Implementing a DBT Program in a Community Mental Health System (Part 2)

October 26, 2020

This feature by Gwen Abney-Cunningham, LMSW is Part 2 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 the first part, Gwen began with some basic questions around what it looks like to provide DBT in a community setting. In this part, we will address phone coaching (during and after hours), having “on call” systems, and reducing burn out for clinicians.

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. Today, we will examine common questions about phone coaching.

Frequently asked questions by Community Mental Health providers:

Question: How do you provide phone coaching during and after hours in a community mental health setting?

It can be a bit scary to think about providing phone calls during and after hours.  Remember that phone calls are not to take the place of therapy.  Phone calls typically take 5 to 15 minutes.  Bear in mind that the overarching goal of phone coaching is to assist / assure generalization into their environment.  Be mindful to follow the hierarchy of targets for phone coaching based on if you are the individual therapist or the skills trainer.

In addition, remember you don’t have to call back right away.  It is recommended to make sure the clinician orients the client of the phone targets, as well as what response time will look like and also to orient the office of recipient rights of the targets of phone calls and response time.  You may explain that – while phone coaching is available 24/7 – the return call may not be immediate and clients are expected to use their skills while waiting for a return call.

CMH systems sometimes make the mistake of coaching individuals to call when it is a crisis. DBT therapists want their clients to call for coaching or to touch base if there is a sense of conflict, alienation, or distance with the therapist.  Remember that individuals calling for coaching and asking for help is a skill.

When someone is emotionally dysregulated, it can be very difficult to think in a Wise Mind manner.  Thus, calling the therapist can assist with that generalization and reduce the likelihood of hospitalization; getting closer to their life worth living goal.

Question: What if the CMH system has an existing “on call system”?

There are many CMH systems that have an established on call system, often through their access center.  It is recommended that  the DBT team/clinician provide the phone coaching. 

The first thing to note is that we do not want to communicate that there needs to be a crisis in order to call during or after hours.

Keep in mind that problematic behaviors could be reinforced by other providers who do not know DBT, the hierarchy of targets of phone coaching, nor the life worth living goals of the person calling.

Question:  There is a huge concern that taking after hours calls will burn a clinician out – how do you address this?

We help to reduce clinician burn out by remembering that it is important to have the hierarchy of targets in mind and follow them. The calls are very focused.  Also, remember the power of shaping. Where they start is not where they are going to land.

The irony is that, in my experience, I do much less addressing/shaping of  “calling too much” behavior and more of addressing / shaping clients “not calling when they need to” behavior. 

In my experience, the many demands, including the paperwork in a community mental health system, is what has increased my burnout. It helps to remember to cheerlead yourself and others, “That doing all the paperwork is a necessity to do the good clinical  work.”  In addition, cheerleading / problem solving in weekly supervision and consultation helps me keep my eye on the ball.

Now that we have talked through some basic considerations implementing DBT in a Community Mental Health setting as well as the role of phone coaching, read here for part 3, in which we will wrap up with a couple final questions about staying within a clinician’s limits.

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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