(PS5-D98) Setting the Agenda for Suicide Prevention Intervention to Promote Health Equity: A Scoping Review of Adaptations for Dialectical Behavior Therapy Outside of the United States of America

Background. Dialectical Behavior Therapy (DBT; Linehan, 1993) is an evidence-based psychotherapy to reduce suicide behavior and nonsuicidal self-injury. While initial studies established DBT’s efficacy within primarily white, Western, women residing in the United States (Linehan et al., 1991), DBT is now being globally implemented. Adapting DBT to new settings or populations may include changes to content (what is discussed in session) or context (e.g., the way it is delivered, including to whom the intervention is offered, practitioners providing it, organizations offering it). To understand the frequency and types of content and context adaptations made in other geographic regions, we conducted a systematic scoping review of studies mentioning DBT conducted outside the United States.

Methods. Following PRISMA guidelines (Tricco et al., 2018), we conducted a systemic search of PubMed, Embase and PsycINFO for articles on “dialectical behavior therapy.” We selected articles that discussed implementation of a component of DBT within a population that was different from the sample in which DBT was originally developed, using identity constructs identified through the ADDRESSING framework (Hays, 1998; Hays, 2008). To examine potential regional differences, we excluded all studies taking place in the United States of America. We used the FRAME framework to inform data extraction, focusing on the justification of content and context adaptations (Stirman, 2019).

Results. Ultimately, 139 articles met study inclusion criteria. Articles were based in Europe (51.8%, 72/139), Australia and Oceania (14.4%, 20/139), North America outside of the United States (10.8%, 15/139), the Middle East (10.1%, 14/139), Asia (7.9%, 11/139), and South America (2.2%, 3/139). A majority of DBT was delivered in outpatient settings (73.4%, 102/139); the majority of included studies implemented comprehensive DBT (36.7%, 51/139) and DBT skills group (63%, 63/139).

The largest number of content adaptations were skipping content elements (56.1%, 78/139) and condensing weeks of treatment (42.4%; 59/139). In most cases, a justification was not provided for the skipping of content elements or condensing of treatment (57.7%, 45/78 and 67.8%, 40/59, respectively.)

Context adaptations were largely not reported with the highest context adaptation being a change in setting, followed by format and a change in personnel being the lowest reported context adaptation (15.1%, 21/139; 13.7%, 19/139; and 6.5%, 9/139). 

Discussion. The most common adaptations made to DBT conducted outside of the United States are content adaptations, specifically skipping content elements and condensing treatment weeks, while context adaptations were largely not reported. The most frequent elements skipped included condensing or omitting skill modules or not including DBT treatment components such as phone coaching or the weekly consultation team. These adaptations were rarely explained, leaving little guidance for researchers, clinicians, or policymakers further adapting DBT. Further study should evaluate the efficacy of these adaptations and evaluate reasons for adaptation to inform further treatment refinement.