Case Study: The DBT Implementation Journey of Dialectical Behaviour Therapy in five European Countries

Case Study: The DBT Implementation Journey of Dialectical Behaviour Therapy in five European Countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Case Study: The DBT Implementation Journey of Dialectical Behaviour Therapy in five European Countries Amy Gaglia Essletzbichler, Miriam Biermann, Magdalena Skuza, Natálie Češková, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9279155/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 7 You are reading this latest preprint version Abstract Background This paper is a narrative review the implementation trajectories Dialectical Behaviour Therapy in five countries, the UK, Germany Norway, Poland, and the Czech Republic in Europe over the past 30 years. The aim of this comparison is to identify common and divergent systems levels facilitators and hinderances of DBT implementation. Methods DBT experts in each respective country were asked to provide a narrative account of their country’s implementation journey. Histories were then considered in accordance with existing DBT implementation frameworks. Results Common themes emerged such as the importance national guidelines on evidence-based treatment shape implementation, university affiliations promote dissemination, implementation and research activities, national societies help to create standards. Conclusion There are common DBT implementation trajectories that exist across geography and nationally specific mental health care systems. The discussion of the refining of national DBT practices based on emerging literature and the importance of outcomes of implementation such as therapists’ behaviour or client related outcome data adds to existing information. DBT Implementation Case Study Introduction Over the last 40 years a revolution in the treatment of Borderline Personality Disorder (BPD) occurred. A significant aspect in the change of the landscape began with Marsha Linehan’s treatment Dialectical Behaviour Therapy (DBT). Linehan’s original aim was to create an effective treatment for individuals engaging in suicidal and self-harming behaviours (Linehan, 1993 ). In the 1980s, to strengthen her applications for research funding, she incorporated the diagnosis of borderline personality disorder (BPD) into her work (Linehan, 2016, UW video lecture Dialectical Behavior Therapy (DBT): Where We Were, Where We Are and Where Are We Going). Publication of the treatment manual, Cognitive Behavioral Treatment for Borderline Personality Disorder, in 1993 further accelerated implementation efforts and firmly aligned DBT with the treatment of BPD. Clinical implementation of DBT in Europe began around 1994, when Linehan provided training to a group of clinicians from the United Kingdom (UK), Germany, and the Netherlands. From that point, Germany, the UK and the Netherlands were the first European nations to establish robust DBT programmes, research initiatives, and national DBT societies. This paper reviews the implementation trajectories in five European countries, spanning over 30 years, and identifies both shared and divergent processes. Common themes include the need for comprehensive training, an emphasis on adherence and fidelity to the treatment manual and structures, the benefits of research and treatment development and adaption, partnerships with universities, and the establishment of national DBT societies. While there are common themes, implementation processes remain highly specific to each country’s healthcare system. Implementation Processes Reviews by Toms et al. (2019) and Navarro-Haro et al. ( 2024 ) identify key facilitators and barriers to DBT implementation. DBT’s team-based structure, considered essential by Linehan ( 1993 ) to protect therapists from burnout and reduce the risk of therapists engaging in unethical behaviour, distinguishes it from most other psychotherapies. All randomized controlled trials (RCTs) that demonstrate DBT’s efficacy and effectiveness have been delivered with the mode of consultation team model. More broadly, implementation literature indicates that team-based models are more likely to produce sustainable system-level change due to team processes (Higgin, Weiner & Young, 2012; McGuier et al., 2023 ) and thus the team-based nature of the treatment may be account for part of the success of DBT. Nevertheless, data from a large scale real-world systemic implementation suggest that some clinicians attempt to deliver DBT without a consultation team. Landes et al. (2107) study of the implementation of standard DBT across the Veterans Health Administration in USA by 59 teams reported that therapists on 26 teams either did not have a consultation team or that they did not really attend consultation team meetings. Effective DBT implementation requires teams that are well-trained, sustainable, able to deliver comparable clinical outcomes, and responsive to the needs of the population (Swales, 2010 a; 2010 b). Reviews by Toms et al. (2019) and Navarro-Haro et al. ( 2024 ) describe implementation as beginning with a preparation phase shaped by organisational culture, communication practices, and information-gathering through external consultation. Organisational support, including protected time for clinicians to train and implement the model, and adequate funding, is critical to successful implementation. Creating an empowered implementation team that can design a plan aligned with both clinician interest and organisational priorities also enhances success. DBT implementation can also be catalysed by broader systemic developments, such as legislative changes or shifts in accepted practices for treating individuals with severe and enduring mental health difficulties. Implementation is more likely to succeed when DBT’s structures, strategies, philosophy, and underlying assumptions help the host organisation fulfil its own values and goals. An early activity in the implementation process involves key stakeholders receiving an orientation to the treatment and engaging in discussions about the treatment’s fit with organisational aims. Such processes tend strengthen organisational commitment to implementation. Establishing supportive organisational structures, such as job planning, communication pathways, accountability systems, financial resources, and physical space, increases the likelihood of long-term success. Additionally, it can help to orient team to information the likelihood staff turnover and the need to plan for relatively early in the implementation process to ensure that teams survive long-term (King et al., 2018 ). Methods Each country selected to participate in the narrative analysis presented their national experience at a DBT dissemination conference organised by the research and implementation group of Project Gradient in the Czech Republic in June 2025. The selected countries represent early, mid, and recent implementers of DBT in change national health contexts. Each narrative description of the unique national history of DBT implementation is provided by a local DBT expert with knowledge of DBT’s developmental pathway in their respective country. Data sources included documentation from national societies as well as other relevant national policy documentation. Common themes were then highlighted by lead author. Themes were discussed in relation to existing implementation frameworks for DBT (Tom et al, 2019). Results Case Studies Implementation trajectories in the UK, Germany, Norway, Poland and the Czech Republic reveal recurring themes, including the influence of public health initiatives, the development of training infrastructures, partnerships with universities, and the establishment of independent professional organisations responsible for assessing adherence and fidelity to the DBT model. Public Health Context and Timeline of Key Developments in DBT in the United Kingdom British Isles Dialectical Behaviour Therapy (biDBT), the most established DBT training organisation in the UK, estimates that slightly more than 250 teams currently deliver DBT in the UK. Over half operate in outpatient settings, and teams exist across the lifespan, with one-third working in child and adolescent mental health (CAMHS) and about 5% in older adult services. These teams offer either comprehensive DBT or “skills-only DBT,” also referred to as “all modes minus individual therapy.” Reaching this level of provision has taken roughly three decades. Implementation of DBT has been in part facilitated by changes in UK public policies. In the 1970s, psychological therapy in the UK increasingly emphasised evidence-based treatments (EBTs), marking a shift toward empirically supported interventions in mental health services. The 1990s saw the expansion of community-based care, promoting treatment outside institutional settings (NHS and Community Care Act, 1990 ). The establishment of National Institute for Clinical Excellence (NICE) in 2001 further embedded research-led practice by formally evaluating and endorsing evidence-based psychological interventions. In 2003, a key policy document stated that personality disorder (PD) should no longer be considered a diagnosis of exclusion (National Institute for Mental Health in England, 2003 ). This improved access to psychological treatment for people with PD and created a more welcoming context for DBT. In 2009, NICE published guidelines on treating BPD, designating DBT as the recommended treatment for women who engage in self-harm (National Institute for Health and Care Excellence, 2009 ). The synthesis of a decade of bottom-up implementation of DBT coupled with policy shifts created fertile conditions for acceptance of a team-based intervention and wider implementation of DBT in the UK. Development of DBT in the UK In 1994, Dr Michaela Swales, arguably the UK’s earliest DBT adopter, trained in the treatment with Professor Marsha Linehan in the United States. Upon returning to the UK, she established the first DBT programmes on an adolescent inpatient unit in Bangor, North Wales. Between 1994 and 1997, Swales, Dr Heidi Heard, a member of Marsha Linehan’s research team, and a colleague from the University of Leeds launched the first formal UK DBT training programme. Partnerships with universities can significantly support the implementation of emerging therapeutic models and research into their effectiveness. A major milestone in long-term implementation was the creation of a national training infrastructure. biDBT, founded in 1997, maintained close ties with Linehan’s US-based training organisations and became the primary provider of DBT training in the UK and Ireland. biDBT offered evidence-based DBT training, including the 10-day Intensive Training™, which prepares whole teams to implement DBT through 5 days of instruction, followed by six months of self-directed implementation activities, and then another 5-day module focused on shaping clinical practice (Navarro-Haro et al., 2019). biDBT also delivered the 5-day Foundational Training for individuals joining established DBT teams (Bender et al., 2023 ). Research Research conducted within the UK healthcare system further supported DBT’s dissemination. Two RCTs, Feigenbaum et al. ( 2012 ) and Priebe et al. ( 2012 ), evaluated DBT against treatment-as-usual in NHS adult outpatient settings. These studies, conducted in collaboration with University College London and Queen Mary University of London respectively, provided evidence for DBT’s acceptability and effectiveness in the UK context. Professional Standards Infrastructure Another milestone for the DBT community was the establishment of nationwide professional standards for DBT delivery through the creation of a professional society. The Society for Dialectical Behaviour Therapy in the UK and Ireland (SfDBT), founded in 2012 by Dr Christine Dunkley and Professor Stephen Palmer, functions similarly to the British Association for Behavioural and Cognitive Psychotherapies (BABCP). An essential element in legitimising DBT was the professional society’s institutional independence from the training company biDBT and other training organisations. SfDBT hosts annual conferences and workshops to promote continuing professional development and networking. In 2014, SfDBT introduced an accreditation process for DBT therapists, aligned with the Linehan Board of Certification (LBC) in the US. Accreditation, more commonly known in other parts of the world as certification, requires clinicians to hold a core mental health professional qualification, be complete 450 hours of DBT training, be delivering comprehensive DBT, maintain an ongoing mindfulness practice, receive individual supervision, and submit work samples that are assessed for their adherence to the DBT model on the DBT-ACS (Linehan & Korslund, 2003 ) originally and more latterly the DBT-ACI (Harned, Schmidt & Korslund, 2023) adherence rating measures. The SfDBT UK and Ireland is also a member organisation of the European DBT Association (EDBTA). SfDBT expanded its accreditation system in 2019 to include the accreditation of supervisors and, in 2021, began accrediting DBT training programmes. In 2024, SfDBT introduced accreditation for DBT treatment programmes, using the Program Fidelity Scale to assess team-level adherence (Harned & Schmidt, 2022 ). University Degree These efforts, similarly, to other implementation efforts, both influenced and were influenced by broader public health developments. In 2020, Bangor University and biDBT received NHS England funding to deliver a fully funded Postgraduate Diploma in DBT ( https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/ ). The Post Graduate Diploma in DBT is a university degree equivalent to a taught masters’ degree without a thesis. The training specifications adopted by NHS England allowed for completers of the degree to have completed all of the SfDBT requirements for an accredited DBT Therapist. Ultimately, this course became an SfDBT level 3 accredited training course and allowed for its graduates to be immediately accredited as DBT therapists. Other level 1 and 2 university level DBT training courses have also started to appear in the UK. Benchmarking: moving from outputs to outcomes As an extension of this project, biDBT launched a national benchmarking website to support the evaluation and continuous improvement of DBT practice in the UK ( https://dbt.uk.net/ ). Benchmarking allows teams offering either comprehensive DBT or “skills only” DBT to compare their programme outcomes with those of RCTS and peers. At a minimum, teams collect data at various points on client’s quality of life, difficulties in regulating emotion and ways of coping. The data is immediately accessible to teams and individual therapist and can be used to inform treatment discussions and consultation team meeting processes. Additionally, the website assists with work capacity calculations for teams and therapists. This system further moves the UK to a focus on outcomes. The movement from output to outcomes began with the introduction of therapist, supervisor, and programme accreditation and now the focus on client outcomes as well helps ensure that money invested in DBT delivers actual change clients’ behaviours and lives. Implementation Pathways, and Further Developments of DBT in Germany Dialectical Behaviour Therapy (DBT) was introduced in Germany in the mid-1990s and has since become one of the most widely implemented and empirically supported psychotherapeutic treatments for borderline personality disorder (BPD) and related high-risk clinical presentations. Its dissemination occurred within a healthcare system characterised by statutory health insurance coverage, a strong inpatient and psychosomatic treatment sector, and an established tradition of evidence-based psychotherapy. These structural conditions provided a favourable context for the “top-down” implementation of a comprehensive, team-based treatment model such as DBT, particularly for patients with severe emotion dysregulation, suicidality, and complex comorbidity. Early Implementation and Research Foundations A key driver of DBT dissemination in Germany was the early integration of clinical implementation with systematic research. In the mid-1990s, Professor Martin Bohus and colleagues at the Central Institute of Mental Health (CIMH) in Mannheim received direct training from Marsha Linehan and subsequently established one of the first comprehensive DBT programmes for patients with BPD in Germany (Linehan, 1993 ). From the outset, the Mannheim programme combined routine clinical delivery with rigorous outcome evaluation. Early randomised controlled trials conducted in Germany demonstrated the effectiveness of DBT in reducing self-harm, suicidal behaviour, and psychiatric hospitalisation among patients with BPD when compared to treatment-as-usual (Bohus et al., 2000 ; Bohus et al., 2004 ). These studies contributed substantially to the international DBT evidence base and played a critical role in legitimising DBT within German psychiatry and psychosomatic medicine. Subsequent naturalistic and routine-care studies showed that DBT could be implemented effectively outside specialised research contexts, supporting its scalability within the German healthcare system (Landes et al., 2016 ). Training Infrastructure and National Dissemination A defining feature of DBT implementation in Germany has been the early establishment of a nationally coordinated training and governance structure. Building on close collaboration with Linehan and US-based DBT training providers, German DBT leaders developed standardised, team-based training pathways emphasising supervised implementation, consultation teams, and long-term sustainability. The Dachverband Dialektisch Behaviorale Therapie (DDBT), founded in the early 2000s, became the central professional organisation responsible for promoting high-quality DBT practice in Germany. The DDBT coordinates training standards, defines requirements for DBT team composition, and supports continuing professional development through conferences, workshops, and supervision networks (DDBT, n.d.). Training in provided by organisations that are provided franchise licenses by the DBBT thus maintaining a dual structure in which training provision is separate from therapist certification institutions. Training typically follows an intensive team-based format, consisting of two multi-day teaching blocks separated by an extended implementation phase. Foundational trainings are offered for clinicians joining established DBT teams, alongside advanced courses for specialised adaptations. Consistent with Linehan’s original model, participation in a DBT consultation team is regarded as a core component of ethical and effective DBT delivery in Germany (Linehan, 1993 ). This strong emphasis on treatment adherence and fidelity has contributed to relatively consistent implementation standards across diverse clinical settings. Scope of Clinical Implementation Over the past three decades, DBT has been implemented widely across Germany in psychiatric inpatient units, psychosomatic hospitals, day clinics, and outpatient services. Particularly strong uptake has occurred in specialised inpatient and day-treatment programmes for personality disorders and trauma-related conditions, where the intensity and structure of DBT align well with service configurations and reimbursement models. DBT is explicitly referenced in German national clinical guidelines for the treatment of borderline personality disorder, reinforcing its status as a standard, evidence-based intervention within routine care. Like developments in the UK and Norway, DBT dissemination in Germany has been facilitated by broader public-health shifts toward evidence-based practice and increased recognition of personality disorders as treatable conditions. Development and Implementation of DBT for PTSD One of the most influential contributions to the international DBT field emerging from Germany has been the development of DBT for Posttraumatic Stress Disorder (DBT-PTSD). This adaptation was developed at the CIMH to address individuals with PTSD related to childhood abuse who also present with severe emotion dysregulation, dissociation, and self-harm, patients frequently excluded from standard trauma, focused treatments. DBT-PTSD integrates trauma-focused cognitive and exposure-based interventions within a DBT framework while retaining core principles such as hierarchical treatment targets, the balance of acceptance and change strategies, and therapist consultation teams. Treatment follows a structured, phase-based approach, with initial emphasis on safety and skills acquisition before the introduction of trauma processing (Steil et al., 2011 ). A series of German randomised controlled trials demonstrated that DBT-PTSD is effective in reducing PTSD symptom severity, depressive symptoms, and global psychopathology in highly complex patient populations (Bohus et al., 2013 ). A large multicentre RCT further showed DBT-PTSD to be at least as effective as Cognitive Processing Therapy (CPT), with lower dropout rates and superior outcomes in emotion regulation and functional impairment (Bohus et al., 2020 ). These findings supported the rapid implementation of DBT-PTSD in German inpatient and day-treatment settings and stimulated international dissemination. Further DBT Adaptations in Germany In parallel with DBT-PTSD, several additional DBT adaptations have been implemented and evaluated in Germany. DBT for adolescents (DBT-A), based on the original model by Rathus and Miller ( 2002 ), has been widely adopted in child and adolescent psychiatric services. German implementations emphasise developmental considerations and caregiver involvement through multifamily skills groups. Empirical evidence from German-speaking contexts (e.g. Fleischhacker et al., 2011) and international trials indicates significant reductions in self-harm, suicidal ideation, and overall symptom severity (Mehlum et al., 2014 ). DBT for Substance Use Disorders (DBT-SUD) has been implemented primarily in inpatient and day-treatment addiction services and dual-diagnosis programmes. This adaptation integrates DBT strategies with addiction-specific interventions such as dialectical abstinence and contingency management. Clinical and empirical findings suggest improved treatment retention and reductions in substance use and self-harm in highly comorbid populations (Landes et al., 2016 ). DBT-based approaches have also been adapted for eating disorders, particularly bulimia nervosa and binge-eating disorder, within specialised psychosomatic settings. DBT-oriented interventions target dysfunctional eating behaviours as maladaptive emotion regulation strategies and have been associated with reductions in binge eating and purging, as well as improvements in emotion regulation (Safer et al., 2009 ). Development of DBT in Norway Research as an implementation driver Dialectical Behavior Therapy (DBT) was introduced in Norway as a university-based initiative originating at the National Centre for Suicide Research and Prevention (NSSF) at the University of Oslo. The first formal training, led by Alec Miller and Sarah Reynolds from the Behavioral Tech Institute (BTech), the USA based training company previously affiliated with Marsha Linehan, was organized by a clinical research team at NSSF in preparation for a randomized controlled trial (RCT) of DBT for adolescents with repeated self-harm. From its inception, the project combined rigorous clinical implementation with a research agenda: two research therapists formed DBT teams at separate sites within Oslo University Hospital and received specialist training. The initiative was motivated by a national public-health objective to reduce self-harm and suicide attempts among young people, and by the research team’s assessment of DBT as a promising intervention warranting evaluation in an RCT. Inspired by Miller’s promising adaptation for suicidal adolescents (Rathus & Miller, 2002 ), NSSF obtained partial funding from the Norwegian Health Directorate and the DAM trust, a foundation that funds health and social welfare research, to conduct a feasibility study and a subsequent RCT, with Professor Lars Mehlum serving as principal investigator. Training Team Since 2006, the DBT Norway Training Program, operating as a university-affiliated non-profit within NSSF, has established a quality-assured system for educating and developing therapists, supervisors, and trainers. Its structure broadly parallels the standards proposed by the EDBTA ( https://edbta.eu/wp-content/uploads/2026/03/Qualifications-for-different-levels-Trainer-levels-fFebruary-2027.pdf ). The program developed nationally adapted guidelines for therapist education, trainer recruitment and development, and mentor/supervisor training. Teaching materials have been translated and adapted to Norwegian from English, and the center implemented a program for the continuing professional development of trainers and supervisors. Trainers can teach in both Norwegian and English. Instead of formal certification processes adopted in the UK and Germany, NSSF utilizes a model of sustained, team-focused supervision. The program provides consistent team supervision over multiple years to many DBT teams across Norway, including opportunities to assess and address treatment adherence. One trainer has received specific training in adherence assessment materials. Adherence rating materials have been translated into Norwegian in collaboration with the DBT-ACS (Korslund & Linehan, 2003 ) and DBT-ACI (Harned, Schmidt & Korslund, 2023) calibration processes. NSSF is in the process of converting its DBT training to a flipped-classroom model, increasing demands on pre-course preparation (e.g., learning objectives review, assigned readings, video lectures, short quizzes, literature summaries, and case-based question formulation). Didactic and demonstration videos have recently been produced to support this transition. The Norwegian Intensive Training model is the evidence based intensive training model (Navarro-Haro et al., 2019). Trainees complete assignments and examinations and implement DBT at their workplaces between sessions. New teams receive monthly consultation, and novice clinicians are mentored by experienced team members. Intensive training is provided both remotely and on-site. Foundational training for clinicians joining existing DBT teams consists of either five or ten full days (Bender, et al 2023 ). NFFS also organizes advanced training courses and a biannual DBT conference. The conferences has gathered clinicians from all over Norway as well as some other nordic coutries biannually for 18 years, last time 250 clinicians participated. All NSSF trainers also function as supervisors, supplemented by two additional supervisory clinicians. The trainers offer supervision to DBT teams irrespective of experience level; currently, half of Norwegian DBT teams receive consultation from experts affiliated with the DBT Norway Training Program, and some teams have benefited from monthly supervision for many years. Formal team and applicant requirements are explicit: teams should include at least four mental health practitioners, with a minimum of half being medical doctors or clinical psychologists. These criteria aim to promote patient safety, diagnostic competence, and the sustainability of local DBT services. The evidence-based implementation of DBT in Norway has been inspired by favorable research outcomes. Both the feasibility study and the RCT of DBT-A for adolescents with repeated self-harm produced positive findings; longer-term follow-up indicated sustained effects, including remission of self-harm and reduced suicidal ideation into adulthood for those treated during adolescence (Melhum, et al. 2014, 2016, 2019 & 2026; Tørmoen et al., 2014 d rmoen et al., 2014). The strong focus on research is ongoing, and a research network with 6 collaborating units in Norway and Denmark is led by the center. Current DBT Landscape in Norway Currently, approximately 50 DBT consultation teams are established across health-care trusts in Norway, and more than 600 clinicians have been trained in DBT by the Norwegian DBT Training Team at the NSSF. For a sparsely populated country, this level of dissemination is remarkable. The teams operate in a range of settings, including adult outpatient clinics, adolescent outpatient services, several specialized services collaborating with child protection agencies, and a small number of substance misuse treatment units. In 2025, the NSSF contributed to the development of new national guidelines for the treatment of personality disorders. A revised guideline, to be published in May 2026, will list DBT as one of the preferred treatment options. Recent developments include the implementation and adaptation of DBT-PTSD, Radically Open DBT, and DBT for substance use disorders (DBT-SUD). Furthermore, Intensive DBT is currently in pilot testing as a preparation for a fully funded randomized controlled trial. Professional Association In 2017 a professional association, Norway-DBT, (N-DBT) aiming to spread knowledge, use and respect for DBT among clinicians, leaders, patients and their next of kin was established by Lars Mehlum. NSSF have a board position in N-DBT to contribute with our expertise due to our special mandate of implementing DBT in Norway given by the National Health Directorate. Development of DBT in Poland: invalidating context Poland provides a markedly different context for the implementation of DBT than the Western European and Scandinavian countries described above. There is virtually no institutional support for evidence-based psychotherapies, resources are limited, and university training in psychotherapy is rarely clinically oriented, while medical universities tend to marginalise psychosocial interventions as treatment options in favour of biological psychiatry. Most of the systemic facilitators of DBT implementation identified in the introduction to this paper, such as evidence-based mental health policy, research infrastructure, and clear institutional mandates, have been absent in Poland for many years and are unlikely to emerge soon. Instead, DBT has developed in Poland in the context of a broader crisis in psychiatry and mental health care, marked by chronic underfunding, political conflicts over how services should be organised, and the politicisation rather than professionalisation of key institutions. In this environment, clinical decision-making is rarely guided by evidence, international examples are not treated as models, and the mental health field is fragmented by long-standing tensions between professional groups and institutions. Despite the lack of facilitators and the presence of systemic obstacles, DBT has developed significantly in Poland over the last 10 years. Development of DBT in Poland: timeline and bottom-up approach Over the past decade, DBT in Poland has developed almost entirely through bottom‑up initiatives. The Polish DBT Association (PTDBT) was founded in 2016 by a small group of clinicians who initially relied on self‑study, short international workshops, and online materials. In 2017 the first larger introductory training with Prof. Martin Bohus gathered around 100 participants, and in subsequent years 10 clinicians completed intensive training abroad and began working together in virtual consultation teams. In 2018 the PTDBT organised the first international DBT conference in Poland. In the same year, cooperation with the National Educational Alliance for Borderline Personality Disorder (NEABPD) was initiated and the first online training for Family Connections (FC) programme leaders was conducted ( https://www.neabpd.org/family-connections ). At that point, it became clear that no there was institutional support or interest in DBT from academia, mental health authorities, or funding bodies in Poland. Therefore, DBT for families in the form of the Family Connections programme, an evidence‑based, pro bono intervention delivered through volunteer networks worldwide, was the only realistic way to develop DBT‑informed services in Poland that matched the available bottom‑up pathway. Since then, around 200 12‑week FC groups have been delivered in Poland, reaching approximately 2,400 family members of people with BPD, emotion dysregulation, and suicidality. This became the primary way to reach the community, educate families about the effectiveness and evidence‑base of DBT. This encouraged a process of advocacy for appropriate care, which prompted many therapists to turn to DBT to better meet their patients’ needs. DBT training system in Poland Since 2020, PTDBT has run an annual Comprehensive DBT training programme under the leadership of Prof. Alan Fruzzetti together with a gradually growing local training team. Each cohort completes four 3‑day modules over 9–10 months, combining didactic teaching with intensive skills practice, case discussions, and consultation‑team mentoring. Participants are organised into DBT teams, or encouraged to form them during the course, and are supported in implementing all treatment modes in their clinical settings as far as local conditions allow. The trainings have also centred on a transfer of technology with a gradual shift from Prof. Fruzzetti delivering the entire training to a shared format in which Polish trainers increasingly co‑teach and independently lead parts of the curriculum under ongoing supervision from Prof. Fruzzetti. The long-term aim is to develop an autonomous local training team. At present, Poland has a small but clearly defined DBT community and infrastructure. Approximately 150 clinicians have completed Comprehensive DBT training, and there is a developing system of training and informal mentoring available in Polish. Around 20 teams currently offer some or all modes of a DBT programme, with about 10 private centres providing comprehensive, multi‑mode DBT services, several of which have proved sustainable over time. Key DBT manuals and books have been translated and are widely accessible, and introductory DBT and DBT skills modules have been incorporated into many 4‑year CBT training programmes. Family Connections groups are now available nationwide, including in several public institutions, with some groups co‑led by family members, so that DBT and FC increasingly provide both individual treatment and environmental interventions. In addition, PTDBT regularly organises national and international conferences and symposia with a recent milestone of this community‑driven development was the co‑organisation of the First European DBT Congress (EDBTA), held in Gdańsk in May 2025. DBT in Poland: challenges and dialectics Despite these achievements, the development of DBT in Poland remains shaped far more by “in spite of” than “because of” systemic conditions. The clinicians most actively involved in DBT are almost all full‑time practitioners in the private sector, without access to protected research time or funding, which means that no systematic outcome studies of DBT have yet been conducted in Poland. Mental health authorities show little interest in promoting or commissioning evidence‑based treatments, and long‑standing tensions and political conflicts between institutions and professional groups further limit the chances of top‑down support. Against this backdrop, the Polish DBT story is less about how much could be achieved with favourable structures, and more about how much has been built through persistence, voluntary effort, and community collaboration in an invalidating system. Development of DBT in the Czech Republic DBT has started to evolve considerably later in Czechia than in the European countries discussed above, with its early development taking place primarily outside the formal healthcare system. The first Czech DBT programme was established as a social service in 2008 at the therapeutic community Kaleidoskop (operating since 2006), led by Renata Tumlířová, which focused on individuals with various personality disorders. Members of this team were the first Czech workers trained in DBT at Behavioral Tech Institute in the US. Early Teams For more than a decade, DBT development in the Czech Republic progressed slowly and remained limited to a small number of highly motivated teams in few mental health facilities in the country. Usually, only components of DBT were incorporated in otherwise treatment as usual practice. A significant milestone in the integration of DBT into the public healthcare system occurred in 2019, when following intensive training from biDBT in the UK, the first fully structured 24-week outpatient DBT programme was launched at the psychiatric clinic of University Hospital Brno led by Dr Pavla Horká Linhartová. This outpatient programme was fully funded by public health insurance and followed all standard DBT principles. Members of this team are also contributing to the growing local evidence base through early outcome studies focusing on the effectiveness of DBT for borderline personality disorder in the Czech context (Látalová, 2023 ), while also conducting wider research on BPD (Linhartova et al., 2020 & Radimecka et al., 2024). Following this development, DBT services in the Czech Republic began to diversify in terms of settings and populations. In 2022, the first inpatient DBT programme for adolescents (14–17) was established at the Children’s Psychiatric Hospital in Opařany, incorporating intensive skills training, family involvement, and a structured daily programme. Research Funding for Additional Team Implementations A further step toward a coordinated national implementation and outcomes evaluation was an initiative of the National Institute of Mental Health in Czechia, which has funded and coordinated the implementation of fully structured 24-week DBT programmes into 5 mental health facilities across multiple regions since 2023 as one of the goals of Project Gradient (Pro zdravi21, z,u). These teams were trained and supervised by the biDBT. Large-scale dissemination and education are also an ongoing processes that support the expansion of DBT components into various treatment programmes and facilities around Czechia, alongside increased availability of DBT programmes and other DBT-informed treatment for people with emotion dysregulation. These initiatives have been complemented by increased collaboration with European partners and participation in international training and research networks. Nascent Professional Organisation The professional organisation of DBT practitioners in the Czech Republic remains in an early stage of development compared to countries with longer DBT traditions. In 2023, a dedicated DBT section was established within the Czech Association for Cognitive Behavioural Therapy, providing an initial platform for networking, peer support, and discussion of therapy and training standards. A national DBT association was also established in 2024, which will eventually provide a structure for therapist certification. Czech clinicians have also become increasingly active within the European DBT Association, presenting implementation processes and emerging clinical and research findings at international conferences and engaging with ongoing discussions around programme fidelity and adaptations. Despite these advances, DBT availability in the Czech Republic remains limited in contrast to clinical need. Key challenges include a shortage of fully trained DBT teams and supervisors, and the nascent state of standardized national training formats and certification system aligned with international standards. Training for new teams as well as support the stability of DBT teams by providing education to individuals filling in the gaps after staff turnover is a challenge. Additionally, another obstacle is funding, as reliance on project-based funding is not sustainable, and long-term solutions in place are needed. Coordination in such processes also needs an independent body of experts (such as a national association) that would be able to guide teams in adherence to national and international standards. At the same time, recent developments suggest a transition from isolated local initiatives toward more systematic, healthcare- as well as social care-embedded implementation of DBT as a standard treatment of borderline personality disorder in the Czech Republic. Discussion The DBT Implementation Framework (Tom et al., 2019) which integrates the stages of implementation discussed in wider implementation science research (planning, engaging, executing, evaluating and reflecting) with the processes that are unique to DBT implementation (context, DBT, evidence, and facilitation) focuses mostly the establishment of new DBT teams. The above case studies describe scaled up versions of DBT implementation processes in its description of five unique national DBT implementation pathways and is like processes described in the national implementation project in Ireland (Flynn, Kells & Joyce, 2019 ). Apart from the situation in Poland, the implementation journeys described here are a mixture of bottom-up and top-down processes. These trajectories indicate that there are commonalities and some important differences related to system issues. Common Facilitators: Contextual Factors and Research as a Driver for Implementation and Innovation In all cases as we might expect from the DBT implementation literature context was key. Implementation processes began through the enthusiasm of one or two clinicians or researchers, which is a bottom-up factor that then transacted with and shaped top-down policies. Processes of DBT dissemination and implementation are facilitated by public policy support for evidence-based treatment and particular standards in mental health care. This was also seen in system-wide implementation projects such as the one in the USA Veterans Association (Landes et al., 2017 ). Attention to the evidence-base also facilitates the incorporation of treatment adaptation as seen throughout Europe and particularly highlighted in the German system’s movement to the wide-spread dissemination DBT-PTSD. The pathway of implementation of DBT in the UK and in the Czech Republic has parallels in that they were both supported by wider systemic reforms of the mental health system to incorporate community care and evidence based treatments for people with severe and enduring mental health conditions such as BPD (NHS 1990, 2003 & 2009; Winkler et al., 2025 ). In the case of Poland, these missing elements have made implementation processes slower and arguably more arduous. Additionally common themes such as access to quality, often evidence-based, training in DBT is highly valued. The importance of evidenced based training in general is widely known and has been shown to increase therapist experience and willingness to work with suicidal clients is a theme that has been explored in other implementation studies (e.g., Navarro-Haro et al., 2024 ). University affiliation, which can be a driver for implementation, also increases the likelihood of research on DBT in the national environment being conducted, which was particularly observed in Norway. These examples also demonstrate that implementation is a long and dynamic process with common milestones such as the establishment of professional societies and/or the affiliation with professional CBT organisations or the establishment of research initiatives. Finally, local treatment landscapes such as a preference for inpatient or outpatient services, for example, in the case of Germany versus the UK, shape implementation processes. The experience of implementation in Poland also demonstrates the benefit of ingenuity and commitment to learning in the realisation of ambitions to deliver evidence-based treatment. The Polish example further demonstrates another common theme, namely employing the strategies of the treatment itself and consider the system in which implementation is desired as the first DBT client can be effective (Swales, 2010 ). Processes of system shaping are continuous and underpinned by the work of DBT Team leaders (Swales, 2010 ). Lessons for newly adapting countries Harness the enthusiasm of the local leaders and DBT champions. DBT champions may not ultimately deliver DBT, and they can be powerful system influencers. Where possible connect DBT with policies on mental health and the incorporation of evidence-based practice. Focus as quickly as possible on creating networks of interested practitioners both nationally through the creation of national societies or special interest groups in existing CBT professional organisations and internationally (e.g. EDBTA or WDBTA). Consider the indicators of success from the beginning. Plan to measure the impact of the implementation both by the establishment of a team with all functions and modes as well as by demonstrable changes in therapist and client behaviour through routine measuring of therapist adherence to the model in sessions and changes in client behaviours and quality of life. Strengths and Limitations In addition to providing information on common processes of DBT implementation and system change, this research adds to the DBT implementation framework literature by highlighting the importance of continuous adaptation of DBT provisions based on emerging research. Relatedly it also points to the need for constant evaluation of the clinical outputs from DBT implementation. Effective implementation pays attention changes in therapist (e.g. adherence and fidelity) and client behaviours (e.g. patient related outcome measures) and adjusts treatment offerings in accordance with data. This narrative review relies on local DBT experts’ description of the implementation histories. Inevitably there will be recall biases and missing information. It is not designed to be comprehensive or even systematic put rather to provide broad descriptions. Conclusion The implementation of DBT across Europe over the past 30 years has changed the treatment landscape for people with BPD. DBT has shaped and been shaped by changing mental health policy landscapes and treatment contexts. Discussion of multiple experiences at the national scale provides information for nations that are seeking to make DBT more widely available. Implementation is a dynamic, iterative, and continuous process of treatment refinement through the incorporation of emerging evidence on the increased effectiveness of treatment adaptations or modifications. Finally, this research also adds to existing literature this topic in its strong focus on post initial implementation processes. Declarations Funding Declaration: There was no funding provided for this research. Ethics declaration : N/A Author Contribution All authors provided case materialAll authors reviewed AGE, MB and AT editted References Bender AM, Wilson RLH, Borntrager L, Orlowski EW, Gryglewicz K, Karver MS. Evaluating dialectical behavior therapy training with mental health clinicians. J Personal Disord. 2023;37(1):95–111. https://doi.org/10.1521/pedi.2023.37.1.95 . Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM. Effectiveness of inpatient dialectical behavior therapy for borderline personality disorder: A controlled trial. Behav Res Ther. 2000;38(9):875–87. https://doi.org/10.1016/S0005-7967(99)00103-5 . Bohus M, Limberger MF, Frank U, Chapman AL, Kühler T, Stieglitz RD. Psychotherapy for borderline personality disorder: A comparison of dialectical behavior therapy and treatment-as-usual. Psychother Psychosom. 2004;73(5):298–306. https://doi.org/10.1159/000078843 . Bohus M, Dyer AS, Priebe K, Krüger A, Kleindienst N, Schmahl C, Steil R, Lyssenko L. 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Mehlum L, Ramleth R-K, Tørmoen AJ, Haga E, Diep LM, Stanley BH, Miller AL, Larsson B, Sund AM, Grøholt B. Long-term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior. J Child Psychol Psychiatry. 2019;60(10):1112–22. https://doi.org/10.1111/jcpp.13077 . Mehlum L, Dibaj IS, Haga E, Helle SE, Morken KTE, Klungsøyr O, Tørmoen AJ. Adult life outcomes for adolescents 12.4 years after dialectical behavior therapy: A randomized clinical trial. Eur Child Adolesc Psychiatry. 2026. https://doi.org/10.1007/s00787-025-02856-w . Advance online publication. National Education Alliance for BPD. (n.d.). Family Connections program. https://www.neabpd.org/family-connections National Institute for Health and Care Excellence. (2009). Borderline personality disorder: Recognition and management (NICE guideline CG78) . https://www.nice.org.uk/guidance/cg78 National Institute for Mental Health in England. Personality disorder: No longer a diagnosis of exclusion: Policy implementation guidance for the development of services for people with personality disorder. National Institute for Mental Health in England; 2003. Navarro-Haro MV, Abanades A, Peris-Baquero Ó, Gagliesi P, Rodante D, García-Palacios A, Osma J. Factors associated with the implementation of dialectical behavior therapy by Spanish speaking mental health professionals who treat suicide risk. BMC Psychiatry. 2024;24(1):813. https://doi.org/10.1186/s12888-024-06243-8 . NHS and Community Care Act. 1990, c. 19. (UK). Priebe S, Bhatti N, Barnicot K, Bremner S, Gaglia A, Katsakou C, Molosankwe I, McCrone P, Zinkler M. Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: A pragmatic randomised controlled trial. Psychother Psychosom. 2012;81(6):356–65. https://doi.org/10.1159/000338897 . Radimecká M, Látalová A, Lamoš M, Jáni M, Bartys P, Damborská A, Theiner P, Linhartová P. Facial emotion processing in patients with borderline personality disorder as compared with healthy controls: An fMRI and ECG study. Borderline Personality Disorder Emot Dysregulation. 2024;11:4. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life-Threatening Behav. 2002;32(2):146–57. https://doi.org/10.1521/suli.32.2.146.24399 . Safer DL, Telch CF, Chen EY. Dialectical behavior therapy for binge eating and bulimia. Guilford Press; 2009. Steil R, Dyer AS, Priebe K, Kleindienst N, Bohus M. Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: A pilot study of an intensive residential treatment program. J Trauma Stress. 2011;24(1):102–6. https://doi.org/10.1002/jts.20617 . Swales MA. Implementing dialectical behaviour therapy: Selecting, training and supervising a team. Cogn Behav Therapist. 2010;3(2):71–9. https://doi.org/10.1017/S1754470X10000061 . Swales MA. Implementing dialectical behaviour therapy: Organizational pre-treatment. Cogn Behav Therapist. 2010;3(4):145–57. Tørmoen AJ, Grøholt B, Haga E, Ramberg M, Diep LM, Stanley BH, Miller AL, Mehlum L. Feasibility of dialectical behavior therapy for adolescents with suicidal and self-harming behavior: A pilot study. Scandinavian J Child Adolesc Psychiatry Psychol. 2014;2(1):3–14. https://doi.org/10.21307/sjcapp-2014-002 . Tørmoen AJ, Grøholt B, Haga E, Brager-Larsen A, Miller A, Walby F, Stanley B, Mehlum L. (2014) Feasibility of dialectical behavior therapy with suicidal and self-harming adolescents with multi-problems: training, adherence, and retention. Arch Suicide Res. 18(4):432 – 44. doi: 10.1080/13811118.2013.826156. PMID: 24842553. Winkler P, Guerrero Z, Kågström A, Petrášová M, Pashoja C, Qirjako A, Hristakeva G, Germanov V, Rojnic Kuzman D, Bošnjak Kuharić M, Havlíková D, Eek L, Maron H, Őri E, Wernigg D, Fanaj R, Krasniqi N, Sile E, Brinkmane L, Thornicroft K, G. Mental health in Central and Eastern Europe: A comprehensive analysis. Lancet Reg Health – Europe. 2025;57:101464. https://doi.org/10.1016/j.lanepe.2025.101464 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 18 May, 2026 Reviews received at journal 12 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers invited by journal 09 Apr, 2026 Editor assigned by journal 03 Apr, 2026 Submission checks completed at journal 03 Apr, 2026 First submitted to journal 31 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9279155","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":623529540,"identity":"df9d03dd-480d-4d1d-8e8a-de2004b9ee42","order_by":0,"name":"Amy Gaglia Essletzbichler","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYPACmwQkDhtRWtJI13KYBC3y7b0HP/yoOJ/HP7v94uMKBjt5BgkUKzGBwZlzyZI9Z24XS9w5U2x4hiHZsEEi7QB+LRI5BhK8bbcTG27kpEk2MDAnMEikN+B32Pw3xj///juXOB+ipZ6wFoYbPGbSvA0HEjfcSD8G1HIYqIWQw87kpVnLHEsuNryRw2zYYHDcsI3nWQJ+h7WfPXzzTY1dntyN9IcPGyqq5fnZ0wzwO4yBB84AqjQgKiLhWtgfEFY8CkbBKBgFIxIAAFNbRk5pgq4aAAAAAElFTkSuQmCC","orcid":"","institution":"Bangor University","correspondingAuthor":true,"prefix":"","firstName":"Amy","middleName":"Gaglia","lastName":"Essletzbichler","suffix":""},{"id":623529541,"identity":"0d517f0b-3c6a-455b-8176-8a5edb92c851","order_by":1,"name":"Miriam Biermann","email":"","orcid":"","institution":"Central Institute of Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Miriam","middleName":"","lastName":"Biermann","suffix":""},{"id":623529542,"identity":"e3998c9b-820d-45c3-b70d-3a75bf9be2b4","order_by":2,"name":"Magdalena Skuza","email":"","orcid":"","institution":"Centrum Zdrowia Psychicznego HarmonJa","correspondingAuthor":false,"prefix":"","firstName":"Magdalena","middleName":"","lastName":"Skuza","suffix":""},{"id":623529543,"identity":"9d81d82d-2a8d-47a3-b9c8-13e10e7eecf4","order_by":3,"name":"Natálie Češková","email":"","orcid":"","institution":"Centrum Zdrowia Psychicznego HarmonJa","correspondingAuthor":false,"prefix":"","firstName":"Natálie","middleName":"","lastName":"Češková","suffix":""},{"id":623529544,"identity":"a6e74617-a83e-4355-8d17-be202ac1d919","order_by":4,"name":"Anita Johanna Tørmoen","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"Johanna","lastName":"Tørmoen","suffix":""}],"badges":[],"createdAt":"2026-03-31 11:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9279155/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9279155/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107162031,"identity":"beee2d78-f26d-420e-9b6e-d26d6451de37","added_by":"auto","created_at":"2026-04-17 13:12:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":270690,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9279155/v1/1c9db44d-d0f3-4a40-a5f4-3734131bc58b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Study: The DBT Implementation Journey of Dialectical Behaviour Therapy in five European Countries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver the last 40 years a revolution in the treatment of Borderline Personality Disorder (BPD) occurred. A significant aspect in the change of the landscape began with Marsha Linehan\u0026rsquo;s treatment Dialectical Behaviour Therapy (DBT). Linehan\u0026rsquo;s original aim was to create an effective treatment for individuals engaging in suicidal and self-harming behaviours (Linehan, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). In the 1980s, to strengthen her applications for research funding, she incorporated the diagnosis of borderline personality disorder (BPD) into her work (Linehan, 2016, UW video lecture Dialectical Behavior Therapy (DBT): Where We Were, Where We Are and Where Are We Going). Publication of the treatment manual, Cognitive Behavioral Treatment for Borderline Personality Disorder, in 1993 further accelerated implementation efforts and firmly aligned DBT with the treatment of BPD.\u003c/p\u003e \u003cp\u003eClinical implementation of DBT in Europe began around 1994, when Linehan provided training to a group of clinicians from the United Kingdom (UK), Germany, and the Netherlands. From that point, Germany, the UK and the Netherlands were the first European nations to establish robust DBT programmes, research initiatives, and national DBT societies. This paper reviews the implementation trajectories in five European countries, spanning over 30 years, and identifies both shared and divergent processes. Common themes include the need for comprehensive training, an emphasis on adherence and fidelity to the treatment manual and structures, the benefits of research and treatment development and adaption, partnerships with universities, and the establishment of national DBT societies. While there are common themes, implementation processes remain highly specific to each country\u0026rsquo;s healthcare system.\u003c/p\u003e\n\u003ch3\u003eImplementation Processes\u003c/h3\u003e\n\u003cp\u003eReviews by Toms et al. (2019) and Navarro-Haro et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) identify key facilitators and barriers to DBT implementation. DBT\u0026rsquo;s team-based structure, considered essential by Linehan (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1993\u003c/span\u003e) to protect therapists from burnout and reduce the risk of therapists engaging in unethical behaviour, distinguishes it from most other psychotherapies. All randomized controlled trials (RCTs) that demonstrate DBT\u0026rsquo;s efficacy and effectiveness have been delivered with the mode of consultation team model. More broadly, implementation literature indicates that team-based models are more likely to produce sustainable system-level change due to team processes (Higgin, Weiner \u0026amp; Young, 2012; McGuier et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and thus the team-based nature of the treatment may be account for part of the success of DBT. Nevertheless, data from a large scale real-world systemic implementation suggest that some clinicians attempt to deliver DBT without a consultation team. Landes et al. (2107) study of the implementation of standard DBT across the Veterans Health Administration in USA by 59 teams reported that therapists on 26 teams either did not have a consultation team or that they did not really attend consultation team meetings.\u003c/p\u003e \u003cp\u003eEffective DBT implementation requires teams that are well-trained, sustainable, able to deliver comparable clinical outcomes, and responsive to the needs of the population (Swales, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2010\u003c/span\u003ea; \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2010\u003c/span\u003eb). Reviews by Toms et al. (2019) and Navarro-Haro et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) describe implementation as beginning with a preparation phase shaped by organisational culture, communication practices, and information-gathering through external consultation. Organisational support, including protected time for clinicians to train and implement the model, and adequate funding, is critical to successful implementation. Creating an empowered implementation team that can design a plan aligned with both clinician interest and organisational priorities also enhances success.\u003c/p\u003e \u003cp\u003eDBT implementation can also be catalysed by broader systemic developments, such as legislative changes or shifts in accepted practices for treating individuals with severe and enduring mental health difficulties. Implementation is more likely to succeed when DBT\u0026rsquo;s structures, strategies, philosophy, and underlying assumptions help the host organisation fulfil its own values and goals. An early activity in the implementation process involves key stakeholders receiving an orientation to the treatment and engaging in discussions about the treatment\u0026rsquo;s fit with organisational aims. Such processes tend strengthen organisational commitment to implementation. Establishing supportive organisational structures, such as job planning, communication pathways, accountability systems, financial resources, and physical space, increases the likelihood of long-term success. Additionally, it can help to orient team to information the likelihood staff turnover and the need to plan for relatively early in the implementation process to ensure that teams survive long-term (King et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003eEach country selected to participate in the narrative analysis presented their national experience at a DBT dissemination conference organised by the research and implementation group of Project Gradient in the Czech Republic in June 2025. The selected countries represent early, mid, and recent implementers of DBT in change national health contexts. Each narrative description of the unique national history of DBT implementation is provided by a local DBT expert with knowledge of DBT\u0026rsquo;s developmental pathway in their respective country. Data sources included documentation from national societies as well as other relevant national policy documentation. Common themes were then highlighted by lead author. Themes were discussed in relation to existing implementation frameworks for DBT (Tom et al, 2019).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results Case Studies","content":"\u003cp\u003eImplementation trajectories in the UK, Germany, Norway, Poland and the Czech Republic reveal recurring themes, including the influence of public health initiatives, the development of training infrastructures, partnerships with universities, and the establishment of independent professional organisations responsible for assessing adherence and fidelity to the DBT model.\u003c/p\u003e\n\u003ch3\u003ePublic Health Context and Timeline of Key Developments in DBT in the United Kingdom\u003c/h3\u003e\n\u003cp\u003eBritish Isles Dialectical Behaviour Therapy (biDBT), the most established DBT training organisation in the UK, estimates that slightly more than 250 teams currently deliver DBT in the UK. Over half operate in outpatient settings, and teams exist across the lifespan, with one-third working in child and adolescent mental health (CAMHS) and about 5% in older adult services. These teams offer either comprehensive DBT or \u0026ldquo;skills-only DBT,\u0026rdquo; also referred to as \u0026ldquo;all modes minus individual therapy.\u0026rdquo; Reaching this level of provision has taken roughly three decades.\u003c/p\u003e \u003cp\u003eImplementation of DBT has been in part facilitated by changes in UK public policies. In the 1970s, psychological therapy in the UK increasingly emphasised evidence-based treatments (EBTs), marking a shift toward empirically supported interventions in mental health services. The 1990s saw the expansion of community-based care, promoting treatment outside institutional settings (NHS and Community Care Act, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). The establishment of National Institute for Clinical Excellence (NICE) in 2001 further embedded research-led practice by formally evaluating and endorsing evidence-based psychological interventions. In 2003, a key policy document stated that personality disorder (PD) should no longer be considered a diagnosis of exclusion (National Institute for Mental Health in England, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). This improved access to psychological treatment for people with PD and created a more welcoming context for DBT. In 2009, NICE published guidelines on treating BPD, designating DBT as the recommended treatment for women who engage in self-harm (National Institute for Health and Care Excellence, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). The synthesis of a decade of bottom-up implementation of DBT coupled with policy shifts created fertile conditions for acceptance of a team-based intervention and wider implementation of DBT in the UK.\u003c/p\u003e\n\u003ch3\u003eDevelopment of DBT in the UK\u003c/h3\u003e\n\u003cp\u003eIn 1994, Dr Michaela Swales, arguably the UK\u0026rsquo;s earliest DBT adopter, trained in the treatment with Professor Marsha Linehan in the United States. Upon returning to the UK, she established the first DBT programmes on an adolescent inpatient unit in Bangor, North Wales. Between 1994 and 1997, Swales, Dr Heidi Heard, a member of Marsha Linehan\u0026rsquo;s research team, and a colleague from the University of Leeds launched the first formal UK DBT training programme. Partnerships with universities can significantly support the implementation of emerging therapeutic models and research into their effectiveness.\u003c/p\u003e \u003cp\u003eA major milestone in long-term implementation was the creation of a national training infrastructure. biDBT, founded in 1997, maintained close ties with Linehan\u0026rsquo;s US-based training organisations and became the primary provider of DBT training in the UK and Ireland. biDBT offered evidence-based DBT training, including the 10-day Intensive Training\u0026trade;, which prepares whole teams to implement DBT through 5 days of instruction, followed by six months of self-directed implementation activities, and then another 5-day module focused on shaping clinical practice (Navarro-Haro et al., 2019). biDBT also delivered the 5-day Foundational Training for individuals joining established DBT teams (Bender et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eResearch\u003c/h3\u003e\n\u003cp\u003eResearch conducted within the UK healthcare system further supported DBT\u0026rsquo;s dissemination. Two RCTs, Feigenbaum et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) and Priebe et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2012\u003c/span\u003e), evaluated DBT against treatment-as-usual in NHS adult outpatient settings. These studies, conducted in collaboration with University College London and Queen Mary University of London respectively, provided evidence for DBT\u0026rsquo;s acceptability and effectiveness in the UK context.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProfessional Standards Infrastructure\u003c/h2\u003e \u003cp\u003eAnother milestone for the DBT community was the establishment of nationwide professional standards for DBT delivery through the creation of a professional society. The Society for Dialectical Behaviour Therapy in the UK and Ireland (SfDBT), founded in 2012 by Dr Christine Dunkley and Professor Stephen Palmer, functions similarly to the British Association for Behavioural and Cognitive Psychotherapies (BABCP). An essential element in legitimising DBT was the professional society\u0026rsquo;s institutional independence from the training company biDBT and other training organisations. SfDBT hosts annual conferences and workshops to promote continuing professional development and networking. In 2014, SfDBT introduced an accreditation process for DBT therapists, aligned with the Linehan Board of Certification (LBC) in the US. Accreditation, more commonly known in other parts of the world as certification, requires clinicians to hold a core mental health professional qualification, be complete 450 hours of DBT training, be delivering comprehensive DBT, maintain an ongoing mindfulness practice, receive individual supervision, and submit work samples that are assessed for their adherence to the DBT model on the DBT-ACS (Linehan \u0026amp; Korslund, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) originally and more latterly the DBT-ACI (Harned, Schmidt \u0026amp; Korslund, 2023) adherence rating measures. The SfDBT UK and Ireland is also a member organisation of the European DBT Association (EDBTA).\u003c/p\u003e \u003cp\u003eSfDBT expanded its accreditation system in 2019 to include the accreditation of supervisors and, in 2021, began accrediting DBT training programmes. In 2024, SfDBT introduced accreditation for DBT treatment programmes, using the Program Fidelity Scale to assess team-level adherence (Harned \u0026amp; Schmidt, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eUniversity Degree\u003c/h3\u003e\n\u003cp\u003eThese efforts, similarly, to other implementation efforts, both influenced and were influenced by broader public health developments. In 2020, Bangor University and biDBT received NHS England funding to deliver a fully funded Postgraduate Diploma in DBT (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/\u003c/span\u003e\u003cspan address=\"https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-c/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The Post Graduate Diploma in DBT is a university degree equivalent to a taught masters\u0026rsquo; degree without a thesis. The training specifications adopted by NHS England allowed for completers of the degree to have completed all of the SfDBT requirements for an accredited DBT Therapist. Ultimately, this course became an SfDBT level 3 accredited training course and allowed for its graduates to be immediately accredited as DBT therapists. Other level 1 and 2 university level DBT training courses have also started to appear in the UK.\u003c/p\u003e\n\u003ch3\u003eBenchmarking: moving from outputs to outcomes\u003c/h3\u003e\n\u003cp\u003eAs an extension of this project, biDBT launched a national benchmarking website to support the evaluation and continuous improvement of DBT practice in the UK (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dbt.uk.net/\u003c/span\u003e\u003cspan address=\"https://dbt.uk.net/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Benchmarking allows teams offering either comprehensive DBT or \u0026ldquo;skills only\u0026rdquo; DBT to compare their programme outcomes with those of RCTS and peers. At a minimum, teams collect data at various points on client\u0026rsquo;s quality of life, difficulties in regulating emotion and ways of coping. The data is immediately accessible to teams and individual therapist and can be used to inform treatment discussions and consultation team meeting processes. Additionally, the website assists with work capacity calculations for teams and therapists. This system further moves the UK to a focus on outcomes. The movement from output to outcomes began with the introduction of therapist, supervisor, and programme accreditation and now the focus on client outcomes as well helps ensure that money invested in DBT delivers actual change clients\u0026rsquo; behaviours and lives.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImplementation Pathways, and Further Developments of DBT in Germany\u003c/h2\u003e \u003cp\u003eDialectical Behaviour Therapy (DBT) was introduced in Germany in the mid-1990s and has since become one of the most widely implemented and empirically supported psychotherapeutic treatments for borderline personality disorder (BPD) and related high-risk clinical presentations. Its dissemination occurred within a healthcare system characterised by statutory health insurance coverage, a strong inpatient and psychosomatic treatment sector, and an established tradition of evidence-based psychotherapy. These structural conditions provided a favourable context for the \u0026ldquo;top-down\u0026rdquo; implementation of a comprehensive, team-based treatment model such as DBT, particularly for patients with severe emotion dysregulation, suicidality, and complex comorbidity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEarly Implementation and Research Foundations\u003c/h2\u003e \u003cp\u003eA key driver of DBT dissemination in Germany was the early integration of clinical implementation with systematic research. In the mid-1990s, Professor Martin Bohus and colleagues at the Central Institute of Mental Health (CIMH) in Mannheim received direct training from Marsha Linehan and subsequently established one of the first comprehensive DBT programmes for patients with BPD in Germany (Linehan, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). From the outset, the Mannheim programme combined routine clinical delivery with rigorous outcome evaluation.\u003c/p\u003e \u003cp\u003eEarly randomised controlled trials conducted in Germany demonstrated the effectiveness of DBT in reducing self-harm, suicidal behaviour, and psychiatric hospitalisation among patients with BPD when compared to treatment-as-usual (Bohus et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Bohus et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). These studies contributed substantially to the international DBT evidence base and played a critical role in legitimising DBT within German psychiatry and psychosomatic medicine. Subsequent naturalistic and routine-care studies showed that DBT could be implemented effectively outside specialised research contexts, supporting its scalability within the German healthcare system (Landes et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTraining Infrastructure and National Dissemination\u003c/h2\u003e \u003cp\u003eA defining feature of DBT implementation in Germany has been the early establishment of a nationally coordinated training and governance structure. Building on close collaboration with Linehan and US-based DBT training providers, German DBT leaders developed standardised, team-based training pathways emphasising supervised implementation, consultation teams, and long-term sustainability.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eDachverband Dialektisch Behaviorale Therapie\u003c/em\u003e (DDBT), founded in the early 2000s, became the central professional organisation responsible for promoting high-quality DBT practice in Germany. The DDBT coordinates training standards, defines requirements for DBT team composition, and supports continuing professional development through conferences, workshops, and supervision networks (DDBT, n.d.). Training in provided by organisations that are provided franchise licenses by the DBBT thus maintaining a dual structure in which training provision is separate from therapist certification institutions. Training typically follows an intensive team-based format, consisting of two multi-day teaching blocks separated by an extended implementation phase. Foundational trainings are offered for clinicians joining established DBT teams, alongside advanced courses for specialised adaptations.\u003c/p\u003e \u003cp\u003eConsistent with Linehan\u0026rsquo;s original model, participation in a DBT consultation team is regarded as a core component of ethical and effective DBT delivery in Germany (Linehan, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). This strong emphasis on treatment adherence and fidelity has contributed to relatively consistent implementation standards across diverse clinical settings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eScope of Clinical Implementation\u003c/h2\u003e \u003cp\u003eOver the past three decades, DBT has been implemented widely across Germany in psychiatric inpatient units, psychosomatic hospitals, day clinics, and outpatient services. Particularly strong uptake has occurred in specialised inpatient and day-treatment programmes for personality disorders and trauma-related conditions, where the intensity and structure of DBT align well with service configurations and reimbursement models.\u003c/p\u003e \u003cp\u003eDBT is explicitly referenced in German national clinical guidelines for the treatment of borderline personality disorder, reinforcing its status as a standard, evidence-based intervention within routine care. Like developments in the UK and Norway, DBT dissemination in Germany has been facilitated by broader public-health shifts toward evidence-based practice and increased recognition of personality disorders as treatable conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment and Implementation of DBT for PTSD\u003c/h2\u003e \u003cp\u003eOne of the most influential contributions to the international DBT field emerging from Germany has been the development of DBT for Posttraumatic Stress Disorder (DBT-PTSD). This adaptation was developed at the CIMH to address individuals with PTSD related to childhood abuse who also present with severe emotion dysregulation, dissociation, and self-harm, patients frequently excluded from standard trauma, focused treatments.\u003c/p\u003e \u003cp\u003eDBT-PTSD integrates trauma-focused cognitive and exposure-based interventions within a DBT framework while retaining core principles such as hierarchical treatment targets, the balance of acceptance and change strategies, and therapist consultation teams. Treatment follows a structured, phase-based approach, with initial emphasis on safety and skills acquisition before the introduction of trauma processing (Steil et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA series of German randomised controlled trials demonstrated that DBT-PTSD is effective in reducing PTSD symptom severity, depressive symptoms, and global psychopathology in highly complex patient populations (Bohus et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). A large multicentre RCT further showed DBT-PTSD to be at least as effective as Cognitive Processing Therapy (CPT), with lower dropout rates and superior outcomes in emotion regulation and functional impairment (Bohus et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These findings supported the rapid implementation of DBT-PTSD in German inpatient and day-treatment settings and stimulated international dissemination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFurther DBT Adaptations in Germany\u003c/h2\u003e \u003cp\u003eIn parallel with DBT-PTSD, several additional DBT adaptations have been implemented and evaluated in Germany. DBT for adolescents (DBT-A), based on the original model by Rathus and Miller (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), has been widely adopted in child and adolescent psychiatric services. German implementations emphasise developmental considerations and caregiver involvement through multifamily skills groups. Empirical evidence from German-speaking contexts (e.g. Fleischhacker et al., 2011) and international trials indicates significant reductions in self-harm, suicidal ideation, and overall symptom severity (Mehlum et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDBT for Substance Use Disorders (DBT-SUD) has been implemented primarily in inpatient and day-treatment addiction services and dual-diagnosis programmes. This adaptation integrates DBT strategies with addiction-specific interventions such as dialectical abstinence and contingency management. Clinical and empirical findings suggest improved treatment retention and reductions in substance use and self-harm in highly comorbid populations (Landes et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDBT-based approaches have also been adapted for eating disorders, particularly bulimia nervosa and binge-eating disorder, within specialised psychosomatic settings. DBT-oriented interventions target dysfunctional eating behaviours as maladaptive emotion regulation strategies and have been associated with reductions in binge eating and purging, as well as improvements in emotion regulation (Safer et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of DBT in Norway\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eResearch as an implementation driver\u003c/h2\u003e \u003cp\u003eDialectical Behavior Therapy (DBT) was introduced in Norway as a university-based initiative originating at the National Centre for Suicide Research and Prevention (NSSF) at the University of Oslo. The first formal training, led by Alec Miller and Sarah Reynolds from the Behavioral Tech Institute (BTech), the USA based training company previously affiliated with Marsha Linehan, was organized by a clinical research team at NSSF in preparation for a randomized controlled trial (RCT) of DBT for adolescents with repeated self-harm. From its inception, the project combined rigorous clinical implementation with a research agenda: two research therapists formed DBT teams at separate sites within Oslo University Hospital and received specialist training.\u003c/p\u003e \u003cp\u003eThe initiative was motivated by a national public-health objective to reduce self-harm and suicide attempts among young people, and by the research team\u0026rsquo;s assessment of DBT as a promising intervention warranting evaluation in an RCT. Inspired by Miller\u0026rsquo;s promising adaptation for suicidal adolescents (Rathus \u0026amp; Miller, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), NSSF obtained partial funding from the Norwegian Health Directorate and the DAM trust, a foundation that funds health and social welfare research, to conduct a feasibility study and a subsequent RCT, with Professor Lars Mehlum serving as principal investigator.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTraining Team\u003c/h2\u003e \u003cp\u003eSince 2006, the DBT Norway Training Program, operating as a university-affiliated non-profit within NSSF, has established a quality-assured system for educating and developing therapists, supervisors, and trainers. Its structure broadly parallels the standards proposed by the EDBTA (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://edbta.eu/wp-content/uploads/2026/03/Qualifications-for-different-levels-Trainer-levels-fFebruary-2027.pdf\u003c/span\u003e\u003cspan address=\"https://edbta.eu/wp-content/uploads/2026/03/Qualifications-for-different-levels-Trainer-levels-fFebruary-2027.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The program developed nationally adapted guidelines for therapist education, trainer recruitment and development, and mentor/supervisor training. Teaching materials have been translated and adapted to Norwegian from English, and the center implemented a program for the continuing professional development of trainers and supervisors. Trainers can teach in both Norwegian and English.\u003c/p\u003e \u003cp\u003eInstead of formal certification processes adopted in the UK and Germany, NSSF utilizes a model of sustained, team-focused supervision. The program provides consistent team supervision over multiple years to many DBT teams across Norway, including opportunities to assess and address treatment adherence. One trainer has received specific training in adherence assessment materials. Adherence rating materials have been translated into Norwegian in collaboration with the DBT-ACS (Korslund \u0026amp; Linehan, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) and DBT-ACI (Harned, Schmidt \u0026amp; Korslund, 2023) calibration processes. NSSF is in the process of converting its DBT training to a flipped-classroom model, increasing demands on pre-course preparation (e.g., learning objectives review, assigned readings, video lectures, short quizzes, literature summaries, and case-based question formulation). Didactic and demonstration videos have recently been produced to support this transition.\u003c/p\u003e \u003cp\u003eThe Norwegian Intensive Training model is the evidence based intensive training model (Navarro-Haro et al., 2019). Trainees complete assignments and examinations and implement DBT at their workplaces between sessions. New teams receive monthly consultation, and novice clinicians are mentored by experienced team members. Intensive training is provided both remotely and on-site. Foundational training for clinicians joining existing DBT teams consists of either five or ten full days (Bender, et al \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). NFFS also organizes advanced training courses and a biannual DBT conference. The conferences has gathered clinicians from all over Norway as well as some other nordic coutries biannually for 18 years, last time 250 clinicians participated. All NSSF trainers also function as supervisors, supplemented by two additional supervisory clinicians. The trainers offer supervision to DBT teams irrespective of experience level; currently, half of Norwegian DBT teams receive consultation from experts affiliated with the DBT Norway Training Program, and some teams have benefited from monthly supervision for many years.\u003c/p\u003e \u003cp\u003eFormal team and applicant requirements are explicit: teams should include at least four mental health practitioners, with a minimum of half being medical doctors or clinical psychologists. These criteria aim to promote patient safety, diagnostic competence, and the sustainability of local DBT services.\u003c/p\u003e \u003cp\u003eThe evidence-based implementation of DBT in Norway has been inspired by favorable research outcomes. Both the feasibility study and the RCT of DBT-A for adolescents with repeated self-harm produced positive findings; longer-term follow-up indicated sustained effects, including remission of self-harm and reduced suicidal ideation into adulthood for those treated during adolescence (Melhum, et al. 2014, 2016, 2019 \u0026amp; 2026; T\u0026oslash;rmoen et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2014\u003c/span\u003ed rmoen et al., 2014). The strong focus on research is ongoing, and a research network with 6 collaborating units in Norway and Denmark is led by the center.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCurrent DBT Landscape in Norway\u003c/h2\u003e \u003cp\u003eCurrently, approximately 50 DBT consultation teams are established across health-care trusts in Norway, and more than 600 clinicians have been trained in DBT by the Norwegian DBT Training Team at the NSSF. For a sparsely populated country, this level of dissemination is remarkable. The teams operate in a range of settings, including adult outpatient clinics, adolescent outpatient services, several specialized services collaborating with child protection agencies, and a small number of substance misuse treatment units.\u003c/p\u003e \u003cp\u003eIn 2025, the NSSF contributed to the development of new national guidelines for the treatment of personality disorders. A revised guideline, to be published in May 2026, will list DBT as one of the preferred treatment options. Recent developments include the implementation and adaptation of DBT-PTSD, Radically Open DBT, and DBT for substance use disorders (DBT-SUD). Furthermore, Intensive DBT is currently in pilot testing as a preparation for a fully funded randomized controlled trial.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eProfessional Association\u003c/h2\u003e \u003cp\u003eIn 2017 a professional association, Norway-DBT, (N-DBT) aiming to spread knowledge, use and respect for DBT among clinicians, leaders, patients and their next of kin was established by Lars Mehlum. NSSF have a board position in N-DBT to contribute with our expertise due to our special mandate of implementing DBT in Norway given by the National Health Directorate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of DBT in Poland: invalidating context\u003c/h2\u003e \u003cp\u003ePoland provides a markedly different context for the implementation of DBT than the Western European and Scandinavian countries described above. There is virtually no institutional support for evidence-based psychotherapies, resources are limited, and university training in psychotherapy is rarely clinically oriented, while medical universities tend to marginalise psychosocial interventions as treatment options in favour of biological psychiatry. Most of the systemic facilitators of DBT implementation identified in the introduction to this paper, such as evidence-based mental health policy, research infrastructure, and clear institutional mandates, have been absent in Poland for many years and are unlikely to emerge soon. Instead, DBT has developed in Poland in the context of a broader crisis in psychiatry and mental health care, marked by chronic underfunding, political conflicts over how services should be organised, and the politicisation rather than professionalisation of key institutions. In this environment, clinical decision-making is rarely guided by evidence, international examples are not treated as models, and the mental health field is fragmented by long-standing tensions between professional groups and institutions. Despite the lack of facilitators and the presence of systemic obstacles, DBT has developed significantly in Poland over the last 10 years.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eDevelopment of DBT in Poland: timeline and bottom-up approach\u003c/h2\u003e \u003cp\u003eOver the past decade, DBT in Poland has developed almost entirely through bottom‑up initiatives. The Polish DBT Association (PTDBT) was founded in 2016 by a small group of clinicians who initially relied on self‑study, short international workshops, and online materials. In 2017 the first larger introductory training with Prof. Martin Bohus gathered around 100 participants, and in subsequent years 10 clinicians completed intensive training abroad and began working together in virtual consultation teams.\u003c/p\u003e \u003cp\u003eIn 2018 the PTDBT organised the first international DBT conference in Poland. In the same year, cooperation with the National Educational Alliance for Borderline Personality Disorder (NEABPD) was initiated and the first online training for Family Connections (FC) programme leaders was conducted \u003cb\u003e(\u003c/b\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.neabpd.org/family-connections\u003c/span\u003e\u003cspan address=\"https://www.neabpd.org/family-connections\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). At that point, it became clear that no there was institutional support or interest in DBT from academia, mental health authorities, or funding bodies in Poland. Therefore, DBT for families in the form of the Family Connections programme, an evidence‑based, pro bono intervention delivered through volunteer networks worldwide, was the only realistic way to develop DBT‑informed services in Poland that matched the available bottom‑up pathway. Since then, around 200 12‑week FC groups have been delivered in Poland, reaching approximately 2,400 family members of people with BPD, emotion dysregulation, and suicidality. This became the primary way to reach the community, educate families about the effectiveness and evidence‑base of DBT. This encouraged a process of advocacy for appropriate care, which prompted many therapists to turn to DBT to better meet their patients\u0026rsquo; needs.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eDBT training system in Poland\u003c/h2\u003e \u003cp\u003eSince 2020, PTDBT has run an annual Comprehensive DBT training programme under the leadership of Prof. Alan Fruzzetti together with a gradually growing local training team. Each cohort completes four 3‑day modules over 9\u0026ndash;10 months, combining didactic teaching with intensive skills practice, case discussions, and consultation‑team mentoring. Participants are organised into DBT teams, or encouraged to form them during the course, and are supported in implementing all treatment modes in their clinical settings as far as local conditions allow. The trainings have also centred on a transfer of technology with a gradual shift from Prof. Fruzzetti delivering the entire training to a shared format in which Polish trainers increasingly co‑teach and independently lead parts of the curriculum under ongoing supervision from Prof. Fruzzetti. The long-term aim is to develop an autonomous local training team.\u003c/p\u003e \u003cp\u003eAt present, Poland has a small but clearly defined DBT community and infrastructure. Approximately 150 clinicians have completed Comprehensive DBT training, and there is a developing system of training and informal mentoring available in Polish. Around 20 teams currently offer some or all modes of a DBT programme, with about 10 private centres providing comprehensive, multi‑mode DBT services, several of which have proved sustainable over time. Key DBT manuals and books have been translated and are widely accessible, and introductory DBT and DBT skills modules have been incorporated into many 4‑year CBT training programmes. Family Connections groups are now available nationwide, including in several public institutions, with some groups co‑led by family members, so that DBT and FC increasingly provide both individual treatment and environmental interventions. In addition, PTDBT regularly organises national and international conferences and symposia with a recent milestone of this community‑driven development was the co‑organisation of the First European DBT Congress (EDBTA), held in Gdańsk in May 2025.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eDBT in Poland: challenges and dialectics\u003c/h2\u003e \u003cp\u003eDespite these achievements, the development of DBT in Poland remains shaped far more by \u0026ldquo;in spite of\u0026rdquo; than \u0026ldquo;because of\u0026rdquo; systemic conditions. The clinicians most actively involved in DBT are almost all full‑time practitioners in the private sector, without access to protected research time or funding, which means that no systematic outcome studies of DBT have yet been conducted in Poland. Mental health authorities show little interest in promoting or commissioning evidence‑based treatments, and long‑standing tensions and political conflicts between institutions and professional groups further limit the chances of top‑down support. Against this backdrop, the Polish DBT story is less about how much could be achieved with favourable structures, and more about how much has been built through persistence, voluntary effort, and community collaboration in an invalidating system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDevelopment of DBT in the Czech Republic\u003c/h2\u003e \u003cp\u003eDBT has started to evolve considerably later in Czechia than in the European countries discussed above, with its early development taking place primarily outside the formal healthcare system. The first Czech DBT programme was established as a social service in 2008 at the therapeutic community \u003cem\u003eKaleidoskop\u003c/em\u003e (operating since 2006), led by Renata Tuml\u0026iacute;řov\u0026aacute;, which focused on individuals with various personality disorders. Members of this team were the first Czech workers trained in DBT at Behavioral Tech Institute in the US.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eEarly Teams\u003c/h2\u003e \u003cp\u003eFor more than a decade, DBT development in the Czech Republic progressed slowly and remained limited to a small number of highly motivated teams in few mental health facilities in the country. Usually, only components of DBT were incorporated in otherwise treatment as usual practice. A significant milestone in the integration of DBT into the public healthcare system occurred in 2019, when following intensive training from biDBT in the UK, the first fully structured 24-week outpatient DBT programme was launched at the psychiatric clinic of University Hospital Brno led by Dr Pavla Hork\u0026aacute; Linhartov\u0026aacute;. This outpatient programme was fully funded by public health insurance and followed all standard DBT principles. Members of this team are also contributing to the growing local evidence base through early outcome studies focusing on the effectiveness of DBT for borderline personality disorder in the Czech context (L\u0026aacute;talov\u0026aacute;, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), while also conducting wider research on BPD (Linhartova et al., 2020 \u0026amp; Radimecka et al., 2024).\u003c/p\u003e \u003cp\u003eFollowing this development, DBT services in the Czech Republic began to diversify in terms of settings and populations. In 2022, the first inpatient DBT programme for adolescents (14\u0026ndash;17) was established at the Children\u0026rsquo;s Psychiatric Hospital in Opařany, incorporating intensive skills training, family involvement, and a structured daily programme.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eResearch Funding for Additional Team Implementations\u003c/h2\u003e \u003cp\u003eA further step toward a coordinated national implementation and outcomes evaluation was an initiative of the National Institute of Mental Health in Czechia, which has funded and coordinated the implementation of fully structured 24-week DBT programmes into 5 mental health facilities across multiple regions since 2023 as one of the goals of Project Gradient (Pro zdravi21, z,u). These teams were trained and supervised by the biDBT. Large-scale dissemination and education are also an ongoing processes that support the expansion of DBT components into various treatment programmes and facilities around Czechia, alongside increased availability of DBT programmes and other DBT-informed treatment for people with emotion dysregulation. These initiatives have been complemented by increased collaboration with European partners and participation in international training and research networks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eNascent Professional Organisation\u003c/h2\u003e \u003cp\u003eThe professional organisation of DBT practitioners in the Czech Republic remains in an early stage of development compared to countries with longer DBT traditions. In 2023, a dedicated DBT section was established within the Czech Association for Cognitive Behavioural Therapy, providing an initial platform for networking, peer support, and discussion of therapy and training standards. A national DBT association was also established in 2024, which will eventually provide a structure for therapist certification. Czech clinicians have also become increasingly active within the European DBT Association, presenting implementation processes and emerging clinical and research findings at international conferences and engaging with ongoing discussions around programme fidelity and adaptations.\u003c/p\u003e \u003cp\u003eDespite these advances, DBT availability in the Czech Republic remains limited in contrast to clinical need. Key challenges include a shortage of fully trained DBT teams and supervisors, and the nascent state of standardized national training formats and certification system aligned with international standards. Training for new teams as well as support the stability of DBT teams by providing education to individuals filling in the gaps after staff turnover is a challenge. Additionally, another obstacle is funding, as reliance on project-based funding is not sustainable, and long-term solutions in place are needed. Coordination in such processes also needs an independent body of experts (such as a national association) that would be able to guide teams in adherence to national and international standards. At the same time, recent developments suggest a transition from isolated local initiatives toward more systematic, healthcare- as well as social care-embedded implementation of DBT as a standard treatment of borderline personality disorder in the Czech Republic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe DBT Implementation Framework (Tom et al., 2019) which integrates the stages of implementation discussed in wider implementation science research (planning, engaging, executing, evaluating and reflecting) with the processes that are unique to DBT implementation (context, DBT, evidence, and facilitation) focuses mostly the establishment of new DBT teams. The above case studies describe scaled up versions of DBT implementation processes in its description of five unique national DBT implementation pathways and is like processes described in the national implementation project in Ireland (Flynn, Kells \u0026amp; Joyce, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Apart from the situation in Poland, the implementation journeys described here are a mixture of bottom-up and top-down processes. These trajectories indicate that there are commonalities and some important differences related to system issues.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eCommon Facilitators: Contextual Factors and Research as a Driver for Implementation and Innovation\u003c/h2\u003e \u003cp\u003eIn all cases as we might expect from the DBT implementation literature context was key. Implementation processes began through the enthusiasm of one or two clinicians or researchers, which is a bottom-up factor that then transacted with and shaped top-down policies. Processes of DBT dissemination and implementation are facilitated by public policy support for evidence-based treatment and particular standards in mental health care. This was also seen in system-wide implementation projects such as the one in the USA Veterans Association (Landes et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Attention to the evidence-base also facilitates the incorporation of treatment adaptation as seen throughout Europe and particularly highlighted in the German system\u0026rsquo;s movement to the wide-spread dissemination DBT-PTSD. The pathway of implementation of DBT in the UK and in the Czech Republic has parallels in that they were both supported by wider systemic reforms of the mental health system to incorporate community care and evidence based treatments for people with severe and enduring mental health conditions such as BPD (NHS 1990, 2003 \u0026amp; 2009; Winkler et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In the case of Poland, these missing elements have made implementation processes slower and arguably more arduous.\u003c/p\u003e \u003cp\u003eAdditionally common themes such as access to quality, often evidence-based, training in DBT is highly valued. The importance of evidenced based training in general is widely known and has been shown to increase therapist experience and willingness to work with suicidal clients is a theme that has been explored in other implementation studies (e.g., Navarro-Haro et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). University affiliation, which can be a driver for implementation, also increases the likelihood of research on DBT in the national environment being conducted, which was particularly observed in Norway. These examples also demonstrate that implementation is a long and dynamic process with common milestones such as the establishment of professional societies and/or the affiliation with professional CBT organisations or the establishment of research initiatives. Finally, local treatment landscapes such as a preference for inpatient or outpatient services, for example, in the case of Germany versus the UK, shape implementation processes.\u003c/p\u003e \u003cp\u003eThe experience of implementation in Poland also demonstrates the benefit of ingenuity and commitment to learning in the realisation of ambitions to deliver evidence-based treatment. The Polish example further demonstrates another common theme, namely employing the strategies of the treatment itself and consider the system in which implementation is desired as the first DBT client can be effective (Swales, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Processes of system shaping are continuous and underpinned by the work of DBT Team leaders (Swales, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eLessons for newly adapting countries\u003c/h2\u003e \u003cp\u003eHarness the enthusiasm of the local leaders and DBT champions. DBT champions may not ultimately deliver DBT, and they can be powerful system influencers. Where possible connect DBT with policies on mental health and the incorporation of evidence-based practice. Focus as quickly as possible on creating networks of interested practitioners both nationally through the creation of national societies or special interest groups in existing CBT professional organisations and internationally (e.g. EDBTA or WDBTA). Consider the indicators of success from the beginning. Plan to measure the impact of the implementation both by the establishment of a team with all functions and modes as well as by demonstrable changes in therapist and client behaviour through routine measuring of therapist adherence to the model in sessions and changes in client behaviours and quality of life.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eIn addition to providing information on common processes of DBT implementation and system change, this research adds to the DBT implementation framework literature by highlighting the importance of continuous adaptation of DBT provisions based on emerging research. Relatedly it also points to the need for constant evaluation of the clinical outputs from DBT implementation. Effective implementation pays attention changes in therapist (e.g. adherence and fidelity) and client behaviours (e.g. patient related outcome measures) and adjusts treatment offerings in accordance with data.\u003c/p\u003e \u003cp\u003eThis narrative review relies on local DBT experts\u0026rsquo; description of the implementation histories. Inevitably there will be recall biases and missing information. It is not designed to be comprehensive or even systematic put rather to provide broad descriptions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe implementation of DBT across Europe over the past 30 years has changed the treatment landscape for people with BPD. DBT has shaped and been shaped by changing mental health policy landscapes and treatment contexts. Discussion of multiple experiences at the national scale provides information for nations that are seeking to make DBT more widely available. Implementation is a dynamic, iterative, and continuous process of treatment refinement through the incorporation of emerging evidence on the increased effectiveness of treatment adaptations or modifications. Finally, this research also adds to existing literature this topic in its strong focus on post initial implementation processes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding Declaration:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThere was no funding provided for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declaration\u003c/strong\u003e: N/A\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAll authors provided case materialAll authors reviewed AGE, MB and AT editted\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBender AM, Wilson RLH, Borntrager L, Orlowski EW, Gryglewicz K, Karver MS. 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Lancet Reg Health \u0026ndash; Europe. 2025;57:101464. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.lanepe.2025.101464\u003c/span\u003e\u003cspan address=\"10.1016/j.lanepe.2025.101464\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"DBT, Implementation, Case Study","lastPublishedDoi":"10.21203/rs.3.rs-9279155/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9279155/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis paper is a narrative review the implementation trajectories Dialectical Behaviour Therapy in five countries, the UK, Germany Norway, Poland, and the Czech Republic in Europe over the past 30 years. The aim of this comparison is to identify common and divergent systems levels facilitators and hinderances of DBT implementation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eDBT experts in each respective country were asked to provide a narrative account of their country\u0026rsquo;s implementation journey. Histories were then considered in accordance with existing DBT implementation frameworks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCommon themes emerged such as the importance national guidelines on evidence-based treatment shape implementation, university affiliations promote dissemination, implementation and research activities, national societies help to create standards.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThere are common DBT implementation trajectories that exist across geography and nationally specific mental health care systems. The discussion of the refining of national DBT practices based on emerging literature and the importance of outcomes of implementation such as therapists\u0026rsquo; behaviour or client related outcome data adds to existing information.\u003c/p\u003e","manuscriptTitle":"Case Study: The DBT Implementation Journey of Dialectical Behaviour Therapy in five European Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-17 13:11:01","doi":"10.21203/rs.3.rs-9279155/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-18T14:58:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-12T21:03:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68795073509367141383869232988034613608","date":"2026-04-12T13:37:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-10T03:19:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-03T09:40:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T09:40:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Borderline Personality Disorder and Emotion Dysregulation","date":"2026-03-31T11:19:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"borderline-personality-disorder-and-emotion-dysregulation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bded","sideBox":"Learn more about [Borderline Personality Disorder and Emotion Dysregulation](http://bpded.biomedcentral.com)","snPcode":"40479","submissionUrl":"https://submission.nature.com/new-submission/40479/3","title":"Borderline Personality Disorder and Emotion Dysregulation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"20cc4262-7355-4f85-b445-677ef5693db0","owner":[],"postedDate":"April 17th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-18T14:58:24+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T15:09:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-17 13:11:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9279155","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9279155","identity":"rs-9279155","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}