A Qualitative Analysis of College Counseling Center Staff Experiences of the Utility of Dialectical Behavior Therapy Programs on Campus

Abstract

Dialectical behavior therapy (DBT) is an evidence-based practice for suicidal and self-injuring behavior with growing popularity in college counseling centers (CCCs). With the exception of a single, quantitative study, no research to date investigates how DBT is used in CCCs or what factors influence program implementation. We conducted qualitative interviews with 15 CCC staff that were delivering DBT programs in order to inform a more richly detailed understanding of the process of developing and implementing a DBT program housed in a CCC.

Introduction

Dialectical behavior therapy (DBT; Linehan 1993) was originally developed to treat chronically suicidal and self-injuring adults. The standard treatment model is a comprehensive treatment approach, including individual therapy, skills training groups, consultation team meetings for the therapists, and between session telephone coaching. Although DBT is most often associated with treatment of borderline personality disorder (BPD), for which it has a very strong evidence base (e.g., Linehan et al., 2006), it is increasingly used for numerous psychological disorders (see Rizvi, Steffel, & Carson-Wong, 2013 for a review). Because BPD is characterized in part by emotion dysregulation (Linehan, 1993) and many individuals with BPD meet criteria for several other diagnoses, research has investigated the effectiveness of DBT for other disorders, including substance dependence and BPD (Linehan et al., 1999), eating disorders (e.g., Telch, Agras, & Linehan, 2001), post-traumatic stress disorder (Harned, Korslund, Foa, & Linehan, 2012), and adolescents with bipolar disorder (Goldstein et al., 2015) with promising outcomes. DBT is increasingly viewed as a transdiagnostic treatment approach (i.e., applicable to a range of diagnoses) that can be applied in cases where a primary presenting concern is emotion dysregulation (Ritschel, Lim, & Stewart, 2015). Given this, DBT is becoming an increasingly popular approach to managing high-risk students on campus.

DBT in College Counseling Centers (CCCs)

Suicide is now the second leading cause of death for college students (Turner, Leno, & Keller, 2013). Adding to this, there have been continued reports of increases in demand for services and severity of mental health concerns on college campuses (Gallagher, 2014). Addressing the needs of high risk students is becoming a significant priority. Given the focus on reducing suicidal, self-injurious, and other high-risk behaviors within the DBT treatment model, some college counseling centers (CCCs) have implemented DBT programs with varying degrees of intensity. Although some CCCs successfully implement the standard DBT treatment model (Engle, Gadischkie, Roy, & Nunziato, 2013; Pistorello, Fruzzetti, MacLane, Gallop, & Iverson, 2012), many opt to focus on DBT group skills training as either a stand-alone or adjunctive service to individual therapy already being provided in the counseling center. While the literature in this area is nascent, several studies indicate that DBT skills training is effective for college students with a range of presenting concerns including BPD (full criteria; Meaney-Tavares & Haskin, 2013), BPD or other cluster B personality disorders or traits (Chugani, Ghali, & Brunner, 2013) and more broadly, those who are identified as having serious psychological concerns (Muhomba, Chugani, Uliaszek, & Kannan, 2017), needing coping skills (Panepinto, Uschold, Olandese, & Linn, 2015), or with emotion dysregulation (Rizvi & Steffel, 2014; Uliaszek, Rashid, Williams, & Gulamani, 2016).

As is the case with other evidence-based practices, despite a preponderance of evidence to suggest that DBT is effective, implementation of programs in real-world practice settings can be challenging. While CCCs must contend with factors that would limit implementation in any practice setting (e.g., locating resources for training, dedication of staff time to learning a new model), they also face campus specific challenges such as the semester or quarter systems, which limit students’ schedules and availability to attend appointments. To date, only one study has investigated DBT implementation in CCCs. This study identified reasons for interest in DBT and barriers and facilitators to implementation (Chugani & Landes, 2016). The primary reasons for interest in DBT among CCC staff include need for effective treatments for students who are suicidal or self-injuring, and increases in students presenting with serious psychological problems. Of the centers offering DBT, 95% had a skills training group, while only 35% reported offering all four primary modes of DBT included in the standard treatment model (Chugani & Landes, 2016). The most frequently endorsed barriers to implementation were 1) productivity demands, 2) not willing to take phone calls or extend limits when needed, 3) lack of individual therapists, and 4) no time for therapist consultation meetings. In contrast, the most frequently endorsed facilitators to implementation were 1) staff interest in DBT, 2) staff expertise in DBT, 3) program models designed for CCCs, and 4) staff experience with DBT.

To date, very little qualitative research has investigated implementation issues associated with DBT and none has been specific to the CCC practice setting. One study of community mental health administrators’ perspectives of DBT implementation found four themes with high relevance to DBT in CCCs (Herschell, Kogan, Celedonia, Gavin, & Stein, 2009). First, while administrators felt that DBT had good face validity, several were concerned with how it would fit into their practice structure and populations served. Second, there were concerns about the amount of resources needed for implementation including financial support, time, and personnel required. Third, administrators described a careful selection process for DBT training guided by concerns related to turn over and leaving more senior staff with less time for supervision and mentorship. Finally, they wondered whether they would receive enough referrals to justify the investment. Administrators felt that securing a referral stream could not fully be addressed at the clinic level, but rather, required the support and buy-in from higher administration.

Although the aforementioned work (Chugani & Landes, 2016; Herschell et al., 2009) provided initial insights into DBT in CCCs, more research is needed to understand the nuances of how DBT programs operate in CCCs, which student groups are viewed as having the highest need, how students have benefitted, and what factors may influence the success of programs. Thus, the current study builds upon previous work investigating DBT implementation issues by inviting the perspectives of CCC staff who are involved in delivering DBT programs to inform a more richly detailed understanding of the process of developing and implementing a DBT program housed in a CCC. This work contributes to a greater understanding of the needs of CCCs and their staff in serving diagnostically heterogeneous students with DBT-informed programs.

Method

Participants

Participants recruited for this study (N = 15) consisted of mental health professionals who were working at CCCs with diverse positions in order to ensure maximal variation within the sample (Patton, 1990). Participants held a range of job titles, with Staff Clinician being the majority of the sample (60%), followed by Postdoctoral Fellow (6.7%), Center Director (6.7%), Supervising Counselor (6.7%), Center Manager (6.7%), Assistant Director for community services (6.7%), and Social Work Specialist (6.7%). Participants’ counseling centers offered a variety of services to students including individual therapy (100%), group therapy (93.3%), and outreach and prevention services (93.3%). Participants were from 12 CCCs across the U.S. (West Coast, Midwest, East Coast, and Southeast regions) and were between the ages of 29 and 59 (Mean = 38.5, SD=9.8). Most of the participants were women (80%) and Caucasian (93.3%; Asian = 6.7 %) and the reported range of years of experience practicing psychotherapy or counseling was three and 30 years (Mean = 11.8 years, SD = 7.3). About half the participants had experience in administrative responsibilities ranging from nine months to 10 years of experience (Mean = 3 years, SD = 2.9). Participants held a range of professional degrees, including Doctor of Philosophy (Ph.D; 40%), Master of Social Work (M.S.W; 26.7%), Master of Arts (M.A; 6.7%), Doctor of Psychology (Psy.D; 6.7%), Masters of Education (M.Ed; 6.7%), Medical Doctor (M.D.; 6.7%), and Doctor of Nursing Practice (D.N.P; 6.7%).

Recruitment

We sought potential participants through the following listervs, which broadly serve collegiate mental health: 1) DBT-CCC (for college counselors and DBT), 2) ACCA (American College Counseling Association Listserv), 3) AUCCCD (Association for University and College Counseling Center Directors Listserv), and 4) ACCTA (Association for Counseling Center Training Agencies) Psychology training directors listserv). The recruitment flyer was posted to each listserv and participation in this study was optional. Participants who responded to the recruitment letter and indicated their interest in the study were provided with a demographic questionnaire and informed consent forms, which were both completed through the REDCap survey platform (Harris et al., 2009). The first and fourth authors conducted the interviews and the first co-authors conducted the analysis. Once the interviews and analysis were completed, participants completed a feedback questionnaire of the results to provide ratings of agreement with the initial findings.

Retrospective Recall Interviews

The retrospective recall method (Rennie, 1992) is a semi-structured interviewing method that relies on participant recalled accounts, enabling them to think back across their experiences. This method aided in eliciting ways in which DBT services and implementation had shifted over time. Additional questions were posed as needed to fully explore participants’ experiences. The interview was developed based upon the researchers’ prior knowledge and experience with qualitative interviewing and utilizing DBT within a CCC. All interviews began with the overarching goal of learning about participant perceptions and experiences in treating college students using DBT or a DBT-informed program of care. Additional questions were asked to clarify the role of other factors that may impact the development and implementation of DBT services. These focused within the following areas: reasons for using DBT in a CCC, factors that influenced DBT implementation, how DBT fits with existing CCC structures, and what a successful DBT program look like within a CCC. Example questions included, “How does DBT fit with the treatment model of your center?” and “Please describe the aspects of college student care that DBT does not address adequately or need to be considered more deliberately? All study procedures were approved by the University IRB and participants provided informed consent prior to the interviews. Each interview lasted 45–60 minutes; interviews were audio recorded and professionally transcribed. Although given the option, none of the participants in the study asked for any part of their interview to be excluded from the analysis or transcripts. No compensation was provided for participating in the interviews.

Analysis

The data were analyzed using thematic analysis, based on the constant comparison method associated with grounded theory (Glaser & Strauss, 1967). This method uses an inductive approach to develop a theoretical model based on the data. Per Rennie and colleagues’ method (1988), the researchers divided the responses into meaning units (MUs), which are segments of text that contain a single idea or theme (Giorgi, 1970). The MUs were compared and organized according to their similarities, creating lower-level sub-categories of MUs, which were further grouped into higher order categories and finally organized into the four main themes.

Interviewing and data analysis occurred simultaneously and continued until saturation was reached. Specifically, the point at which transcripts added to the model did not result in additional higher order categories or sub categories. In this study, saturation was achieved at the 12th interview, and the last three transcripts did not add any new data. The first co-authors also kept a record of developing theories about participants’ experiences throughout the process of analysis (i.e., memoing; Rennie, 2000).

Credibility Checks

To enhance the credibility of the study, three types of credibility checks were used. First, participants were asked questions at the end of each interview to check that the responses were thorough and seek out any omitted information (e.g., “Was there anything we did not ask that seemed important in this interview?”). Second, a process of consensus was used in the creation of categories and the development of the model between the first co-authors who exchanged feedback on the analysis and coded the data over approximately four months. This procedure of seeking consensus was used to support the researchers to raise issues based upon their perspective for the other to consider. Third, participants were emailed a summary of the findings of the study and asked to provide feedback by indicating their level of agreement to the summary descriptions of each theme.

Results

The data derived from the interview transcripts (N=15) yielded 350 MUs across all transcripts. The analysis produced four main themes, 10 categories, and 38 sub-categories (see Table 1 for theme and category titles).

Table 1:

Theme and Category titles

Themes	(N)	Categories	(n)
Theme 1: A comprehensive DBT model is impacted by CCC resources, and DBT is integrated and adapted to fit with existing clinical services	14	Factors that limit CCC abilities to offer comprehensive DBT services	11
		CCCs use varied methods to integrate and adapt DBT into center services and culture	13
		Funding, training, and administrative support are key facilitators to DBT implementation	10
Theme 2: DBT fits well with centers’ approaches to clinical care and serves a broad range of student needs, including those with more serious mental health concerns	15	DBT benefits students by providing a needed clinical intervention and a safe space that facilitates change	12
		DBT-based interventions address a wide variety of student needs	14
Theme 3: Skills training groups are a main focus of DBT programs in CCCs due to the tangible benefits of skill development to students	15	Factors that facilitate delivery or effectiveness of skills training groups	14
		Factors that interfere with delivery of skills training groups	11
		A focus on tangible goals or skills benefits students	11
Theme 4: Clinician perceptions of DBT and satisfaction with implementing DBT can have a substantial impact on the success of DBT programs	13	Varied clinician perceptions of DBT contribute to shifts in DBT implementation in CCCs	11
		CCC clinicians who practice DBT want to be supported to continue to improve their practice	8

Theme 1: A comprehensive DBT model is influenced by CCC resources, and DBT is integrated and adapted to fit with existing clinical services

Participants who contributed to this theme (n = 14) described ways in which implementation of a comprehensive model was affected by resources available to their center and how they adapted and integrated DBT into center-wide services in order to develop a DBT-focused model of care. When participants were asked to give feedback on whether this theme fit with their experience of DBT in CCC’s, the mean response on a scale of 1–7 (1= not at all, 4- somewhat, 7 – very much) suggested a high level of agreement (Mean =6.6, SD =.5). There were three categories within this theme.

Theme 1, Category 1: Factors that limit CCC abilities to offer comprehensive DBT services

In this category , participants (n=11) described factors that interfered with their centers’ ability to offer comprehensive DBT services. Factors such as limited number of therapists trained in DBT, difficulty setting up consultation team meetings, space and time availability, group length, and administrative time impacted the extent to which comprehensive DBT services could be offered. One participant noted that the main barrier to a comprehensive program is their CCCs’ short-term model of treatment:

I think that in some ways we’ve tried to, over the years, become more and more of an adherent team. Like I said, I say that lightly because I’m very clear. I try to be very clear with the students that we serve as well that we do not offer comprehensive, adherent DBT. I certainly don’t want to be advertising something that’s simply not accurate. We do try, as best as we can, to stay within the model in our setting and in our structure. Like I said, that’s not something that we’re able to fully do. When I first started working here, the DBT team was actually only meeting once a month. Really, strongly advocating that the team has a minimum of two meetings a month...

(P. 6)

Many participants expressed a desire to be able to implement more DBT services while acknowledging that their center could not fully support the kind of resources needed. One participant noted,

It [DBT] fits nicely in. However, I think the challenge is that trying to balance around the limitations we have, for example, space and only being allowed an hour to meet each week. Some of these pieces are out of our control, our challenges. I definitely think there’s room for improvement. In what ways it could be improved? I am not sure. I think there would have to be some administrative type changes that came from the chain, the top.

(P. 14)

Within this category, participants were interested in working towards a more comprehensive model but seemed to understand that this would likely be a long-term process with change occurring in smaller increments over time.

Theme 1, Category 2: CCCs use varied methods to integrate and adapt DBT into center services and culture

Within this category , participants (n=13) described efforts to engage staff and students in DBT. One participant talked about how they are attempting to integrate DBT across staff members,

The other thing, I think we provide maybe more education, information to the staff who may be referring clients to the DBT skills group, not just send out that inclusion/exclusion, but actually have some discussion and interaction with them and answering questions to clarify what we are looking for and what the clients need to commit to.

(P. 4)

Participants described trying to engage the individual therapist in their efforts to increase participation in DBT across their CCC. They noted that ongoing DBT group efforts had to involve being creative in order to increase the presence of DBT by integrating it into existing processes and procedures within their system. Some focused on increasing referrals to skills groups and many noted that they modified the frequency of DBT services offered due to time and space limitations as well as due to working with student and semester schedules.

Theme 1, Category 3: Funding, training, and administrative support are key facilitators to DBT implementation

Several participants (n=10) identified the importance of support both financially and from administrators (e.g., “buy-in”) to engage in training as critical implementation facilitators. According to one participant,

I would say buy in from staff members and from administration. What I mean when I say buy in is, the belief that this is an important thing to do, that this is a worthwhile investment of time, that this is a worthwhile investment of resources, that this is a worthwhile investment for our students, and that it’s important that we are offering treatment. I can speak for myself and say that I’m a strong proponent of evidence-based treatment. I think it’s really important that in the interventions that we provide and what we do that we are working from some body or form of evidence behind what we’re doing.

(P. 6)

The idea of having administrative buy-in was noted by several participants, and some described grant support and increasing DBT research in CCCs as an important avenue through which additional support might be obtained for more intensive DBT services. Participants also noted the importance of flexible options for training staff in DBT. They wanted to have access to options for training such as informal consultation by DBT experts in the community and inexpensive online training options, as they noted that it is difficult for several staff members to receive intensive DBT training due to the costs associated with it.

Theme 2: DBT fits well with centers’ approaches to clinical care and serves a broad range of student needs, including those with more serious mental health concerns

Participants who contributed to this theme (n =15) viewed DBT as a good fit with their center mission and goals for clinical care; they saw DBT as serving a wide range of student needs. When participants were asked to give feedback on whether this theme fit with their experience of DBT in CCC’s, the mean response suggested a high level of agreement (Mean =6.7, SD =.5). There were two categories in this theme.

Theme 2, Category 1: DBT benefits students by providing a needed clinical intervention and a safe space that facilitates change

Many participants (n=12) felt that DBT concepts and skills were helpful in empowering change among students and DBT groups served as a community of care and a safe space for students. One participant said,

I think it [DBT] fits really well just in the field in general as far as empowering agency to make changes while still recognizing the tension of change, that it’s hard and you can only do what you can do, and people are doing the best they can.

(P.5)

DBT was also seen as serving a legitimate need for those students that were considered high risk and seen as a needed clinical intervention for CCCs. One participant noted,

So we kind of put our heads together and it went all the way up to the University president who literally went to the director of our health network, because we have both medical and counseling combined in our center which is pretty cool, and he told the director, he gave her a magic wand and he literally said, “All right, here’s a magic wand. If you were going to make a state-of-the-art treatment what would you need?” and he gave us the money to create this resource. We’re researching what are some of the most effective treatments, what seems to be the most helpful thing for people who are dealing with chronic suicidal ideations, self-harm behaviors, some of those chronic high-risk behaviors, what seems to be the most effective approach. So we looked at DBT as the best model to try and use inspirations, figuring out how do we get as much adherence as possible but also understand that we are in a specific context and setting that we’re not a treatment center. We provide treatment within a University context.

(P.13)

Participants acknowledged the utility of DBT in helping students learn the skills needed to reach their academic and personal goals. They also noted that DBT provided a sense of safety and a needed intervention for students who struggle with serious mental health concerns. For instance, one participant said,

To be able to have that skills focus in particular and be able to track some of those things on our diary cards and as we’re reviewing them to see “Here’s some of the trends that are happening every time you have these urges for suicide that are pretty powerful” or “Every time you cut this is the trend that seems to happen”, the precipitating factors. Watching students have the realization and gain the confidence and self-efficacy of “Oh wow. I really can have strong shame and be able to manage it effectively. I can have a rough day and know what to do where I don’t just close down.”

(P. 13)

Participants within this category described DBT as providing a safe space in a variety of ways that was particularly needed for their students.

Theme 2, Category 2: DBT-based interventions address a wide variety of student needs

While participants (n=14) considered DBT as helpful for those with more chronic or serious mental health needs, DBT was also utilized to treat a variety of diagnostic concerns. For instance, one participant noted, “We use DBT with many students, not just students who are in the group because it’s so applicable to all kinds of issues that are really relevant to what we are trying to accomplish” (P. 1). A few participants discussed having a “hybrid” model of DBT where they used some components of DBT within other clinical services at their centers such as interpersonal effectiveness groups as well as within a consultation model where therapists noted using diary cards in the context of a brief consultation with students who did not necessarily engage in therapy. In this way, DBT could be applied to a diverse range of students who presented for treatment.

Theme 3: Skills training groups are a main focus of DBT programs in CCCs due to the tangible benefits of skill development to students

All participants (N =15) provided their perspectives on factors that facilitated as well as interfered with the effectiveness of skills training groups. Many noted that their group program was a core part of their CCCs’ services. When participants were asked to give feedback on whether this theme fit with their experience of DBT in CCCs, the mean response suggested a moderate to high level of agreement (Mean =5.7, SD =1.6). There were three categories in this theme.

Theme 3, Category 1: Factors that facilitate delivery or effectiveness of skills training groups

Within this category, participants (n=14) were in agreement that DBT groups were more effective when students invested more time and were committed to the group and practiced their skills. Participants also reported that modifications to groups included the skills modules selected, running groups with a single leader due to difficulty finding group co-leaders, and length of time that the group ran. Several participants expressed the importance of the screening process for DBT groups and its utility in increasing the level of student commitment and buy-in for skills training. According to one participant,

We have gotten better, over the course of the semester, doing it with the screening process, and really kind of laying it out there in the screening process … This is what the group is, this is what we expect of you, these are our behaviors we’re looking to decrease, or behaviors we want to increase … We have them sign a contract, with some expectations, and that has significantly helped. The first couple of semesters, we didn’t do that, and we had a lot of dropout, and a lot of low numbers. Now we’re feeling like the screening is really helping us get the right people before the group starts.

(P. 7)

Some participants reflected on the importance of having individual therapists stay connected to the DBT group process. One participant said,

When a student is working with an individual therapist who at least has some DBT knowledge and is integrated DBT in their work and talking with the student about what they’re doing in group and maybe even reviewing handouts and practice and stuff like that, we feel like the students do better in the group; that they get more out of the group.

(P. 1)

Within this category, participants advocated for more involved screening for group fit and increasing the level of knowledge among non-DBT trained therapists so that they could use some basic level DBT concepts in individual therapy.

Theme 3, Category 2: Factors that interfere with delivery of skills training groups

Within this category, participants (n=11) noted group dropout to be a major challenge that interfered with the delivery of skills training groups. Planning groups around student and academic schedules was difficult due to shorter length of time to cover all of the skills. It was also difficult for participants to elicit commitment to participate in the group from the students who seemed to need it most. As one participant shared,

No, it’s [DBT group] not ongoing. We’ve offered it two separate times, so two six-session groups are offered. At that time, we did some screening and that was one of the barriers…is trying to find people who are appropriate for the group and then also people who are committed to the group. For example, the second time we did the group I think we offered it to maybe eight to ten people, and only one or two came regularly. Scheduling is hard and getting that commitment with all the stuff they have going on at school was a challenge, as well.

(P. 5)

This category highlights the importance of focusing on screening and recruiting students to engage in group skills training, including screening for logistical issues such as scheduling preferences and availability. In addition, it is important to find effective methods of eliciting a strong commitment to DBT and to regular group attendance in order to minimize dropout.

Theme 3, Category 3: A focus on tangible goals or skills benefits students

Within this category, participants (n=11) spoke about the benefits of focusing on tangible, concrete goals and skills for students. DBT groups were seen as helpful in improving students’ ability to navigate difficult developmental transitions and roles by learning to tolerate distress. One participant noted,

I think for them in terms of not having it be an all or nothing kind of lens, developmentally where they are there’s so much that seems black and white and the nature of DBT is that that’s not true. There’s a lot more nuance than that, and so I think it helps articulate a lot of things that they’re struggling with. It’s just a good framework to work through that all or nothing tension that might encounter across a variety of issues in terms of separating from their family and do I have to be completely independent or completely dependent, that sort of thing, or trying to change dangerous or risky behaviors that still somehow work for them. Do I have to completely give this up or what does this mean if I can’t completely give this up, have I failed? I think there’s just more room for the DBT language is acceptance almost through a kind of grace or forgiveness and that allows them to continue and not so much use shame as a motivator for change, but kind of be compassionate towards themselves.

(P.5)

Students were viewed as functioning more effectively in their environments when they could use concrete skills from DBT groups. Participants also noted that they asked their group members for consistent feedback on the groups and data was collected to make further improvements or modifications to their DBT groups.

Theme 4: Clinician perceptions of DBT and satisfaction with implementing DBT can have a substantial impact on the success of DBT programs

Participants who contributed to this theme (n = 13) explained that clinician perceptions of DBT and overall satisfaction with DBT implementation played a significant role in the degree to which DBT programs were ultimately successful. When they were asked to give feedback on whether this theme fit with their experience of DBT in CCC’s, the mean response was (M=5.8, SD=1.2) suggesting a moderate level of agreement with the findings. There were two categories in this theme.

Theme 4, Category 1: Varied clinician perceptions of DBT contribute to shifts in DBT implementation in CCCs

Participants (n= 11) noted that many clinicians in their centers viewed DBT as a modality that requires a lot of clinician commitment and time. At times this served as a barrier to participating in DBT training or offering DBT services. One participant discussed the time involved in doing DBT,

Also because this is kind of an extra thing [consultation team meeting] that we need to do, it doesn’t take away our other clinical responsibilities or administrative, so it is added time commitment for everyone who is involved to do this one hour. Also in terms of skills group, I think it does require more prep time to put the binders together, select skills. Our expectations for doing other things are not lessened because of this additional requirement.

(P.4)

Some clinicians noted that DBT was also viewed as rigid or reductionist in style by clinicians within their center and that they had varied levels of interest and comfort with doing DBT. Some participants also noted that DBT did not offer much perspective on multicultural issues,

I think one huge missing piece, I always feel like this, is more multicultural considerations. I just feel like DBT doesn’t address much in terms of the set of particular skills depending on cultural factors. When we were doing our training, we addressed this a little bit with the interpersonal effectiveness skills in particular. I think we adjust for the group, but there are sometimes students we work with, our campus is very, very diverse and some skills really are countered to where people are coming from culturally. I feel like that’s a missing piece of DBT.

(P.1)

Thus, clinician perceptions of the process of delivering DBT as well as their beliefs about its applicability to the students’ needs appear to be guiding factors that may govern program feasibility, acceptability, and satisfaction among clinical staff members.

Theme 4, Category 2: CCC clinicians who practice DBT want to be supported to continue to improve their practice

Participants (n=8) in this category expressed wanting to be more supported within their centers to continue to practice DBT and viewed DBT consultation teams as an essential support and training mechanism. They also expressed a desire to obtain advanced training in DBT in order to improve and expand their clinical practice and applications of DBT. One participant noted,

I think that we would definitely like to get a group of staff intensively trained. That may only be two or three or four, but whatever we could muster up to do, and we would have an actual treatment team. Then we would be able to start from our initial assessment, in screening people, to see if they would be an appropriate person to maybe consider them for that track, because we have an Eating Disorder Specialty, we have a Substance Abuse Specialty, we now offer trans care and stuff like that … There is a way in our center that we could make a very specific DBT track … We just need to do that.

(P. 7)

Another participant discussed the rewards in practicing DBT with a student population,

For me, I think one of the most important and beneficial things of implementing DBT has been working with skill acquisition. As a therapist, I find it actually very rewarding when you’re working with a student who comes back with a diary card that shows, “Oh, I have practiced the tip skill three times last week” or “I did this skill.” I think that’s motivating, one, for a therapist to see that your patient is really putting in the work themselves.

(P. 6)

Within this theme, clinician perceptions, training, and interest in engaging in DBT practice affected the extent to which DBT services were ultimately offered in their CCCs. While clinicians found success with DBT to be reinforcing, they also wanted more support to continue to develop their DBT expertise in order to provide more comprehensive services to students.

Discussion

Participants’ descriptions of DBT in their CCCs yielded four main themes, all of which aid in the understanding of the factors that influence implementation and sustainability of DBT programs on campus. In this study, participants sought to utilize their DBT training in a creative and integrated fashion, so that DBT practice did not have to be an “all or nothing” option for CCCs. This point is important because although it may be helpful to have a best practice model or standardized protocol for DBT in CCCs in some regards, not having this type of resource means that clinicians are able to customize treatment programs to the specific needs of their student populations and campus cultures. Operating in this fashion may also reduce negative impressions of DBT as a rigid or inflexible treatment approach among staff members.

Consistent with previous research (Chugani & Landes, 2016) we found that CCC clinicians faced significant barriers in the implementation of DBT. However, they also reported that they have persisted in presenting DBT material to both staff and students as a method of reducing certain barriers, such as increasing “buy-in” for DBT or helping staff identify students on their individual caseloads that may benefit from the program. Participants also supported their programs by structuring groups to include skills with the highest relevance for the particular student group as well as working within the students’ abilities, needs, cultures, and other contextual factors (e.g., physical space, time, academic calendar, etc.).

Another challenge in DBT implementation that was frequently noted by participants is that the decision to participate in the DBT program meant that they would take on this role and responsibility in addition to their other required activities. It may be that it is easier for clinicians to implement a comprehensive model when the clinician is practicing DBT as their primary job role in the CCC. At minimum, this also suggests the importance of finding solutions related to release time or productivity requirements that are supported by CCC administrators, as this would likely make participation in delivering DBT both more attractive and feasible for center clinicians.

Interestingly, we found a dialectic within the findings from this study. In DBT, the term dialectic refers to co-existing truths that conflict with one another. The goal of becoming aware of dialectical tension is to try and reach a synthesis rather than to accept only one position or the other as the truth. In this case, participants recognized the difficulty in implementing a comprehensive model of DBT at CCCs. On the other hand, they also expressed a strong wish to move towards more intensive DBT training for their staff with the long-term goal of implementing a more robust and comprehensive DBT program at their centers. Participants felt strongly that DBT programs benefitted a range of student needs, from those with more serious or high-risk concerns to those navigating normal developmental issues. Increasing attention to multicultural issues within DBT programs or skills training groups could enhance these benefits. As identity is a significant part of college life and transition to adulthood, intentionally integrating or applying DBT skills learned to the various identities that students often hold may better support them in navigating their mental health issues.

Conclusion

Our findings are largely consistent with previous research related to DBT implementation both on and off campus. Time, funding for training, and other resources (e.g., space, staff availability and interest, etc.) remain the top barriers to implementation. Given the applicability of DBT to a wide range of student concerns, more research focusing on the cost to benefit ratio may assist CCCs in obtaining better administrative buy-in and support, including funds for training, release time from productivity requirements for learning, and dedicated time for DBT. More broadly, understanding what factors are most salient in both obtaining and maintaining campus administrations’ support for DBT programs is likely to yield more effective strategies to promote DBT program sustainability. Finally, more research is needed to enhance factors that contribute to DBT program acceptability across CCC clinicians. While our participants were all engaged in providing DBT, not all clinicians in a center will be interested in delivering this type of therapy. Our findings suggest that DBT programs in CCCs are likely to be more feasible when center clinicians refer appropriate students to the program and support student participation in DBT through individual therapy sessions.