New year, new blog!!! Starting in 2024, I will be introducing pertinent information in the field of DBT through semi-regular blog posts. For my first post, I wanted to focus on something near and dear to my heart, and one of the most heavily discussed topics in the DBT world: The Importance of Adherence and Fidelity in DBT. Welcome, friends to my new blog. Please feel free to reach out with questions. I am always happy to discuss all things DBT!
Get in contact with me, HERE.
As a DBT-Linehan Board of Certification, Certified Clinician™, I often emphasize the importance of adherence and fidelity in comprehensive Dialectical Behavior Therapy (DBT). But what do these terms really mean in the context of the treatment model created by Marsha Linehan?
What are Adherence and Fidelity in DBT?
Adherence in DBT refers to the accuracy and integrity with which the treatment is delivered in a single session, aligning with the principles and protocols established by Linehan in her original DBT manual (Harned, et al, 2023). It’s about ensuring that DBT is not just implemented but implemented correctly. This encompasses the core strategies, skills training, and the balance of acceptance and change techniques that are foundational to DBT.
According to an article published in the Journal of Consulting and Clinical Psychology by Dr. Melanie Harned, et al in 2022, therapist adherence was strongly correlated to fewer subsequent suicide attempts and decreased dropout.
Fidelity, on the other hand, relates to whether a DBT program offers all four modes of treatment that are part of the evidence-based treatment designed by Dr. Linehan (“The DBT Adherence and Fidelity Project”, n.d.). In comprehensive DBT, this means that all clients attend weekly skills training classes and structured weekly individual therapy sessions using a diary card, have access to phone coaching, and receive treatment from a provider who is on a weekly consultation team. Without these four modes present, it is not truly DBT. Research indicates that programs with greater fidelity are predictive of better overall outcomes (Fox, et al, 2020).
The essence of comprehensive DBT lies in its structure, which is designed to address complex and severe mental health issues, particularly Borderline Personality Disorder. Each component of DBT plays an important role in the treatment process and missing any aspect can compromise the effectiveness of therapy.
The Impact of Adherence in DBT
Adherence in the context of DBT refers to the faithful and accurate implementation of the treatment as designed by Dr. Linehan (“The DBT Adherence and Fidelity Project”, n.d.). This means delivering DBT with all its essential components and methodologies intact. Adherence ensures that the therapy remains true to its evidence-based roots, incorporating the right balance of acceptance, change strategies, and dialectical philosophy. DBT therapists strive for adherence in every single session they conduct.
When therapists maintain adherence to DBT, they are more likely to see the results that numerous research studies have documented. High adherence to DBT protocols has been associated with:
- Decreased suicidal ideation and related behaviors (Linehan et al, 1991, Linehan et al, 2006, Koons et al., 2001, Pistorello et al., 2012)
- Decreased frequency and severity of self-harming behaviors (Linehan et al, 1991, Linehan et al, 2006, Mehlum et al, 2014, Priebe et al., 2012, 6. Verheul et al., 2003)
- Decreased substance use (Linehan et al, 1999)
- Decreased depression (Goldstein, et al, 2015)
- Decreased hospitalization (Linehan et al, 1991, Linehan et al, 2006)
- Decreased hopelessness (Koons et al, 2001)
- Decreased anxiety (Clarkin et al, 2007)
The Importance of Fidelity for Therapists and Clients
Fidelity, on the other hand, involves consistently applying DBT’s comprehensive strategies across all facets of the treatment. This includes:
- Skills Training: Teaching and reinforcing DBT skills in both group and individual settings.
- Individual Therapy: Tailoring therapy to the specific needs of the client, addressing their most life-threatening, therapy-interfering, and quality-of-life-interfering behaviors.
- Phone Coaching: Providing in-the-moment coaching to clients, helping them apply DBT skills in real-life situations.
- Consultation Teams: Engaging in regular therapist consultation, which supports therapists in their work and helps prevent burnout.
For therapists, fidelity to these components ensures that they provide the comprehensive, multifaceted approach that DBT demands. It helps maintain a high standard of care and supports continuous learning and development.
For clients, experiencing a DBT program that has fidelity to its core principles means they receive a well-rounded, effective treatment. It ensures that they are not just learning skills but are being supported in applying these skills to their everyday lives, leading to more meaningful and lasting change.
Fidelity and Adherence are not just administrative checkboxes in the practice of DBT. They are essential elements that guarantee the effectiveness of the treatment. They ensure that therapists provide DBT in a way that is true to its research-backed origins and that clients receive the full spectrum of care that DBT offers. As a therapist dedicated to this approach, I can attest to the profound difference it makes when DBT is delivered with the commitment to these principles.
The Risks of Compromised Adherence in DBT
When adherence to the DBT model is compromised, the integrity and effectiveness of the therapy are at risk. DBT is a complex treatment designed to address severe mental health issues, and any deviation from its structured model can lead to suboptimal outcomes. Some of the risks include:
- Ineffectiveness: Without strict adherence to DBT protocols, the therapy may fail to produce the desired outcomes, such as reducing self-harm behaviors or improving emotional regulation.
- Misinterpretation: DBT requires a delicate balance of acceptance and change strategies. Misapplying these principles can lead to confusion and frustration for clients, potentially exacerbating their symptoms.
The Consequences of Inadequate Fidelity
Similarly, inadequate fidelity to the comprehensive nature of DBT can have significant consequences:
- Incomplete Skill Development: If clients do not receive the full range of DBT skills training, they may lack critical tools for managing their emotions and behaviors.
- Lack of Support and Decreased Safety: DBT’s effectiveness is partly due to its support system, including phone coaching and consultation teams. Without these, clients may feel unsupported in challenging times and their risk for suicidal or self-harming behaviors may not resolve.
- Therapist Burnout: Therapists not engaging in regular consultation teams, as per DBT’s model, may experience burnout, affecting their ability to provide effective treatment.
Upholding the Standards of DBT
The potential negative impacts of straying from DBT’s adherence and fidelity underscore the responsibility of therapists to uphold the standards of this treatment. It’s not just about following a set of guidelines; it’s about ensuring that clients receive the best possible care, tailored to their unique needs and challenges.
As a practitioner, I am committed to maintaining these high standards in my practice, recognizing that the journey through DBT is not just about managing symptoms but about fundamentally transforming lives, and supporting our clients in building a life that they believe to be truly worth living!!!
For more information on DBT Adherence and Fidelity and the measures used to assess them, visit the following website: https://www.dbtadherence.com/project
Works Cited
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American journal of psychiatry, 164(6), 922-928.
DBT Adherence and Fidelity: The DBT Adherence and Fidelity Project, (n.d). Retrieved from https://www.dbtadherence.com/project#references9.
Fox, A. M., Miksicek, D., Veele, S. & Rogers, B. (2020). An evaluation of dialectical behavior therapy for juveniles in secure residential facilities. Journal of Offender Rehabilitation, 59, 478-502. https://doi.org/10.1080/10509674.2020.1808557
Goldstein, T. R., Fersch-Podrat, R. K., Rivera, M., Axelson, D. A., Merranko, J., Yu, H., … & Birmaher, B. (2015). Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial. Journal of child and adolescent psychopharmacology, 25(2), 140-149.
Harned, M.S., Schmidt, S.C., Korslund, K.E., Gaglia, A. (2023). Therapist adherence to dialectical behavior therapy in routine practice: Common Challenges and Recommendations for improvement. Journal on Contemporary Psychotherapy. https://link.springer.com/epdf/10.1007/s10879-023-09601-x?sharing_token=TTCSh2AX-mcqvVkU-ck-E_e4RwlQNchNByi7wbcMAY7KTRqSCH9n8pbMxJZ8ShWkRQTtoJ-PVdF7ehuZjHsx202z3ZBmLVgofDKfeAWI72-3DCzWMPaqBz2jpUaylA47nDhYkkleEnN08WFvKY5MiGrVAUz8OnrEXKj5cbdi6II=
Harned, M. S., Gallop, R. J., Schmidt, S. C., & Korslund, K. E. (2022). The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy. Journal of Consulting and Clinical Psychology, 90(3), 272–281. https://doi.org/10.1037/ccp0000714
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., … & Bastian, L. A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior therapy, 32(2), 371-390.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of general psychiatry, 48(12), 1060-1064.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., … & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry, 63(7), 757-766.
Linehan, M. M., Schmidt III, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug‐dependence. The American journal on addictions, 8(4), 279-292.
Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., … & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial.
Pistorello, J., Fruzzetti, A. E., MacLane, C., Gallop, R., & Iverson, K. M. (2012). Dialectical behavior therapy (DBT) applied to college students: a randomized clinical trial. Journal of consulting and clinical psychology, 80(6), 982.
Priebe, S., Bhatti, N., Barnicot, K., Bremner, S., Gaglia, A., Katsakou, C., … & Zinkler, M. (2012). Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial. Psychotherapy and psychosomatics, 81(6), 356-365.
Verheul, R., Van Den Bosch, L. M., Koeter, M. W., De Ridder, M. A., Stijnen, T., & Van Den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. The British journal of psychiatry, 182(2), 135-140.