Phase 1—Qualitative Interviews
Five main themes were identified from the analysis process which encompassed challenges at different points of the implementation process and advice for future DBT teams: ‘team formation’, ‘implementation preparation’, ‘client recruitment’, ‘service challenges’, and ‘team leader role’.
Theme 1—Team formation
The first theme relates to team member selection and team size. Of the eight teams who trained with the project, seven teams self-selected to attend Intensive Training. Team member selection for the remaining team was primarily decided upon by management. Participants discussed the importance of considering team size and associated advantages/disadvantages. At the time of DBT training for this cohort of teams (2013), a minimum of four therapists were required to establish a new DBT team while the maximum number was ten. Challenges identified with having a larger team included time pressure in the weekly team consultation and an uneven distribution of work within the team:
“There is this sense that if you are a part of a big team, you know, the bystander effect—it’s somebody else’s responsibility to do that”.
Team dynamics was sometimes a challenge in larger teams. While participants from smaller teams reported strong team cohesion, there was also the challenge of having the required resources available to offer all modes of treatment with a smaller number of therapists.
Theme 2—Implementation Preparation
The second theme highlighted the importance of various tasks completed by the teams in preparation for the implementation of DBT in their service. A significant amount of groundwork was completed prior to implementation with six participants reporting that they delivered a presentation on DBT to management, consultant psychiatrists and their local multi-disciplinary teams. The presentations typically provided general information on the DBT programme, as well as specific information about the referral process and eligibility criteria. Participants felt that the presentation provided the DBT team with the opportunity to "[sell] the programme both at management and at grass roots level”. The presentation also facilitated open discussions with other health professionals, in particular with Psychiatrists, so they “knew who we were, what we did, and who was appropriate and who wasn’t appropriate, that was critical”.
The opportunity to link with and get advice from an existing team was also identified as useful when preparing for DBT implementation. Of the eight participants, three reported having an opportunity to do this, while another two participants recommended this for future teams in their preparation for implementation. The teams that had an opportunity to meet with a pre-existing team found it useful in terms of identifying potential barriers to implementation and access to resources:
“I found that really helpful…they were able to kind of go through any teething problems they had, any difficulties, and then by looking at the difficulties that they had encountered I suppose we were able to prevent ourselves having similar difficulties and we were able to see what worked for them that could maybe work for us”.
Theme 3—Client Selection
The third theme related to the selection of suitable clients for the DBT programme. Seven participants identified challenges including client commitment issues, the duration of the pre-treatment phase and rushed recruitment. The latter was a particular issue for some participants given the requirement that their DBT programme have commenced before Intensive Training Part 2 took place:
“we did our part one training and then it was kind of said to us you know you need to have this programme up and running…..by the time you do part two”.
Participants recommended giving more time for screening and pre-treatment (more than 4 weeks) in order to determine suitability of clients and ensure commitment:
“I suppose it’s really starting the referral process well in advance of the programme, em I think realistically it may take like 2 or 2 and half months to identify someone…I think be willing to let the client go during the pre-treatment stage, if you’re too invested in actually getting the client on for the wrong reasons, because nobody else is coming on, that really throws up a lot of problems later on in the programme.”
Theme 4—Service Level Challenges
All eight participants identified various challenges to DBT implementation in their service including issues around referral eligibility criteria, phone coaching and lack of back-fill for existing workload. With regard to referral criteria, most of the adult DBT teams encountered issues with some initial multidisciplinary team reticence in the use of borderline personality disorder or emotionally unstable personality disorder as a diagnostic label:
“I think the consultants were quite reluctant to put, give the diagnosis of personality disorder to clients and I think that kind of came up initially at the start and the referrals were quite slow…”
While the issue of diagnostic labels emerged as a challenge for participants working in AMHS, this was not the case for participants working in child/adolescent services as diagnostic labels for BPD are not typically utilised in CAMHS in Ireland.
Issues with phone coaching were identified in six teams with participants reporting therapist reluctance to provide out of hours phone coaching, no time-off-in-lieu given for out of hours phone cover, lack of management support for phone coaching, and an issue regarding clinical responsibility for DBT clients outside of core work hours. In considering these challenges, participants noted that individual therapists on their teams set personal limits with regard to the provision of phone coaching:
“we couldn’t offer it uniformly as a service, so some people did, as an individual negotiation between them and their client, but as a service, we offer nine to five during working days, typically Monday to Friday.”
Five participants felt that balancing the demands of DBT with the other aspects of their clinical work was difficult. Although teams had received support to commit 1.5 days per week for the provision of DBT at the training application stage, the reality was that many therapists still had to manage their pre-existing workload in addition to the allocated time for DBT.
“Well you see that’s the thing it’s not really a day and a half if you’re actually still doing everything else with it…you know we were sticking it in our diaries but then you’re squashing everything into the rest of the time that you usually would have a whole week to do.”
Other challenges to implementation included: lack of administrative support such as preparing and developing materials (n = 5); staff being pulled from weekly consultation (n = 4); logistical or practical challenges (e.g. obtaining room space for treatment delivery; n = 4); and resistance from staff outside of the DBT team given the time commitment required by DBT trained staff to develop and implement the programme (n = 3).
Theme 5—Team Leader Role
The fifth theme referred to the role of the team leader and the corresponding responsibility and commitment. Participants noted that there was additional pressure and stress accompanying the role of team leader; five participants reported that their DBT work required more than the allocated 1.5 days. Half of the participants (n = 4) also highlighted that the DBT team leader needs to have the ability to manage team dynamics and conflict within the team:
“…it was about trying to manage those different difficult dynamics coming up, and I think being aware of different, kind of, interpersonal kind of conflicts and how to manage them is something you need to be able to do.”
Strong interpersonal and communication skills, organisation and delegation skills, and the ability to keep the team motivated were other important qualities identified for success in the team leader role. In addition, four participants stated that a team leader needs to look beyond the everyday work of DBT and look to the future in terms of planning logistics and governance:
“I also think keeping an eye on the bigger picture all the time, like I feel I’m constantly aware of a step ahead of what’s happening.”
Two participants also recommended having additional support for team leaders such as individual supervision or a team leader forum to help guide them on challenges associated with their role.
Phase 2 - Therapist Surveys
The findings from phase one informed the content of the surveys distributed to the therapists in phase two of the study. Participants (n = 74) completed a survey which comprised several aspects of implementation including participants’ experience of the coordinated implementation approach, impact of expert supervision, facilitators and barriers encountered, and impact of DBT Foundational Training on their service.
Experience of the coordinated implementation
Participants were first asked about their experience of participating in a coordinated implementation of DBT. Almost half of the sample (46%; n = 34) felt additional information/assistance could have been provided by the NDBTPI coordinating team to help with the implementation of DBT in their area. The most common suggestions included increased liaison from the DBT coordinating team with health service senior management (n = 6), the organisation of days where DBT teams could meet and share ideas (n = 6), and the provision of more I. T. resources and materials (n = 5).
Seventy-six percent of participants (n = 56) indicated that additional training would be helpful for therapists/teams to assist with long-term sustainability of DBT in their service. Training suggestions were put forward by 37 participants with the most common occurring proposals including booster and refresher training, group skills workshops or training in allied DBT informed programmes such as Family Connections. Participants also identified that liaising and meeting with other DBT teams to share/discuss difficulties and experiences (n = 18), ongoing supervision (n = 17) and the need to train new staff (n = 15) to combat staff attrition and turnover would be helpful for long-term sustainability.
All participants rated supervision to be either ‘very helpful’ or ‘somewhat helpful’ in their practice regarding the programme elements of DBT (skills group, individual therapy, phone coaching, team consultation). In particular, participants found supervision helpful with regard to advice and adherence to the programme. In terms of structuring the environment or service related issues, 78% of participants found supervision either ‘very helpful’ or ‘somewhat helpful’ for their DBT practice. Given that supervisors were based in jurisdictions outside of the Irish public health system, some participants found advice relating to local service issues less helpful when compared to programme elements advice. Participants highlighted issues with I. T., noting that many local services did not support video calls. Therefore, teams were limited to using telephone conference calls for communicating with supervisors. In addition, systemic I. T. difficulties meant there were issues when trying to send and share therapy recordings with supervisors.
In terms of sufficiency of supervision resources made available, 68% of participants found the allocation by the NDBTPI to each team to be sufficient, 23% of participants did not, and 9% of participants did not specify. When asked to provide further detail, three main themes were identified with participants preferring a more face-to-face supervision interaction, a requirement for more regular supervision, and the importance of sustaining supervision in the future.
A total of 78% of participants reported that additional support could be provided regarding supervision opportunities to help with long-term sustainability of DBT in their service. When asked to elaborate, participants identified ongoing supervision and training local supervisors as two main areas that would be helpful.
Facilitators and barriers in implementing DBT
Having personally invested, highly dedicated team members was identified as the main facilitating factor for the implementation of DBT programmes (n = 26). Over a quarter of participants (n = 18) noted that support from local management and the wider community team was the most facilitating factor for DBT implementation. Other identified facilitators included having an effective team leader, supervision and training (see table 2).
Perceived barriers to the implementation of the DBT programme included lack of management support (n = 28) and logistical challenges including lack of space, geographical factors impacting client access to DBT and a lack of resources for programme delivery (n = 15). Time commitment and staffing resources were further implementation barriers identified (see table 2).
DBT Foundational Training
DBT Foundational Training is a five-day training for clinicians who wish to join an existing Intensively Trained DBT Team. This training was offered to DBT teams who had trained via the NDBTPI on an annual basis. When participants were asked to qualitatively describe the impact of additional therapists joining their team, four main themes emerged: 1. increased capacity to deliver DBT services, 2. new perspectives, 3. maintaining the team, and 4. the challenge of new team dynamics. Participants were then asked what additional supports, if any, would help to facilitate the integration of new team members in their DBT team. Participants highlighted the importance of supervision and additional support in the initial stages, in particular guidance and direction on how to support and train up new team members, and support with navigating team dynamics in the context of changing membership.