral degree? Moderate significance. No qualitative support.
Office Space Moderate significance. * Some qualitative support.
Supervision Team Climate Team Cohesion Team Communication All interpersonal constructs.
Structural Implementat characteristi ion cs Outcomes Age, size, Specific makeup, structural DBT Implement Outcomes & etc. elements Descriptions by doing Research age of staff implementa university agency type size modification practice, denial of don’t know don’t know don’t know logistical program turnover tion team affiliation Networks and s practice tracking how what why concerns communicati on Team Mobilization relationships of others communicati connecting to administratio DBT cohesion commitment impact ancillary psychiatry community advocacy on team n community Culture and climate Desire for Competing DBT culture Safe climate effectiveness interests Other culture of BPD benefits of DBT policy collective therapist competence/ buy-in DBT culture goals vision empathy DBT compatibility conflicts energy stress EBP client therapist characterist characterist process ics ics imp. reinforcemen legal alternatives strategies t concerns Readiness for implementat ion Funding, Knowledge Expenses, and Leadership Workload Technology bureaucracy/ funding money overhead workload knowledge technology supervision hierarchy administrati insurance facilities supplies time training books manuals clients therapists taping on behaviors
More technology utilization by clinicians.
What barriers exist in implementing DBT in the VA? Can we support implementation on a larger level with limited resources?
n = 39 7 teams -6 VAMCs -1 Vet Center
No significant change in # of barriers Top barriers however, changed over time
Barrier to Implementation % (n) Conflict between agency policies and DBT philosophy or practice 78% (29) Productivity demands 73% (27) 62% (23) Difficulty meeting with each other/sporadic attendance at consultation meetings No release time provided for learning and implementing a new program 51% (19) Lack of support or direct conflict about program with key administrators 49% (18)
Barrier to Implementation % (n) Productivity demands 71% (30) Patients accustomed to treatment they have had, and are resistant to 52% (22) change No release time provided for learning and implementing a new program 48% (20) Conflict between agency policies and DBT philosophy or practice 45% (19) Lack of individual therapists 38% (16)
Many unaware Unable to access outside of others’ work and duplicating resources (e.g., efforts DBT Wiki site) Lots being done at grass roots level Limited resources available
Practical implementation assistance Online community of practice
Accessed every Materials added Consults work day since from across the requested its launch country Training Discussion requested forum utilized
165 • Average requests per day 1334 • Distinct users 5 VISNs • Locations of top 5 users 3 • Discussion forum posts
56 • Average requests per day 247 • Distinct users 5 VISNs • Locations of top 5 users 3 • Discussion forum posts
1. What to do – First sessions checklist 2. Diary card 3. Note template – Individual 4. Mindfulness exercise – Sound 5. Handout – Chain analysis 6. Mindfulness exercise – Breath 7. Mindfulness exercise – Physical Sensations 8. Handout – Letting go of emotional suffering 9. What to do – Leading mindfulness practice 10. Handout – Managing distress … 34. Measure – DERS scoring file
Handout – DBT summary/notes 1. Diary card 2. Handout – Skills summary 3. Handout – Mindfulness homework 4. Presentation – Running an effective DBT group 5. What to do – First sessions checklist 6. Note template – Skills group 7. Handout – Treatment overview handout 8. Presentation slides – Individual DBT: What to do 9. 10. Mindfulness exercises … 50. Measure – BSL
MST List EBP Coordinator VA Mental Health List Intranet Site National Center Existing DBT for PTSD Intranet Contacts Site Sara’s Email DBT SharePoint Key VA Folks Signature
Social network analysis Survey of DBT across VA Training Veteran crisis line staff in DBT skills Implementation in other settings Residential Trauma Recovery Program Homeless Veterans Rehabilitation Program
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