Implementing a DBT Program in a Community Mental Health System (Part 3)

Nov 9, 2020 | DBT in Various Treatment Settings

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.

Much of Gwen’s blog had to do with phone coaching in DBT. If you would like to read more about this topic, check out this blog!

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.


Disclaimer: The Behavioral Tech Institute blog is designed to facilitate the sharing of ideas, experiences, and insights related to Dialectical Behavior Therapy (DBT). The content and views expressed in the articles, comments, and linked resources are those of the individual authors and do not necessarily reflect the views, policies, or positions of Behavioral Tech Institute or staff. Content is provided for information and discussion purposes only and is not intended as professional advice. Contributors to the Behavioral Tech Institute blog are independent, and their participation does not represent an endorsement by Behavioral Tech Institute.

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