Therapist Adherence to Dialectical Behavior Therapy in Routine Practice: Common Challenges and Recommendations for Improvement

Delivering Dialectical Behavior Therapy (DBT) with adherence to the manual is a critical aspect of quality assurance and leads to better outcomes for clients. However, DBT is a challenging treatment to deliver adherently as it requires therapists to learn many strategies and to know when and how to apply them effectively. To date, little is known about the degree to which therapists in routine care deliver DBT adherently or what adherence challenges may be most common in these settings. This paper presents data from two studies in which the DBT Adherence Coding Scale (Linehan, M. M., & Korslund, K. E. (2003). Dialectical behavior therapy adherence coding scale manual. University of Washington.) was used to evaluate 158 DBT individual therapy sessions delivered by 63 therapists to 78 clients in routine practice (non-academic or research) settings. Nearly all therapists (98.4%) had read the DBT manual and attended DBT workshops (M = 17.9 days). Across studies, therapists delivered DBT individual therapy slightly below adherence on average (M = 3.96, SD = 0.18; cut-off for adherence = 4.00). Overall, 54.4% of sessions were adherent and 45.6% of sessions were non-adherent. On average, therapists exhibited highest adherence for acceptance-oriented strategies, moderate adherence for structural strategies, and lowest adherence for change-oriented and dialectical strategies. Informed by these results, we provide recommendations for how to improve adherence for the strategies most frequently delivered non-adherently as well as how to increase use of underutilized strategies.