Implementing a DBT Program in a Community Mental Health System (Part 1)

October 12, 2020

This feature by Gwen Abney-Cunningham, LMSW is Part 1 of 3 in a series about implementing a DBT program in a Community Mental Health system. Through this series, Gwen will address some of the questions that her own team or other programs have struggled with in their experiences. In this first part, Gwen begins with some basic questions around what it looks like to provide DBT in a community setting.

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.

Whatever the system a team is in and attempting to implement DBT, there will be challenges. Frequently, CMHs receive some of the most challenging individuals who have not been successful in standard outpatient treatment modalities. 

I have compiled a list of questions that my team or other programs have struggled with, specifically in a CMH system. The responses give you an idea of how we have answered these questions. We are always striving to provide the most effective treatment to assist individuals we work with to develop a life worth living, honor the fidelity of the model, AND balance the many demands of working in a sometimes-challenging environment.

Frequently asked questions by Community Mental Health  providers:

Question: Can comprehensive Dialectical Behavior Therapy be provided in a Community Mental Health setting?

Comprehensive Dialectical Behavior Therapy (DBT) was developed for individuals with severe behavioral dyscontrol, focusing on emotion regulation and  distress tolerance. Standard DBT was originally developed providing the treatment in an outpatient setting in the community, assisting individuals with developing a life worth living. The premise being to learn, strengthen, and generalize skills while in the living in the community.  As with CMH outpatient services, the goal is to assist people in their lives and ideally remain in the community.   

The best course of action is to follow the research and adopt the standard model. There are many community mental health settings providing comprehensive DBT.  It can be done with no or minimal adaptations.

Question:  What does providing DBT in a community setting look like?

Providing comprehensive DBT in a CMH system retains the theoretical model, principles, and therapeutic strategies of standard comprehensive DBT. Remembering to follow the five functions and corresponding modes of comprehensive outpatient DBT is imperative when developing, implementing, and sustaining a DBT program.    

As a program is being developed, starting with a team of at least three clinicians who have a strong desire to implement DBT is very important. The status of voluntold by administrators, in my experience, often is problematic for all involved. 

As for all clinicians, there are many demands. In a CMH system, there can be even more with the many evidence-based treatments they are expected to learn and deliver. It is sometimes a challenge to schedule weekly individual sessions and weekly skills training sessions due to the high demand of a very high case load.

Many teams have negotiated with administration to reduce caseloads using, of course, the skills of DEAR MAN, GIVE and FAST. It is of utmost importance that the organization’s administration knows that comprehensive DBT is not just a new type of standard outpatient therapy. There should be allowances for weekly consultation team of all the staff implementing DBT, skills groups of at least two hours weekly with a cap of 12 clients and always two facilitators, and time built into the schedule for skills coaching and regular supervision.

I have found the most successful and sustainable teams are the ones that start small, receive initial and on-going training, keep their feet to the fire of following the model of DBT, and meet weekly in consultation team come hell, high water, and/or Coronavirus.

To increase success to both individuals providing DBT and to the program as a whole, as in other evidence-based treatments, it  imperative that the clinicians receive weekly supervision focused on DBT.  This can be a challenge for new teams in which everyone is at the base line of  just learning DBT.  In these cases, teams often provide peer supervision, reviewing and offering feedback for taped sessions of each clinician providing DBT to the individuals they serve. 

Now that we have started by looking at the overall considerations for implementing DBT in a Community Mental Health setting, we are ready to get into some tactical questions. Read here for part 2 of this series, in which we will address phone coaching (during and after hours), having “on call” systems, and reducing burn out for clinicians.

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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