Engaging Line Staff in Dialectical Behavior Therapy (Part 2)

Jan 24, 2021 | DBT in Various Treatment Settings

This feature by Nicole Kletzka, PhD is Part 2 of 2 in a series about engaging line staff in Dialectical Behavior Therapy. In the first part, Nicole begins by sharing background on DBT and the role of line staff, examining the importance of the structure of DBT programming, and noting the link between staff empowerment and company outcomes. Here in part two, Nicole explores structuring the environment, administrative challenges to overcome, and factors for line staff buy-in.

We left off in part 1 (read here) with the idea that feeling included and valued is central to employee engagement, which is linked to company outcomes (Fernandez & Moldogaziev, 2013; Simpson, 2009). With DBT in mind, agencies can increase engagement by providing DBT training, defining the role of line staff in providing DBT, and providing a structure and ongoing opportunities to allow line staff to actively participate in meeting DBT treatment targets. 

Structuring the environment with inpatients differs from establishing structure in a community environment. In the community, the clinician may be working with the patient to create the most effective contingencies. The unit is structured for safety, without taking individual factors into account. This artificial environment may ameliorate stressors seen in the community, possibly inadvertently reinforcing helplessness or engendering a false sense that problems are resolved rather than fostering effective and skillful behaviors. It can be challenging to identify ways to help patients generalize newly-learned skills in a way that will be effective upon hospital discharge. Line staff are in a unique position to observe how patients respond to unit contingencies and to find possible reinforcers and natural punishers which staff and clinicians with less patient contact might miss. Involving line staff on all shifts in the creation and implementation of behavior plans can therefore help patients obtain better outcomes while simultaneously empowering line staff. With multiple shifts and different team members on different units, coordination and communication across team members and shifts are important to implement successful behavioral plans. This is another area in which administrative support is central to success.

Many DBT inpatient programs provide an initial investment in training both line staff and clinical staff in DBT, but do not consider long-term funding and supports needed, so it is not uncommon for there to be gaps in administrative support once initial training is received. With staff turnover, line staff who are trained may leave, and new staff who are not provided with the intensive training because there is no funding allocated to send them to training may not be as engaged or motivated to provide the treatment. It is therefore important to ensure that follow-up trainings are available for new staff and for helping to re-energize existing staff. 

In addition, large systems may have other priorities or challenges arise after the implementation of DBT programming which can derail the original program structures and priorities. Middle managers and administrators at different facilities may expect that DBT be conducted without providing ongoing time resources necessary to increase the motivation and capability of the line staff. Skills trainers and individual therapists often face this challenge when carving out time for weekly DBT team consultation meetings. With many competing work demands, many facilities are reluctant to reduce productivity expectations for DBT team members to attend team consultation meetings. 

Even if administration recognizes the importance of carving out time to provide additional training and consultation for all DBT team members, for line staff there may be practical challenges which at times seem insurmountable. Line staff have many duties which require coordination of multiple line staff schedules. Scheduling time for lunches can be difficult, much less carving out time for weekly team meetings that pull them off of the floor. If understaffed, line staff may be pulled to other units, making them unavailable for team meetings, trainings, or other DBT activities. Additionally, staff may be mandated to cover existing unit needs or to cover shifts. In this circumstance, to allow someone to attend a DBT team meeting might require mandating another staff member to cover their unit duties during this time. Pulling staff for DBT team meetings in that case could potentially result in resentment among staff not involved in the DBT program. In addition, providing training and consultation for individuals across different shifts can create other challenges. Midnight or afternoon shift workers are often not included in training opportunities because they are scheduled during normal working hours. Because these challenges are more the norm than the exception, it is important to include a DBT administrative liaison or support person to work with the team in an ongoing manner to help navigate these logistical challenges.   

Because of both logistic and structural challenges, sometimes standard team consultation meetings have not been practical for line staff. Some agencies have attempted to include a DBT Team Consultation meeting as part of the normal clinical team meetings; however, without having dedicated time focused on DBT, the DBT agenda to build motivation and capability often gets put aside for the team’s “crisis of the day.” Other strategies to help line staff build motivation and capability outside of a standard DBT Team Consultation meeting include assigning staff as co-leaders to skills training groups to increase their knowledge of skills while attending to regular duties and assigning each line staff a mentor who is someone able to attend team consultation meetings. The assigned mentor would meet with the line staff weekly, focusing on the targets of increasing capability and motivation for the line staff member. A staff DBT diary card has been created to assist DBT Team Consultation members in mentoring line staff who are not able to attend the weekly team meeting. The card includes columns for line staff to learn a DBT skill or strategy, role play the skill with a co-worker, and practice the skill in the milieu (Kletzka & Witterholt, 2014). Regardless of the mechanism in which line staff are provided with consultation and support, it is important that this function be addressed. 

In inpatient programs, providing a day or two of training to line staff without providing adequate ongoing support in terms of team consultation can create an iatrogenic effect. Fox (2018) says an inadequately supported DBT program is like having patients only take medication on alternate days to save money. As an example, I worked with a line staff who was enthusiastic after receiving initial training although her facility did not provide time for weekly team consultation or other supports for line staff. When working with a highly assaultive patient who was escalating, she emphatically told him to use his DBT skills. Because her knowledge of DBT remained formulaic, she had not used a validation strategy prior to pushing for change. Unsurprisingly, the client’s behavior escalated, resulting in an assault. Following this, she came to believe that DBT was ineffective, and she disengaged from the program. The problem is significant enough that Fox states that “the project team should contain at least one person with managerial status sufficient to recruit organizational support, book rooms, allocate staff time, and if necessary, halt the implementation process rather than deliver an under-resourced treatment” (p.652).

In addition to the structural challenges for training and supporting line staff, there are also individual factors that influence line staff buy-in. For line staff who are hired under “security” there may be resistance to being forced into a clinical role. A solution for this problem would be to include clinical descriptors into the original job description so that the job description matches the job itself. In that case, the staff person would know the expectations and could choose to take a job which included a DBT role. DBT is a complex treatment which involves a great deal of investment and learning, it is therefore not a treatment which can be forced upon a staff member post-hoc. Just as DBT is considered a voluntary treatment for patients, it is also voluntary for staff to join the team. In some agencies, staff are “voluntold” to provide DBT services. In these cases, engagement is reasonably very low. The DBT Team must take on the role of educating administration and helping the team members who do not engage to leave the team in this circumstance.

Alternatively, many staff members who were initially resistant to DBT have become its fiercest advocates after seeing the positive impact that DBT has on the patients and on the inpatient setting in general. Presenting treatment outcomes to staff has helped build engagement, particularly when outcomes are linked to line staffs’ immediate concerns. Reduced patient-on-patient or patient-on-staff assaults, reduced behavioral outbursts and other similar outcomes are particularly motivating. I personally have seen line staff change their opinion about DBT when they see stable behavioral change in a patient with whom they did not believe change was possible. Another method to increase line staff buy-in is to help staff link the DBT skills and strategies to their personal lives. Applying the skills to reduce staff burnout can be especially helpful in engaging line staff in an inpatient setting. 

Because they are with the patients 24 hours a day, line staff are in a unique position to help patients generalize their DBT skills in inpatient settings. I recall working with a highly assaultive young man who told me in skills training that he knew the DBT skills, but that when someone made him mad, the skills went right out of his mind and his fist engaged. During one of these aggressive episodes, non-DBT staff intervened. They physically restrained him. At that moment, our DBT line staff coach entered the room. Because of his relationship with this patient, he was able to validate him, helping him calm down. While the patient was still in a manual hold, the coach asked him if he was willing to use a DBT skill rather than being secluded. The patient physically relaxed and, within minutes, staff were able to release the manual hold. The patient walked calmly and independently to the quiet room, where he was able to regain his composure. As this example illustrates, with proper engagement and training, line staff can be some of the most influential people in an inpatient DBT program for the patients as well as the DBT team.

Did you find this blog useful? If so, you may want to check out our series from Gwen Abney-Cunningham, LMSW on Implementing a DBT Program in a Community Mental Health System.

Nicole Kletzka, PhD is DBT Supervisor of the Center for Forensic Psychiatry in Saline, MI, completed the Linehan Board of Certification process in 2015 and joined Behavioral Tech Institute in 2016. Read Nicole’s full bio here.

REFERENCES (part 1 and part 2):

Bloom,  J.M., Woodward, E.N., Susmaras T., & Pantalone,  D.W.. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: A systematic review. Psychiatric Services, 63(9), 81-89.

Fernandez, S., & Moldogaziev, T. (2013). Employee empowerment, employee attitudes, and performance: Testing a causal model. Public Administration Review73(3), 490-506.

Fernandez, S., & Moldogaziev, T. (2011). Empowering public sector employees to improve performance: does it work?. The American Review of Public Administration41(1), 23-47.

Fox, E. (2018). Delivering DBT in an inpatient setting. In The Oxford Handbook of Dialectical Behaviour Therapy.

Kletzka, N., & Witterholt, S. (2014). DBT staff diary card.  

Kletzka, N., Lachat, C., Echols, S., & Witterholt, S. (2014, November). Structuring dialectical behavior therapy treatment in a forensic inpatient setting: Patient progress and staff perceptions.  19th Annual ISITBT DBT Conference. Philadelphia, PA. 

Krawitz, R., & Miga, E. M. (2019). Cost-effectiveness of dialectical behaviour therapy for borderline personality disorder. In The Oxford handbook of dialectical behaviour therapy.

Lieb, K., Zanarini, M.C., Schmahl, C., Linehan, M., & Bohus, M. (2004). Borderline personality disorder, The Lancet, 364, 453-461.

Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behavior therapy for borderline personality disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (p. 470–522). The Guilford Press.

Simpson, M. R. (2009). Engagement at work: A review of the literature. International Journal of Nursing Studies46(7), 1012-1024.  

Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. In L.A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders and settings (pp. 69-111). The Guilford Press.   


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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