Dialectical Behavior Therapy (DBT), an evidence-based treatment developed for individuals meeting criteria for Borderline Personality Disorder, is one of the primary interventions delivered at Westchester Jewish Community Services (WJCS). In an effort to supplement existing training and practice in DBT and provide peer support during the pandemic, we developed a remote DBT Peer Consultation Group. The 30-week group provided a weekly opportunity to practice DBT strategies in an informal, supportive setting. Given increased needs in a post-pandemic world for remote learning and practice, the opportunity to explore the feasibility of virtual peer consultation groups was especially valuable.
Our research study about the DBT Peer Consultation Group aimed to determine the effect of remote peer consultation on clinician perceptions of self-efficacy in delivering DBT-informed treatment, as well as self-assessment of adherence to the DBT model. The group focused on various topics essential for comprehension of, and adherence to, a DBT treatment model. Specific interventions for augmenting participants’ knowledge and confidence included didactics/discussion of readings, case discussion, and role-playing. The study measured changes in clinicians’ perceptions of self-efficacy related to delivering DBT-informed treatment as a function of involvement in peer consultation group, clinicians’ attitudes toward incorporating DBT into their future practices at the conclusion of peer consultation group, and the feasibility of peer consultation via virtual consultation sessions.
Measurement tools included a pre-group survey of group participants, as well as a 6-month and post-group follow-up. We also administered a weekly survey measuring usage of DBT strategies in clinical work. Clinician confidence was measured by such questions as: “I am confident in my ability to work with clients who experience suicidal behaviors” and “I am confident in my ability to effectively use DBT chain analysis in individual therapy.” There were 13 confidence questions in total, and the responses were measured according to a Likert scale.
Starting at Week 10, clinicians were asked each week to report if they had used various DBT interventions covered in group. Several strategies were coded as “key” strategies because they were newer skills for participants: use of a DBT commitment strategy, creation of a new target hierarchy, reference to a previously created target hierarchy, utilization of a DBT diary card, or completion of a DBT chain analysis.
The research sample included 10 clinicians at WJCS, six of whom were masters-level clinicians, and four of whom were psychology doctoral students. Six had prior DBT experience (defined by attending at least one intensive DBT training, receiving training in an externship or internship setting, and/or providing significant DBT-informed individual treatment), and four did not. On average, participants carried a weekly caseload of four DBT-informed cases (range 2-8).
On average, each participant in the group used 3.3 DBT strategies per week attended. Across the first 3 sessions after measuring, 72% of participants reported using key strategies that week. Across the last 3 sessions, 93% reported using key strategies each of those 3 weeks. There was a trend toward a correlation between increased number of DBT clients and more frequent use of DBT strategies. There was no difference in frequency of DBT strategy usage between participants with prior DBT experience and participants without prior DBT experience, which could point to willingness of participants without prior experience to try new strategies for the first time.
We specifically examined the use of chain analysis because it is considered one of the more difficult DBT strategies to implement, and something many group participants were nervous about implementing. Exactly half of the final total sample (n = 8) did chains more than 50% of weeks that they attended group. By Week 25 and each week after that, every attendee (100%) reported doing a chain every week. On average, participants with no previous DBT training completed chains during the weeks of 57% of the peer group sessions they attended. In contrast, participants with previous DBT training completed chains during the weeks of 49% of the peer group sessions they attended. Again, this could point to willingness of participants without prior experience to try new strategies for the first time.
Attitudes toward DBT demonstrated a positive trend from pre-group to post-group. At pre-group, 25% of participants somewhat agreed that they would like to incorporate DBT into their future practice, while 50% agreed and 25% very much agreed. At post-group, 42.9% agreed that they would like to incorporate DBT into their future practice, and 57.1% very much agreed. At pre-group, 20% of participants somewhat agreed that DBT can be adapted to fit the needs of a community mental health setting, while 60% agreed and 20% very much agreed. At post-group, that trend was reversed; 60% agreed that DBT can be adapted to fit the needs of a community mental health setting, while 40% very much agreed.
At baseline, there was a significant difference in DBT confidence scores between clinicians who did and did not have previous experience t (8) = -2.535, p < .035. At pre-group, clinicians with prior DBT experience scored an average confidence value of 39 (out of a total possible confidence value of 65), and clinicians without prior DBT experience scored an average confidence value of 30. Overall, clinician confidence in delivering DBT increased an average of 11 points from pre-group to last recorded measure (6-month or post-group follow-up), t (7) = -2.808, p = .026.
Qualitative themes, as measured by open-ended questions on the follow-up surveys, indicated that post-intervention, participants:
- Were more comfortable adapting DBT in community mental health (i.e., “The concepts are universal and the skills are adaptable”)
- Found it less overwhelming to deliver DBT-informed treatment with more training and practice (i.e., “I feel more confident about delivering DBT informed treatment than I did prior to the group”)
- Had plans to incorporate DBT into their future practices (i.e., “DBT is now one of the main therapies that I identify using as a therapist, which it was not prior to this group”)
- Saw value in remote consultation groups (i.e., “I feel that they are at least as effective as in-person, and personally I feel more comfortable speaking up in an online setting than I usually do in person; The experiment this year has worked and it relieves me of having to travel”)
- Found the peer group supportive (i.e., “I find it easier to talk candidly in this group because it truly feels like a supportive group of peers without the hierarchy of supervisors, clinic directors etc.; This group was an essential part of my feeling less professionally isolated while working remotely during the pandemic”)
There are several key implications of our research findings. First, the findings point to the value of peer consultation groups in terms of increasing clinician confidence and competence. In addition to increased confidence scores and a reported increase in usage of key DBT strategies throughout the course of the group, participants appeared to value its nature as a peer-, rather than supervisor-led group. Participants also noted that the remote group provided greater opportunity for cross-clinic relationships, and the ability to connect with and get support from other therapists doing similar work. These findings point to the value of remote, peer-led consultation groups in terms of skill and confidence-building for clinicians, as well as the value of offering such groups remotely, both during and after the COVID-19 pandemic.
Liza Pincus, PhD, and Kelly Daly, PhD, conducted this research as Psychology Fellows at Westchester Jewish Community Services. Elana G. Spira, PhD, is Director of Research at WJCS, one of the largest human service agencies in Westchester County. To learn more about WJCS mental health services, please go to www.wjcs.com/services/mental-health.
