Making Lemonade out of Lemons: Dialectical Behavior Therapy via Telehealth During a Pandemic

Abstract

The COVID-19 pandemic has created a burden on healthcare systems and increased demand for mental healthcare at a time when in-person services are limited. Many programs offering dialectical behavior therapy (DBT) for complex clients have pivoted to telehealth in order to increase access to critical mental healthcare. There is, however, limited research on the provision of telehealth treatment for clients with complex psychopathology more broadly, or the telehealth implementation of DBT more specifically. The aim of this study was to examine the use of telehealth services and related clinician attitudes and experiences in the context of DBT. We examined the degree of telehealth platform adoption among DBT clinicians, as well as changes in stress and self-care strategies. A supplemental aim was to gather clinicians’ recommendations for providing DBT via telehealth. Participants included N = 99 DBT practitioners (79.8% female; 20.2% male). Qualitative and quantitative methods were used for data analysis. Findings show that telehealth DBT has been widely adopted among DBT clinicians, and that clinicians’ attitudes to telehealth DBT are cautiously optimistic. Participants described three main areas of stress associated with DBT via telehealth provision, as well as lost and novel self-care strategies.

The COVID-19 pandemic has burdened healthcare systems worldwide (Hamid et al., 2020, Miller et al., 2020) while simultaneously exacerbating mental health problems. In Canada and elsewhere, heightened rates of depression, anxiety, and substance use have occurred during the pandemic, compared with previous years (Angus Reid Institute (ARI)., 2020, Centre, 2023, Panchal et al., 2021, Ren et al., 2020). Mental health professionals have increasingly adopted telehealth platforms, using modalities such as telephone or videoconferencing to provide therapy services remotely and meet the increased need for mental health services while limiting the spread of COVID-19 (e.g., Zhou et al., 2020).

Although telehealth has likely maintained or increased access to effective mental health treatment, questions remain regarding the effectiveness and acceptability of remote therapy services for populations with complex mental health concerns. Even prior to the COVID-19 pandemic, telehealth has been increasingly adopted to improve the accessibility of services for patients who otherwise might not have been able to benefit from in-person services (O’Reilly et al., 2007, Vimalananda et al., 2015). Moreover, telehealth services have been found to be efficacious for several mental health concerns, including anxiety (Rees & Maclaine, 2015), depression (Berryhill et al., 2019), and substance use disorders (Lin et al., 2019). There is, however, limited evidence for the use of telehealth with clients with more complex psychopathology, such as those who are suicidal or who have borderline personality disorder (BPD) or related difficulties. Further, clinicians’ attitudes and perceived acceptability and feasibility of telehealth in the context of evidence-based care for complex clients has been relatively unexplored (although see Chapman & Hood, 2020, for a recent review).

adapting dialectical behavior therapy for telehealth

A comprehensive, cognitive behavioral therapy, dialectical behavior therapy (DBT; Linehan, 1993), has garnered a substantial evidence base for the treatment of patients with complex mental health concerns (e.g., DeCou et al., 2019) and has been adapted for telehealth before (Lopez et al., 2020, Zendegui, 2015) and during the COVID-19 pandemic. DBT is based on a biosocial developmental model of complex psychopathology, where transactions of temperamental vulnerabilities (impulsivity and emotion vulnerability) with the social environment shape the development of emotion dysregulation and related difficulties, such as nonsuicidal self-injury, suicidal behavior, and BPD (Crowell et al., 2009, Crowell et al., 2014, Linehan, 1993). Standard DBT involves four core components: individual therapy, group skills training, telephone consultation (often referred to as phone coaching; Chapman, 2019), and a therapist consultation team (Linehan, 1993). As clients with complex mental health concerns may need a comprehensive, evidence-based treatment, particularly during a stressful period such as the pandemic, it is crucial to explore the adoption and adaptation of telehealth DBT services. Moreover, even beyond the pandemic, a portion of mental health services likely will continue to occur via telehealth. Lessons learned from the use of telehealth DBT during the pandemic, therefore, will inform the continued evolution of telehealth-based care for complex clients.

There are some key, potential challenges in providing DBT via telehealth. Clinicians with standard DBT programs, for example, have had to quickly become familiar with telehealth technology and related ethical and logistical considerations, often in the context of treating high-risk clients. For example, a recent review found that only a minority of clinicians had positive views of telehealth for suicidal clients and reported concerns about the lack of access to behavioral observations and limited control over client actions during suicidal crises (Chapman & Hood, 2020). As DBT has multiple components, clinicians have had to find ways to provide both individual and group treatment services online as well as maintain connection to their DBT consultation team. The consultation team is a crucial support system for therapists treating complex clients, particularly when navigating the additional challenges related to providing DBT by telehealth. Managing dysfunctional client behavior during DBT groups, determining what to do when someone disappears or goes off video, creating and implementing a strong crisis plan, and developing a strong therapeutic alliance with clients who have only been seen online, are all potential challenges for clinicians providing telehealth DBT.

Despite these possible obstacles, the nature of DBT may be protective against certain barriers to telehealth. Clinicians offering standard DBT are already familiar with providing limited telehealth services (phone coaching can be considered telehealth) and managing suicide risk on the phone or via other means (text, email, etc.). Many of the special considerations for the management of suicide risk during phone coaching, for example, are identical to those involved in telehealth more broadly (Chapman, 2019, Chapman and Hood, 2020). Prior to the pandemic, only two studies had examined the utilization of telehealth in DBT-related therapies (Lopez et al., 2020, Zendegui, 2015). Despite evidence of good acceptability and feasibility of telehealth DBT groups (Zendegui, 2015), there was some evidence that group cohesion was weaker when online compared to in-person (Lopez et al., 2020). A more comprehensive examination of the benefits and barriers associated with telehealth DBT is needed.

The structure of DBT could be well-suited for treatment adaptations occurring during a stressful global pandemic. The focus in DBT on maintaining clinician motivation and skill could buffer some of the stressors associated with clinical work, either during or not during a pandemic. DBT is a team-oriented treatment, with a consultation team providing ongoing, weekly support for clinicians engaging in challenging work. DBT clinicians are also encouraged to personally utilize DBT skills and to maintain a regular mindfulness practice, which may contribute to more resilient coping during a time of global and career-related upheaval. Research has indicated that use of the DBT skills, especially mindfulness skills, is associated with lower perceived stress and burnout for DBT clinicians (Jergensen, 2018, Perseius et al., 2007). Identifying clinicians' perceived changes in stress and self-care strategies may further inform the field about the advantages and disadvantages of conducting telehealth DBT.

study aims

In this study, we explored the use of telehealth services and related clinician attitudes and experiences in the context of DBT. First, we aimed to explore the degree of telehealth platform adoption among DBT clinicians for the different treatment components (i.e., individual therapy, skills group, and consultation team). Second, we examined clinicians’ perceived changes in stress and changes to self-care strategies. We addressed these aims using both qualitative and quantitative methods.

Methods

procedures and sample

The study received ethical approval from the Research Ethics Board at Simon Fraser University. Participants included English speaking therapists who self-identified as practicing DBT. Data collection took place over 9 months, from June 2020 to January 2021. Self-report data was collected through an online survey that included quantitative scales and open-ended questions. Participants were recruited through emails to clinical list serves and to clinicians at centers known to practice DBT. We encouraged clinicians to share the study recruitment email with their colleagues or other professionals who may be interested in participating. The recruitment email included a link to a Qualtrics survey, which did not solicit any identifying information, allowing participants to remain anonymous. Data collection occurred primarily in the fall of 2020.

measures

The majority of measures used were created specifically for this study, given the specificity necessary to address the research goals and the lack of extant COVID-19-related scales available. The survey was developed to examine the following areas: demographics, familiarity with technology, background in DBT, attitudes and experiences using telehealth during the COVID-19 pandemic, experiences of stress and self-care, and recommendations for other clinicians.

Demographics

Participants were asked to self-report their age, gender identity, ethnicity, education level, and profession, in multiple-choice format.

Familiarity With Technology

Participants responded to several items assessing their familiarity and comfort with telehealth services. These items were all assessed using 5-point Likert scales. Participants were also asked about the devices they owned (i.e., desktop computers, tablet devices, etc.) and the frequency of their usage of devices to infer general comfort with technological devices.

Background in DBT

Participants were asked about their DBT training and the duration of their work as DBT practitioners. Participants were also asked to specify whether they practiced DBT exclusively, predominantly, or as an adjunct to other therapy. They also answered questions regarding their participation in team consultation prior to and since COVID-19, to inform whether the pandemic had impacted team meetings in frequency, length, or effectiveness.

Attitudes and Experiences Using Telehealth

Open-ended questions assessed participants’ perceived benefits and barriers to using telehealth services in DBT. A 5-point Likert scale (ranging from strongly disagree to strongly agree) was used to determine participants’ attitudes towards using telehealth in DBT (using prompts such as “DBT via telehealth is not private/secure” and “DBT via telehealth is appealing to my clients”). Participants’ experiences implementing DBT via telehealth were assessed through items addressing the number of hours per week practitioners spent implementing DBT via telehealth, how long they have been administering DBT via telehealth, the platforms they used, and whether they were doing individual and/or group DBT using these platforms.

Recommendations

At the end of the survey, participants were asked to report on their recommendations to other clinicians providing DBT via telehealth.

analysis

Quantitative

Quantitative data were analyzed using descriptive statistics.

Qualitative

Qualitative data were analyzed using thematic analysis, as outlined by Braun and Clarke (2006; see Table 1 for details of each step). To ensure credibility of findings, investigator triangulation was conducted whereby the first and second author completed each step of the analysis independently, meeting weekly to discuss and resolve conflicts.

Table 1.

Qualitative Data Analysis Steps

Phase No.	Analysis	Analysis Process
1	Familiarization	Recordings listened to with transcriptions in hand to ensure accuracy
2	Coding	Data systematically annotated with initial codes and collated into spreadsheet – then second round coding undertaken
3	Stage 1 themes	Initial themes and sub-themes generated
4	Stage 2 themes	Themes reviewed and refined as per Patton’s (1990) criteria of internal homogeneity and external homogeneity
5	Final themes defined and named	Remaining themes defined and named by identifying appropriate extracts for each theme and sub-theme, and constructing an organized and consistent account of data

The COVID-19 pandemic is a novel situation with little previous research in the area; thus, an inductive strategy was used. Inductive thematic analysis does not try to fit codes or themes into any previously established theory. The current thematic analysis was also predominantly explicit or semantic, meaning participants’ responses were coded or interpreted at the level they were given, and researchers did not attempt to go beyond the semantic material provided. Thus, researchers coded based on explicit participant responses and then theorized at the final stage of analysis.

Reflexivity. According to a critical realist perspective, the researcher must demonstrate awareness of their own self-location, position and interests, and how these influence the process (Pillow, 2010). Accordingly, we used strategies outlined by Berger (2013), including triangulation as discussed above, keeping a research diary and maintaining an audit trail.

Results

The final sample consisted of 99 participants. Detailed demographic information is provided in Table 2 .

Table 2.

Participant Demographics

Demographic Variable	N	%
Gender
Female	79	79.8%
Male	20	20.2%
Other	0	0.0%
Age
20–29	16	16.2%
30–39	37	37.4%
40–49	25	25.3%
50–59	15	15.2%
60+	6	6.1%
Ethnicity
White	82	82.8%
Chinese	2	2.0%
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)	6	6.1%
Black	1	1.0%
Latin American	2	2.0%
Korean	1	1.0%
Indigenous	1	1.0%
Other	1	1.0%
Prefer not to answer	3	3.0%
Profession
Clinical psychologist	34	34.3%
Counseling psychologist	1	1.0%
Psychiatrist	3	3.0%
Counselor	19	19.2%
Psychotherapist	9	9.1%
Social worker	22	22.2%
Occupational therapist	1	1.0%
Registered Nurse	1	1.0%
Post-doctoral fellow	1	1.0%
Clinical psychology graduate student	4	4.0%
Other Education	2	2.0%
College certificate or diploma	1	1.0%
Bachelor’s degree	5	5.1%
Master’s degree	58	58.6%
Doctoral degree	34	34.3%
Other	1	1.0%

the degree of telehealth platform adoption among dbt clinicians

Most participants predominantly (45.5%) or exclusively (24.2%) use DBT in their practice. The majority of clinicians were either very (52.6%) or mostly comfortable (37.4%) with technology. Most clinicians were using telehealth platforms between 1–5 hours (32.3%) or 5–10 hours (22.2%) per week. Zoom was the most commonly reported platform across all aspects of DBT (skills training, individual, and team meetings). Of note, 1.9–6% of clinicians reported not utilizing a major component of DBT (skills training, individual therapy, or consultation team). These data appear in Table 3, Table 4 .

Table 3.

Clinicians’ DBT Experience and Telehealth Platform Adoption

Variable	N	%
DBT Experience
Exclusively use DBT	24	24.2%
Predominantly use DBT	45	45.5%
Use some DBT	25	25.3%
Other	5	5.0%
Comfort with Technology
Not at all comfortable	1	1.0%
A little comfortable	2	2.0%
Somewhat comfortable	7	7.1%
Mostly comfortable	37	37.4%
Very comfortable	52	52.5%
Weekly Hours of DBT Provision
Never	1	1.0%
1–5 hours	27	27.3%
6–10 hours	28	28.3%
11–15 hours	15	15.2%
16–20 hours	8	8.1%
21+ hours	13	13.1%
No Response	7	7.0%
Weekly Hours of Tele-DBT Provision
Never	6	6.1%
1–5 hours	32	32.0%
6–10 hours	22	22.2%
11–15 hours	11	11.1%
16–20 hours	7	7.0%
21+ hours	14	14.1%
No Response	7	7.0%

Table 4.

Components of DBT and Telehealth Platform Use

Tool	Component of DBT
	Skills Training	Individual Therapy	Team Meetings
Zoom	56 (56.6%)	61 (61.6%)	63 (63.6%)
Bluejeans	1 (1.0%)	1 (1.0%)	1 (1.0%)
Skype	2 (2.0%)	4 (4.0%)	2 (2.0%)
Doxy.me	6 (6.1%)	20 (20.2%)	4 (4.0%)
Thera-link	1 (1.0%)	1 (1.0%)	2 (2.0%)
Clocktree	0	1 (1.0%)	0
Vsee	8 (8.1%)	14 (14.1%)	8 (8.1%)
Other	28 (28.3%)	35 (35.4%)	31 (31.3%)
No Tool Used	5 (5.1%)	0	4 (4.0%)
Don't do this aspect of DBT	2 (2.0%)	2 (2.0%)	2 (2.0%)
No Response	14 (14.1%)	14 (14.1%)	14 (14.1%)

*Participants were permitted to select multiple tools for each DBT component.

clinicians’ attitudes towards telehealth-delivered dbt

Ninety-two participants (92.9%) responded to questions assessing their attitudes towards providing DBT via telehealth. Overall, clinicians were cautiously optimistic about the provision of DBT via telehealth, while highlighting concerns about not having sufficient knowledge and skills to provide DBT in this medium, as well as privacy and security. Of note, the vast majority of clinicians (80%) agreed or strongly agreed that DBT telehealth can provide effective treatment, and that DBT via telehealth is convenient (85%). In contrast, 69% agreed or strongly agreed that they do not feel skilled or confident providing DBT via telehealth, yet 76% reported confidence in their knowledge of ethical/professional guidelines regarding telehealth. Detailed results are presented in Table 5 .

Table 5.

Clinicians’ Attitudes Towards Telehealth-Delivered DBT

Attitude Statement	Strongly disagree N (%)	Somewhat disagree N (%)	Neither agree nor disagree N (%)	Somewhat agree N (%)	Strongly agree N (%)
There is not enough evidence to support the use of DBT via telehealth	7 (7.1%)	17 (17.2%)	41 (41.4%)	19 (19.2%)	8 (8.1%)
I do not feel skilled/confident providing DBT via telehealth	4 (4.0%)	7 (7.1%)	12 (12.1%)	31 (31.3%)	38 (38.4%)
I don’t know what services are available to me to offer DBT via telehealth	6 (6.1%)	11 (11.1%)	16 (16.2%)	25 (25.3%)	34 (34.3%)
I feel confident in my knowledge of the ethical guidelines surrounding the delivery of telepsychology	4 (4.0%)	3 (3.0%)	9 (9.1%)	51 (51.5%)	25 (25.3%)
DBT via telehealth is appealing to my clients	2 (2.0%)	15 (15.1%)	21 (21.2%)	39 (39.4%)	15 (15.2%)
DBT via telehealth is accessible no matter where the client lives	4 (4.0%)	26 (26.3%)	15 (15.2%)	28 (28.3%)	19 (19.2%)
DBT via telehealth is convenient	0 (0.0%)	4 (4.0%)	3 (3.0%)	44 (44.4%)	41 (41.4%)
DBT via telehealth is not private/secure	2 (2.0%)	9 (9.1%)	19 (19.2%)	42 (42.4%)	20 (20.2%)
DBT via telehealth is not reliable	2 (2.0%)	13 (13.1%)	28 (28.3%)	34 (34.3%)	15 (15.2%)
DBT via telehealth can provide effective treatment	0 (0.0%)	2 (2.0%)	10 (10.0%)	42 (42.4%)	38 (38.4%)
Suicidal clients require face-to-face support	6 (6.1%)	25 (25.3%)	23 (23.2%)	26 (26.3%)	12 (12.1%)

perceived barriers to telehealth-delivered dbt

An inductive thematic analysis generated three themes and five sub-themes. The relationships between these themes, sub-themes, and some salient codes, are outlined in Figure 1 .

Figure 1.

Thematic map for “Perceived Barriers to Telehealth Delivered DBT”.

Technology Issues

This theme includes a variety of broad statements made by individuals about technological issues such as poor Internet connection, being disconnected, and other issues operating technology. Adapting various aspects of therapy to an online format proved difficult for some clinicians, with many individuals indicating difficulties with diary cards, diary card review and completion, chain analysis, and mindfulness practices. One clinician reported that they have been “spending more time troubleshooting than doing therapy.”

Privacy concerns. This theme encompasses technology-related concerns about client privacy. Many clinicians reported that their clients lacked a private space to participate in therapy. One clinician expressed concerns around their client having a lack of “Privacy/comfort discussing intense emotions from home… [it is] especially difficult to do Stage 2 work [which often involves addressing trauma] with clients living at home, when [the] invalidating environment is right on the other side of their door.” Adolescent clients may be particularly affected by privacy issues when receiving telehealth services. As one clinician noted:

For adolescents, privacy is a major concern. They really have had difficulty with parents being close by, interrupting sessions, animals/pets coming by, [and] other family members being around or listening.

Barriers to access. Many clinicians reported having clients with barriers to accessing telehealth. Financial barriers were commonly reported, particularly for clinicians serving clients who “can't afford a smartphone or internet access” or have a “lack of technology literacy.” Some specific populations reportedly affected by technological access included lower income individuals, incarcerated individuals, and elderly individuals.

Concerns About Client Safety

The second theme encompasses frequently raised concerns around client safety. Clinicians reported increased concerns about managing clients’ self-injuring behaviors and urges, conducting accurate risk assessments, helping clients to regulate emotions, and “getting clients back” who had dissociated. “Managing safety (e.g., knowing where client is, making sure no sharps [sic] around them)” came up for both self-injuring and highly suicidal clients. One clinician reported:

Not being able to be in the room with the client is challenging sometimes, particularly if it is a high-risk or highly dysregulated client. We had a client actively self-harming in group off camera and no one knew until afterwards, which was extremely stressful.

While another one stated:

Working with a suicidal person in my office is distressing but not as distressing as working on telehealth. Worst case scenario, I can put my chair in front of the door if I think they are going to leave and kill themselves. I do not have these same assurances [sic] in telehealth.

Despite being raised less often than technological issues, these safety concerns seemed particularly salient and distressing to some clinicians.

Missing the in-Person Connection

Difficulty interpreting cues. Clinicians reported the lack of in-person connection with both clients and colleagues as a barrier to DBT for themselves and their clients: for example, being unable to read clients’ body language, nonverbal, and facial cues. One clinician reported that the lack of in-person sessions causes “greater difficulty in connecting interpersonally/emotionally with clients through telehealth.”

Lack of community and rapport. Not being in-person has also had negative impacts on clinicians’ sense of community and ability to build rapport with clients. This impact was particularly felt in group settings, with one clinician stating that there is “Less community building with clinicians and between clients. I miss that [sic]. Clients are less connected to each other in groups and I'm noticing it.”

Issues with engagement. Some clinicians also reported a variety of engagement issues and therapy-interfering behaviors present over telehealth that may not affect in-person therapy. For example, clients may engage in “escape behaviors,” such as exiting the session or turning off cameras without warning.

perceived benefits to dbt via telehealth

An inductive thematic analysis generated three themes and five subthemes. The relationships between these themes and some particularly salient codes are outlined in Figure 2 .

Figure 2.

Thematic map for “Perceived Benefits to Telehealth Delivered DBT”.

Increased Access and Attendance

This theme captured patterns in clinician statements about increased access and attendance in DBT delivered via telehealth. Clinicians indicated that for many clients, therapy became more accessible as a result of the online format. Financial benefits were emphasized, and clinicians referenced the online format being particularly helpful for reducing financial barriers for clients who may previously have struggled to afford transport costs (e.g., public transit fees, parking). Some clinicians also identified specific groups who would have better access to therapy from home, including clients with agoraphobia or social anxiety, adolescent clients, clients living in remote areas, and clients without access to childcare or transportation.

Clinicians frequently commented that increased attendance was a major benefit of telehealth DBT. One clinician identified that if an individual forgets about a session, “they can often join right away and not miss out.” Another clinician reported they have had “almost zero cancellations or no shows” due to providing therapy online.

Schedule flexibility was associated with both access and attendance. Clinicians identified that individuals with busy schedules or odd work hours were better able to attend and schedule therapy sessions. As such, this scheduling flexibility contributed to both access and attendance. Some clinicians also identified benefits of scheduling flexibility for themselves. This included being “more efficient in starting and ending sessions on time,” “holding sessions earlier,” and the ability to “be more flexible with appointment times since I am not encumbered by a commute that is often an hour each way.”

The Benefits of the Home Environment

Clinicians described several benefits related to at-home delivery of DBT.

Comfort and convenience. Some clinicians highlighted the personal convenience and comfort of working from home as well as benefits to clients including greater comfort participating in sessions at home and a reduction in stigma as they can no longer be seen entering a clinic. A minority of clinicians, however, indicated they did not enjoy working from home.

Generalizability. Clinicians indicated that conducting DBT while their client was in their home environment allows clients to generalize skills more easily. For example, one clinician stated that “another BIG pro is that the clients are learning and practicing the skills in their homes, which is often where they need to use them,” and another reported that “Clients are located in their natural environment, which helps skill generalize more quickly [sic].”

Insight and family involvement. Clinicians also indicated that it was helpful to see their client’s environment; one clinician even described this as “a game changer.” More specifically, many described that viewing the clients at home revealed things the client may not have spoken about in therapy. Some clinicians remarked that it has been beneficial that family members have become more involved and engaged in at home compared with in-person therapy.

Mastery

Self-monitoring. Clinicians identified being better able to self-monitor their own expressions or reactions through video therapy sessions, leading them to feel they were providing better therapy. Many reported learning a lot about their automatic reactions to events in therapy sessions, and how this shows up in their facial expressions.

Technology. Some clinicians described learning to use specific DBT tools online, for example, diary cards and chain analyses. Additionally, they reported developing more general technology skills, and feeling increased competence in general telehealth skills. One clinician reported:

The use of breakout rooms and the access to whiteboards and share screen was very beneficial. We had the option to private chat with clients that needed help as well as private chat for the co-leaders to communicate if needed.

clinician-reported sources of stress related to telehealth

An inductive thematic analysis generated three themes and four subthemes; these, and their relationships, are outlined in Figure 3 .

Figure 3.

Thematic map for sources of stress related to telehealth.

Strained Personal Resources

Fear of infection and pandemic fatigue. Many clinicians expressed fears around exposure to the virus, with one clinician citing “chronic stress of [sic] living in a country in which we don’t know what is happening with the pandemic” as a source of increased stress. This sentiment was elaborated on by another clinician:

The stress from hearing the pain and suffering that others are experiencing from the changes and illnesses from pandemic and the contrast from the behaviors in the community [sic] negating facts and acting as if the virus is a hoax. Knowing that it is a matter of time before I get the virus due to the amount of illness that is present in our workplace.

While fear of infection was frequently reported, many clinicians also expressed pandemic-related fatigue; for example: “I’m burned out on COVID more than I’m burned out on [sic] my job. I’m tired of wearing masks and social distancing, and so are clients.” Building on this, one clinician expressed “uncertainty about how clients will respond to heightened safety requirements at the office.”

Lack of access to previous self-care activities. Many clinicians reported feeling as though their self-care tools had been taken away from them. One attributed their increased stress to the following:

lack of access to things in my personal life that bring me joy, spending a great deal of time inside, no access to vacation/escape.

Another attributed increased stress to:

decreased access to self-care methods used prepandemic; for example, yoga at my local studio, volunteering in person, going to the movies.

Feelings of isolation. Clinicians frequently cited their own feelings of isolation, as well as the isolation being experienced by their clients as a source of increased stress. One clinician stated “we're working at home, so we have less contact with other clinicians. We do have a peer consult meeting weekly but miss seeing people in person,” while another clinician emphasized missing the in-person connection with clients:

I got into this career to be with people, working with people face-to-face. I have been more tired and drained working on a computer. It’s more work and less effective with my under twelve-year-old patients [sic].

Challenges in maintaining team camaraderie over telehealth were described, and clinicians frequently cited feeling unsupported by employers. Indeed, one clinician said that the main source for their stress is “my agency’s expectations of me and lack of support” while another described:

Increased issues with business practices due to telework, poor communication from agency leadership, issues that were previously present (due to Compliance with Medicaid, Medicare, and State standards) are much, much, worse. I work a 10-hour day, Monday to Friday, without a break.

Zoom Fatigue

“Zoom fatigue” was frequently cited as a source of stress, with many clinicians describing associated physical symptoms (e.g., headaches), a need for them to bring greater energy to make sessions with clients effective, and an increasingly sedentary lifestyle as particularly problematic.

Blurring of Work-Life Boundaries

Clinicians frequently described a blurring of work-life boundaries as a source of increased stress. For example, one clinician stated that it was “harder to have boundaries and structure teleworking”; and another said, “I feel overwhelmed with not having any break from work since [sic] working from home.”

This theme also played an interesting counterpart to the subtheme of isolation. Indeed, although seeing less family was a reason for stress, so was family being home due to COVID: “I had a baby right before COVID hit and it's just been a lot [sic] to have all of my children here, maintain a job, and a launch a business.” Similar statements indicated a “greater need by [sic] my own adolescents which I have to balance with work; fewer in person contacts with colleagues and friends.” Overall, much distress was associated with not being able to see friends and family, but also with having children at home during work hours.

Client demand. Many practitioners reported an increase in the number of clients or “influx of patients,” including “a drastic increase in caseload and increase in severity with clients’ presenting problems.” One clinician reported: “Most people are struggling [sic] so there are less lighter sessions and less to celebrate,” while others similarly expressed they were now seeing “more clients who are high risk and high utilization of phone coaching.” This increase in demand led one clinician to report they are “finding online visits more mentally exhausting. With clients who I used to see biweekly we have had to switch back to weekly due to increased stress.”

adapting self-care for the pandemic

An inductive thematic analysis generated two themes and six subthemes. The relationships between these themes, subthemes, as well as some particularly salient associated codes are outlined in Figure 4 .

Figure 4.

Thematic map for “Adapting Self-Care for the Pandemic”.

Loss of Prior Self-Care Strategies

This theme encompasses the loss of clinicians’ self-care strategies that accompanied stay at home orders and various closures during the COVID-19 pandemic.

Social. Many participants indicated the loss of social self-care strategies due to factors such as “fewer social events,” “having more time with a smaller number of people,” “no church since the beginning of the pandemic,” and being unable to see friends, supportive coworkers, and extended family. According to one clinician:

I can't do many of the things I enjoy ([sic] meeting up with friends, restaurants, travel). All of my work-related activities have also been canceled ([sic] conferences, in person trainings) [sic] so I'm also missing that level of connection with colleagues.

Overall, it was apparent that many clinicians felt “decreased social support” during this time.

Hobbies and general activities. Beyond social activities, individual pursuits were also impacted by the pandemic. This theme represents the general feeling that clinicians “don't have access” to their normal or primary coping strategies during the COVID-19 pandemic. According to one clinician, “there are some activities that really helped with my burnout pre COVID and that just cannot be done now.” These lost activities included movies, restaurants, dance classes, going to the gym, getting coffee, swimming, and traveling.

Creation of New Self-Care Strategies

Many clinicians identified that the loss of their ability to participate in prior methods of self-care has led them to develop new strategies that are “feasible and safe to do” during the pandemic. Unfortunately, not all clinicians indicated they had found new ways of coping; for example, one clinician stated, “work is consuming. I am not engaging in coping strategies that I know work.” Those that did report new strategies frequently described them as being virtual or “more independently focused rather than spending time with others in-person.”

Mindfulness and direct mental well-being practices. Many clinicians indicated they have increased engagement in activities directly related to their own mental health. The most common practices included meditation, informal mindfulness, and attending personal therapy.

Pets as a source of support. Many individuals mentioned using pets for coping with stress. For one clinician, one of their biggest sources of self-care during the pandemic has been:

Snuggling with cats and telling myself I’m getting oxytocin (I don’t know if this is true, but it’s a mindful lie I’m willing to tell myself).

Development of solo hobbies. Many clinicians also identified a host of new “personal” or “solo” hobbies they had begun to engage in since the onset of the pandemic. These included recreational activities (e.g., watching TV, building puzzles, reading, writing, and baking), exercise (e.g., taking walks, doing at-home workouts), and spending time outside.

Engaging in a virtual social world. Many clinicians described moving aspects of their personal life online for social support and community engagement. Virtual social events were a source of support for some clinicians, although “Zoom fatigue” was mentioned as a downside of these; according to one clinician:

It's harder to spend time with others. Due to COVID all social activities are online which I am finding exhausting especially after spending all day seeing patients online.

Gaining new self-care strategies due to the isolation was surely an unexpected benefit born from the stress and isolations of the pandemic. Many of these new coping mechanisms brought clinicians enjoyment, despite occurring as a result of the loss of their prior strategies and the loss of their social and group activities.

“dear future self”: recommendations to clinicians transitioning to telehealth-delivered dbt

At the end of the survey, participants were asked to provide recommendations for other clinicians transitioning to DBT via telehealth.

Upskill and Become Comfortable With Technology in Advance

DBT clinicians considering telehealth-delivered DBT should make sure that they are comfortable with, and knowledgeable about, telehealth provision and platforms in advance. Clinicians frequently highlighted privacy and security and recommended staying up-to-date on telehealth guidelines, using a HIPAA-compliant platform, and orienting clients to specific risks associated. They also recommended practicing technology ahead of time (with a colleague or friend rather than a client) to increase comfort using online platforms.

Be Prepared to Manage High-Risk Clients

Participants recommended that clinicians plan ahead for managing high-risk clients rather than waiting to respond in the moment. One suggested:

Openly communicate boundaries about safety concerns during session…, adapt safety plan and have contact numbers necessary to implement (local crisis response teams, family emergency contacts, etc.), ensure the client is stationary for the session and know the address for the location, don’t fragilize people and know your comfort level.

Other specific recommendations included conducting risk assessments consistently, having emergency contact information for all high-risk clients, and having a back-up platform available in case of technological difficulties.

Conduct a Technology Orientation With Clients

It is important to orient clients to telehealth, and clinicians note that this can make a substantial difference to DBT delivery:

Orienting clients to telehealth needs to be part of orientation and commitment, and ideally a separate group orientation would be helpful. We've seen a difference between clients who have received this orientation and their readiness and commitment versus clients who did not. We have had to add telehealth expectations to group rules.

Some clinicians listed specific factors to include in orientation, including the importance of conducting sessions in a private setting and etiquette for telehealth sessions that clients may assume are more informal. One clinician succinctly suggested telling clients, “if you wouldn’t do it in the room, don’t do it on Zoom.” Finally, it is important to conduct an informed consent process around telehealth platforms, and to ensure clients are aware of screen-recording risks in group settings.

Watch Your Energy

Clinicians frequently noted the toll of providing telehealth services on one’s energy levels. Participants recommended that clinicians using telehealth take longer breaks between clients and schedule fewer clients per day.

consider telehealth suitability

Just as face-to-face therapy may not be ideal for every client, telehealth may not always be suitable. Participants recommended screening clients to ensure that telehealth is appropriate.

Practice Your DBT Skills

DBT skills were described as a source of support for many clinicians. Some of the skills highlighted were nonjudgmental stance, radical acceptance, the PLEASE skill, and distress tolerance skills.

Discussion

The aim of this study was to examine the use of telehealth services and related clinician attitudes and experiences in the context of DBT. We examined the degree of telehealth platform adoption among DBT clinicians, as well as changes in stress and self-care strategies. Additionally, we sought to gather clinicians’ recommendations for providing DBT via telehealth, with a view to providing a resource to clinicians undergoing a similar transition. These aims were broadly achieved, with findings providing a snapshot in time of clinicians’ attitudes toward and experiences of telehealth DBT.

Findings indicated that telehealth-delivered DBT has been widely adopted among DBT clinicians, and that clinicians’ attitudes to telehealth-delivered DBT are cautiously optimistic. When asked specifically about their attitudes toward telehealth DBT, clinicians were predominantly optimistic that telehealth DBT can be effective but also perhaps concerned that they do not feel skilled or confident providing DBT via telehealth. That said, it is important to note that DBT is a complex, multicomponent treatment, and that these clinicians may experience a similar lack of confidence in providing in-person DBT. Indeed, DBT adherence is considerably lower in community settings than in research settings (Harned et al., 2021).

Combined with the finding that most participants reported confidence in their knowledge of ethical/professional guidelines regarding telehealth, these findings suggest that clinicians are confident in approaching telehealth from a general professional perspective but cautiously optimistic about specifically providing DBT via telehealth. We suspect this will change as clinicians gain more experience with telehealth DBT, but these findings also suggest the need for more DBT-specific training focused on how to navigate telehealth in the context of this treatment for complex clients.

The results of our study indicate that DBT clinicians are experiencing both benefits and barriers to adapting DBT for telehealth. Barriers included technology issues, missing the in-person connection, and concerns about client safety, while benefits included increased access and attendance to therapy, clinicians’ experiences of mastery, and benefits of the home environment. It was particularly interesting that some of the benefits and barriers represented two sides of the same coin; for example, while clinicians expressed concerns around privacy and the potential for family to overhear sessions, they also emphasized the insight that family involvement provided. Similarly, while many expressed frustrations about technology, they also expressed the advantages of telehealth tools to their provision of DBT. Notably, in line with previous research on telehealth for suicidal clients (see Chapman & Hood, 2020, for a review), clinicians expressed specific concerns regarding safety and privacy for highly suicidal clients.

The second study aim was to explore how adapting DBT for telehealth during the COVID-19 pandemic is impacting clinician stress and self-care. Participants reported experiencing telehealth and pandemic-related stress in three key areas: strained personal resources, blurring of work-life boundaries, and Zoom fatigue. Clinicians also reported losing previously effective self-care strategies as a result of the pandemic (e.g., swimming, gyms, travel, restaurants, religious activities), and outlined some of the ways that they have adapted their self-care strategies to suit life in a pandemic (e.g., more cooking, crafting, reading, time outdoors). Research has shown the importance of clinician self-care in maintaining professional competence in mental healthcare provision (Guy et al., 1989, Rupert and Dorociak, 2019). Furthermore, self-care is an ethical obligation in many mental health professions; for example, the American Psychological Association (2017) code of ethics emphasizes the need for clinicians to be cognizant of their mental and physical health, and make sure that it is not impacting their work. With this in mind, our results could be used to normalize feelings of loss experienced by clinicians in this situation, as well as potentially providing them with new ideas for pandemic-proof ways to engage in self-care.

Clinicians have demonstrated extraordinary resilience in response to these challenging circumstances—circumstances that are particularly challenging for mental healthcare providers considering the increased demand for mental health support in the community (Angus Reid Institute (ARI)., 2020, Centre, 2023, Brooks et al., 2020). This resilience is evidenced by their abilities to develop pandemic-friendly self-care strategies, or, phrased in DBT terms, their ability to make lemonade out of lemons.

limitations and future directions

Several study limitations may inform future research. First, the study was cross-sectional, only capturing a snapshot of the transition to telehealth. Data collection took place during the height of the pandemic (June 2020 to January 2021), and it would be valuable for research to examine how clinicians have settled into using telehealth platforms over the past year, and whether their perspectives around barriers and benefits have changed, particularly with the advent of mass vaccination. Second, as there was no existing validated measure of clinicians’ attitudes to telehealth, we developed our own, and further data on its reliability and validity are needed. In view of this, we used no inferential procedures with this portion of the data. Third, the clinicians participating in this study may not have been using comprehensive, standard DBT (including individual therapy, group skills training, telephone consultation, and the DBT consultation team). Nearly 80% of participants reported either predominantly or exclusively used DBT in their practice, but this does not mean they use all components of DBT. We have found that many clinicians in practice use some (e.g., group skills training) but not other components of DBT consistently (often, phone coaching or consultation team). Notwithstanding, our findings suggested that a small percentage of participants reported not using a specific component of DBT (1.9–6%).

conclusion

This was a timely study examining DBT clinicians’ experiences of transitioning to telehealth during a uniquely stressful period in history. Telehealth is undeniably here to stay, and the results of this research can be used both to inform future research (discussed above), as well as to inform the clinical practice of organizations/individual practitioners seeking to make the transition to telehealth delivered DBT services, and perhaps more generally to telehealth utilized with complex or suicidal clients.