This feature by Gwen Abney-Cunningham, LMSW is the final part of a three-part series about implementing a DBT program in a Community Mental Health system. Through this series, Gwen has addressed some of the questions that her own team or other programs have struggled with in their experiences. In the first part, Gwen began with some basic questions around what it looks like to provide DBT in a community setting. In the second part, we addressed phone coaching (during and after hours), having “on call” systems, and reducing burn out for clinicians. Today, we wrap up with a shorter final segment about staying within a clinician’s personal limits and what keeps clinicians doing DBT in a CMH system.
For the last 25 years, I have had the honor to assist with developing and implementing a DBT program in a Community Mental Health (CMH) system. I have also provided DBT services as a clinician for the last 25 years, and I have been privileged to provide training and consultation to many CMH programs desiring to develop, implement, and sustain a comprehensive DBT program in their system.
I have compiled a list of questions that my team or other programs have struggled with, specifically in a CMH system. In part 1 (read here), we began with more basic questions. In part 2 (read here), we explored the subject of phone coaching more deeply. Today, we take a look at staying with the clinicians’ limits to keep them practicing DBT within a CMH system.
Frequently asked questions by Community Mental Health providers:
Question: What if taking calls is past a clinician’s personal limits?
One of the functions of comprehensive outpatient DBT is to assure generalization in the environment, and one of the modes is via phone coaching. In order to provide comprehensive DBT, phone coaching is necessary., but it is totally understandable if this is past a clinician’s limits. It may be that the clinician chooses to not do DBT, or they utilize their consultation team to assist with stretching their limits.
Question: How does a DBT program manage the attendance policy in a CMH system that mandates that a consumer be provided services?
In DBT, if someone misses four consecutive individual session or four consecutive skills classes, they are out of DBT. If a person violates the attendance policy, it is recommended that they be referred to another therapist in the outpatient clinic and/or referred to another service, such as case management. The individual would not be denied service altogether. They would just not be receiving DBT services.
In many DBT programs in a CMH system, they have developed a “return policy,” specifying a set time they would need to wait to “reapply.” If the program is willing to take individuals back into the program, it is important to problem solve what got in the way and what will be different. It is helpful to discuss referrals and “returnees” in consultation. In addition, having a clear inclusion/exclusions criterion is very important.
QUESTION: What keeps clinicians doing DBT in a CMH system? (i.e DBT seems much harder than treatment as usual)
When I take a step back and pause before answering this question……
For me, the answer is many things…….
Number one is the individuals I have had and continue to have the privilege to work with. They teach me, and I learn something at least daily, if not hourly!!!
Number two is that the treatment works. I have worked with many individuals over the years in a CMH system. They get better. Plus, many leave the CMH system or step down to less restrictive services. Sometimes, just psychiatric services.
Number three is my consultation team. I am so grateful that they keep my feet to the fire and, because I care about them, of course I keep their feet to the fire, as well.
Finally, I get really reinforced by doing hard things and having positive results.
Gwen Abney-Cunningham is the director of Evidenced Based Practices of InterAct of Michigan, Inc., a not-for-profit organization that provides contract services to two West Michigan Community Mental Health and Substance Abuse Services Boards. Gwen is also a DBT trainer and consultant with Behavioral Tech Institute for the past 20 years. Read Gwen’s full bio here.
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