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Engaging Line Staff in Dialectical Behavior Therapy (Part 1)

1.6.2021 - Engaging Line Staff in Dialectical Behavior Therapy Part 1

This feature by Nicole Kletzka, PhD is Part 1 of 2 in a series about engaging line staff in Dialectical Behavior Therapy. Through this series, Nicole will explore strategies to improve line staff engagement in DBT. In this first part, Nicole begins by sharing background on DBT and the role of line staff, examining the importance of the structure of DBT programming, and noting the link between staff empowerment and company outcomes.


Since its inception, Dialectical Behavior Therapy (DBT) has proven effective for treating a variety of different populations across many different settings.  It was initially researched with outpatient samples of individuals diagnosed with borderline personality disorder (Linehan, 1993).  Because inpatient settings routinely treat individuals with life-threatening behaviors, and because as many as 72% of individuals with BPD will be inpatients at some point during their life, there has been a great deal of interest in establishing DBT treatment programs within inpatient settings (Lieb et al., 2004).  A review of published studies on inpatient DBT programs by Bloom et al. (2012) found that many inpatient DBT programs report reductions in patients’ suicidal ideation, non-suicidal self-injury, depression and anxiety. Anger and aggression outcomes were more mixed.  Thus, the research suggests that inpatient programs are effective yet also have areas in which they can be improved.

Regardless of the setting, comprehensive DBT programs address five different functions:  engaging and motivating clients, client skill acquisition, structuring the environment, helping clients generalize skills, and attending to the motivation and capability of treatment providers (Linehan et al., 2001). Within inpatient programs, unit staff work on the floor with patients 24 hours a day.  They may come from mental health or security backgrounds and are given various job titles, including line staff, mental health associates, frontline staff, or security staff.  For this blog, they will be referred to as line staff. Because they predominantly work on the floor with the patients, they are central in helping structure the environment and assisting patients with DBT skill generalization.  This blog will explore strategies to improve line staff engagement in DBT.  

The structure of DBT programming in an inpatient facility can play a large, yet often unnoticed role in line staff engagement.  DBT program structure is impacted by decisions made at multiple systemic levels.  High level administrators and state systems often invest in DBT because it is an evidence-based program with strong outcomes in reducing suicide, self-harm, and other problematic behaviors.  In addition, these systems recognize that their initial financial investment will ultimately result in cost savings because of the reduction in mental health hospitalization rates for DBT consumers (Krawitz, & Miga, 2019).   Mid-level administrators make decisions about the day-to-day operation, staffing and structure of the units.  Educating administrators about the different functions of comprehensive treatment programs and involving administrators at all levels throughout the DBT training process can improve the long-term outcomes of the program by helping them make educated decisions about how to implement the DBT program in ways that work for both the consumers and the staff involved in providing DBT.

Large system implementation projects often focus on training DBT clinicians to provide both individual therapy and skills training. In recent years, they have also included line staff in training ventures, recognizing their central role in treatment.  As DBT training and consultation models have evolved, system-wide implementation projects have begun budgeting for ongoing consultation and repeated training to help ensure that staff trained have adequate supports to implement and sustain the programs.  Several of these programs have seen their line staff engagement drop significantly over time despite the resources dedicated to initial training and ongoing consultation.  Identifying and resolving these challenges will help agencies develop effective and sustainable DBT programs rather than finding themselves in a pattern of repeated training without gaining traction with the DBT inpatient programs. 

Just as structure is a core component of individual DBT, it is central to DBT program success. Not considering the DBT program structure is like asking an agency to sew an outfit by providing them with a needle and thread, but not providing the fabric.  In these circumstances, line staff may initially be excited and engaged, but may quickly set aside their new skills because they are lacking a platform to implement their use. The type of fabric is less important than having a fabric. Some agencies establish a DBT milieu to meet this need.  This can foster a sense of engagement for line staff as it allows line staff on the unit to be immersed in the DBT culture in the physical environment.  The unit may create posters that list the DBT agreements and assumptions, or post definitions of core DBT skills.  The milieu might include unit-wide, daily mindfulness activities, or teach the skill of the day to the entire unit.  A DBT milieu can also integrate DBT skills use into patient plans of service and can include protocols in which DBT strategies are integrated into the milieu.  One example is the egregious behavior protocol.  This is a protocol in which the unit responds to destructive unit behaviors using DBT strategies and principles.  In such a case, the patient would be separated from others on the unit while they complete their own chain analysis/assessment of the problematic behavior. They can then debrief with their primary therapist, line staff, and other treatment team members and find a way to make reparations for the problematic behavior.   With such an integrated approach, the benefits of DBT skills training are apparent and supported directly by line staff, which increases line staff engagement with the DBT process.

For some agencies, creating a DBT milieu may not be practical, however. This can occur in situations where other treatment needs supersede emotional and behavioral regulation goals.  Forensic settings and psychiatric inpatient hospitals may fall into this category.  In these settings, treating psychosis or working on problems related to the legal system are primary.  Patients with emotional or behavioral dysregulation may be interspersed on different units.  In this scenario, the hospital may create a structure that is more like an outpatient DBT program: providing skills and/or individual treatment as ancillary to the milieu. When this happens, it is much more challenging to engage line staff in DBT. 

Organizational psychology research on staff engagement and empowerment suggests that feeling included and valued is central to employee engagement and commitment and is also linked to company outcomes (Fernandez & Moldogaziev, 2013; Simpson, 2009). Specifically, a review of public organizations found an increase in perceived performance if employees are given the knowledge and skills to work effectively and if they are given discretion to change work processes (Fernandez & Moldogaziev, 2011). Applying this to DBT, agencies can increase engagement by providing DBT training, defining the role of line staff in providing DBT, and providing a structure and ongoing opportunities to allow line staff to actively participate in meeting DBT treatment targets. Even without a full DBT-dedicated milieu, units can adopt effective DBT milieu strategies.  Writing DBT-focused interventions into patients’ individual plans of service can help solidify the line staff’s role.  Staff may be enlisted to help patients with weekly DBT homework. Skills trainers may email homework to line staff following the weekly skills training groups, so that staff can assist patients in completing the homework between groups.  Many skills trainers share links to media examples of the skills with line staff to help them more effectively work with patients in the milieu. Staff may be particularly motivated to implement DBT strategies when provided with outcomes to illustrate the efficacy of DBT treatment overall and with their specific patients.  Some hospitals have even been able to gather outcome data to illustrate that there is greater patient improvement when staff are involved as patient mentors and coaches (Kletzka et al., 2014). 

Now that part 1 has set the stage for the importance of staff engagement, keep watching for part 2 of this series, in which Nicole will further explore program structure and investment, dealing with practical challenges, and other factors that may influence staff buy-in.


Nicole Kletzka, PhD is DBT Supervisor of the Center for Forensic Psychiatry in Saline, MI, completed the Linehan Board of Certification process in 2015 and joined Behavioral Tech in 2016. Read Nicole’s full bio here.

REFERENCES (part 1 and part 2):

Bloom,  J.M., Woodward, E.N., Susmaras T., & Pantalone,  D.W.. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: A systematic review. Psychiatric Services, 63(9), 81-89.

Fernandez, S., & Moldogaziev, T. (2013). Employee empowerment, employee attitudes, and performance: Testing a causal model. Public Administration Review73(3), 490-506.

Fernandez, S., & Moldogaziev, T. (2011). Empowering public sector employees to improve performance: does it work?. The American Review of Public Administration41(1), 23-47.

Fox, E. (2018). Delivering DBT in an inpatient setting. In The Oxford Handbook of Dialectical Behaviour Therapy.

Kletzka, N., & Witterholt, S. (2014). DBT staff diary card.  

Kletzka, N., Lachat, C., Echols, S., & Witterholt, S. (2014, November). Structuring dialectical behavior therapy treatment in a forensic inpatient setting: Patient progress and staff perceptions.  19th Annual ISITBT DBT Conference. Philadelphia, PA. 

Krawitz, R., & Miga, E. M. (2019). Cost-effectiveness of dialectical behaviour therapy for borderline personality disorder. In The Oxford handbook of dialectical behaviour therapy.

Lieb, K., Zanarini, M.C., Schmahl, C., Linehan, M., & Bohus, M. (2004). Borderline personality disorder, The Lancet, 364, 453-461.

Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behavior therapy for borderline personality disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (p. 470–522). The Guilford Press.

Simpson, M. R. (2009). Engagement at work: A review of the literature. International Journal of Nursing Studies46(7), 1012-1024.  

Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. In L.A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (pp. 69-111). The Guilford Press.