Adapting Dialectical Behavior Therapy Skills Training for Self-Guided Internet Delivery: Initial Co-Design and Mixed-Methods User Testing Study (Preprint)

BACKGROUND Digital mental health interventions (DMHIs) represent a promising tool for leveraging innovation to increase access to mental health services. Considerably fewer DMHIs have been based on dialectical behavior therapy skills training (DBT-ST) which is typically offered as an in-person group intervention for depression, anxiety, eating disorders, and substance use disorders. While several internet-delivered DBT-ST (iDBT-ST) exist, few have involved PWLLE to potentially improve DMHI engagement and retention. OBJECTIVE The current study describes a two-phase process to adapt standard in-person group DBT-ST to a self-guided iDBT-ST DMHI. METHODS In Phase 1, PWLLE advisory members reviewed the goals of adaptation, contributed to a needs assessment, and assisted with adaptation and implementation planning to co-design intervention materials. An intervention adaptation framework was used to guide the process, and we outlined changes using established reporting guidelines. In Phase 2, a prototype iDBT-ST DMHI was built on an e-learning platform and underwent user-testing with a new sample of PWLLE participants invited to preview the intervention within a mixed-methods study. Following a cognitive walkthrough of the intervention, participants completed an interview about its benefits and potential improvements and provided ratings of perceived appropriateness and acceptability. Qualitative and quantitative data were used to examine convergence and divergence. RESULTS In Phase 1, 22 PWLLE participated in the co-design process, with iDBT-ST seen as a free and accessible DMHI suitable for delivery through the internet without needing to meet with a professional. Clinician skills training videos covering 26 DBT skills and PWLLE videos describing the use of DBT skills in daily life were included in the final materials, along with royalty free images, slides, quotes, suggested homework exercises, and practice examples. In Phase 2, participants’ qualitative feedback was largely positive and focused on the educational value of the intervention, the structural and systemic benefits, and opportunities for enhancement. 24 out of 25 participants (96%) expressed a willingness to potentially initiate the intervention, supporting feasibility of recruitment and potential adoption. Appropriateness and acceptability of the intervention were supported by converging qualitative and quantitative evidence, with most participants providing positive feedback about its potential implementation. CONCLUSIONS By involving more than 45 PWLLE, we have built a promising iDBT-ST DMHI delivered through an e-learning platform. Knowledge gained from the adaptation process will inform its initial evaluation through a registered pilot trial to understand its potential efficacy while generating additional early implementation-relevant data. Future research may also evaluate therapist-supported versions of iDBT-ST to support broader access and availability of DBT as well ensuring its proposed mechanisms of action are maintained.