The main aims of this study were to analyze: 1) differences in therapist burnout, concerns and self-efficacy in treating suicide and confidence to apply DBT as well as in the level of implementation of DBT treatment modes and the number of patients treated before (part 1) and after (part 2) a DBT-IT; 2) the relationships between therapist attitudes regarding suicide risk treatment and the implementation of DBT treatment modes as well as barriers to implement DBT in clinical practice between part 1 and 2 of the DBT-IT.
Regarding the first aim, the results of the study showed a statistically significant increase in professionals’ confidence to apply DBT and in self-efficacy in assessing and managing suicide risk between part 1 and 2 of the DBT-IT. These findings also correspond with a study with young professionals in Argentina, in which, after a brief training in Safety Planning Intervention, a significant increase in their perception of self-efficacy in the management of suicide risk was found and even maintained two months after training (36). These results are relevant because low perceived self-efficacy is precisely one of the main barriers found among professionals who prefer not to work with clients with suicide risk (9,10). Therefore, DBT-IT could help increase therapists’ self-efficacy and thus increase the likelihood that more clients might be treated.
Furthermore, a statistically significant reduction in professionals' concerns about their lack of competence and training to address suicidal behavior was also found. The lack of qualified training in working with suicide risk represents another major barrier to work with this population. In general, studies noted a widespread lack of access to and quality of specialized training to address suicide risk (4, 5, 12, 13). However, DBT-IT appears to achieve an initial significant reduction in professionals' concerns about their lack of competence and training for treating suicide, which suggests that including DBT-IT training as part of the accredited programs might be a good solution to reduce professionals’ worries regarding training.
Concerning the implementation of DBT treatment modes, results indicate high rates of implementation of DBT by professionals participating in the DBT-IT. Specifically, statistically significant increases in the implementation of the DBT treatment modes (sum of all modes) and in the number of hours devoted to the consultation team among professionals and the number of DBT team members between part 1 and part 2 were found. In addition to the training content, as suggested by Flynn et al. (29), the possibility of attending supervisions/mentoring the study participants during the process of implementation between part 1 and 2 could be a facilitator for the successful implementation of DBT.
When analyzing implementation of each mode, the most frequently implemented mode was individual therapy (89%), followed by group skills training (87.7%) and consultation meetings (71,2%). The least implemented mode was phone coaching (69.9%), which, as discussed by Flynn et al. (29), may have to do with the requirement for extended patient care time outside working hours. The percentage of implementation of the phone coaching mode after training was slightly higher than the one found by Landes et al. (24) (61.9%). Interestingly, results of the study cited indicate that the three barriers rated as unable to be overcome by the highest percentage of centers that had received DBT training were related to the implementation of telephone coaching. Therefore, including strategies to improve implementation of phone coaching mode or other ways to allow the generalization of patient skills might be an important target during DBT-IT.
Nonetheless, findings of the study also showed a significant increase in the implementation of each of the treatment modes, except for individual therapy, between part 1 and 2. This result could be related to the fact that individual therapy is the least demanding mode in terms of human resources and it was already used largely by the professionals before the intensive training. Additionally, higher implementation of the DBT group skills training mode was found for Latin American participants. A possible interpretation is that most professionals from Latin America were working on private practice so more opportunities to carry out group skills training may be available.
General findings of this study show similar rates (above 75–87% across all modes) of implementation of DBT treatment modes to studies conducted with professionals from the US and UK after DBT-IT (21,22,24), being individual therapy and group skills training the most implemented modes and phone coaching and consultation team meetings the least implemented. These results contribute to the existing evidence on the effectiveness of DBT-IT to increase implementation of DBT, in this case by Spanish-speaking professionals.
Exploring therapist variables that could influence the implementation of DBT treatment modes, findings indicated a greater general number of implementation barriers detected among professionals who had not implemented phone coaching mode compared to those who had applied it. On the other hand, a higher number of barriers related to “team problems” (e.g. “team members left”, “no real commitment to learn and implement DBT”, “lack of reinforcers in team meetings”) among professionals who did not implement the consultation team meeting mode. Except for implementation barriers, no further differences regarding therapist characteristics were found in the rest of the study variables regarding treatment modes implementation. In this regard, other studies (24, 29) have found similar barriers to implementing telephone coaching (having to work outside working hours or not having funding for this work) and standard DBT (time commitment and balance of other functions, and staff resources such as attrition).
To our knowledge, no previous studies had related barriers to the level of implementation of each specific treatment modality. The results of this study illustrate the relationship between professional-reported barriers and implementation of DBT treatment modes. Thus, if successful implementation of the telephone coaching and consultation team modes are to be achieved, it will be necessary to address important barriers such as team commitment and other organizational barriers. Findings of this study may also allow to evaluate the suitability of different implementation strategies before carrying them out in a specific system and suggest that training programs should include strategies to overcome barriers to implementation. These results are also in line with the existing knowledge of the selection tasks prior to the training such as the recommendations published by Swales (36) where important aspects to ensure a successful implementation of DBT are pointed out, such as the selection of staff capable of delivering an effective treatment, the reallocation of clinician time and the strategies for achieving team and organizational commitment.
Moreover, correlation analyses showed significant positive relationships between confidence to apply DBT and self-efficacy to work with patients with suicidal behavior, and between confidence to apply DBT and the implementation of all modes of treatment. These findings correspond to some studies in which lower training needs, greater previous DBT experience (12,21) and therapist skills were identified as facilitators for the implementation of DBT (21).
Significant positive correlations were also found between the total implementation barriers and burnout. Specifically, burnout was associated with higher administrative and structural barriers and the latter with lower DBT implementation. These results are similar to previous studies such as the one by Carmel et al. (26) in which burnout appears to be related to many of the barriers that impede the implementation of new evidence-based psychological treatments. Therefore, therapists’ burnout may be another important variable to decrease in order to improve the implementation of DBT.
Finally, regarding reach after DBT-IT, DBT was implemented to a lesser extent by those professionals with the highest patient load. In this study, “too many patients” was also one of the most reported barriers. These findings could be related to all the other findings already cited, such as burnout, barriers related to time commitment and balance of other practitioner roles and lack of staff resources. Therefore, it would be interesting to evaluate these factors as potential predictors of implementation of DBT.
Limitations and future directions
Although promising, the findings of this study must be considered in light of their limitations. First, despite the research team's efforts to increase participants response rates, completion rate for the survey from part 2 was lower than expected. This could lead to think that therapists who did not respond had a more negative opinion or would not have been able to implement DBT to the same extent. Another interpretation may be that, during part 2, a more intensive and active participation was demanded from the professionals, which might reduce the energy required to complete the survey. The generalizability of these data may also be affected by the existence of an unequal distribution in the variable "country", with a greater number of participants from Latin America than from Spain. Another important limitation is that no follow-up was conducted after training and no group comparison was included in this study. Future longitudinal research with bigger samples and experimental designs are needed to confirm these results. On the other hand, it is also hoped further research with Spanish-speaking professionals will be carried out. Finally, exploring predictors of implementation of DBT, specially in modes less frequently implemented, such as phone coaching and consultation team, may be needed.