: Implementation of Dialectical Behavior Therapy in a Residential Setting: Dissemination and Evaluation

Background: The use of evidence-based practices (EBPs) in social services is gaining momentum as the standard of care. However, many residential settings employ individuals without advanced formal education and training as Direct Service Professionals (DSPs). Typically, these lower-level workers provide the majority of daily care to the more challenged clients, often leading to poorer quality of client care, staff burnout, and high staff turnover rates. The use of EBPs has the potential to mitigate poor client and staff outcomes in such settings when appropriate training can support fidelity to the intervention model.

A promising intervention is Dialectical Behavior Therapy (DBT), an EBP that reduces suicidality, psychiatric hospitalization, and substance use, while improving treatment retention. However, training is required to successfully implement DBT as a therapeutic intervention, and maintenance relies on reinforcement by the program milieu in which it is delivered. Provision of training on EBPs, such as DBT, is important for both quality of client care and workforce development.

This paper presents a DBT training delivery model and a process evaluation designed to provide feedback on the implementation of the model.

Objectives: The DBT training initiative sought to create a “DBT-informed program culture” through staff training and program-level consultation in four phases. The evaluation designed sought to 1) assess individual staff knowledge and retention following DBT training, 2) evaluate the impact of organizational culture, and 3) assess fidelity of DBT service delivery.

Methods: Five residential programs of Resources for Human Development serving individuals with severe mental illness, chemical dependency, and/or forensic involvement in the greater Philadelphia area volunteered to participate in the training initiative from 2013-2015.

Staff knowledge retention was measured through administration of an 18 question assessment of principles and skills associated with the four DBT modules: emotional regulation, distress tolerance, interpersonal skills, and mindfulness at 3 months post-training. Organizational culture was assessed using the Organizational Readiness for Change Part D (ORC-D4) (TCU Institute of Behavioral Research, 2009) measure at conclusion of training Phase 2. Fidelity of DBT service implementation was measured during Phase 3 and 3 months post-completion using the DBT Skills Group Observation tool (2009, DBT Center of Michigan) and client completion of the Session Rating Scales (SRS v3.0; Miller & Duncan, 2000).

Results: Thirty-four staff completed a knowledge retention quiz. Staff were predominantly female (76.5%), African-American (79.4%), and with a mean age of 34.2 (SD=8.4). Most had completed some college (58.8%), with a total of 79.4% of the sample attaining less than a four year degree at the time of training. Mean score on the 3 month post-training knowledge assessment was 83.3% with 61.8% of the sample scoring 83.3% or higher. 

Conclusions: Results of the first phase of the training initiative suggest that it is feasible to train DSPs in the principles of DBT in a cost-effective manner, but attention is required to uneven knowledge retention. Future directions should include examination of the relationship of knowledge retention to measures of fidelity and organizational culture.