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Do your clients come to session and say they used Opposite Action to get there?  Do you assess to determine whether the skill used was effectiveI have spent a lot of time over the last 25 years working with individuals, teams, and organizations both public and private.  I have had the benefit of participating in internal planning and processes while also being an outside observer.  Each year I marvel at how dedicated, caring, and passionately the people working so hard to learn DBT are when it comes to patient care, client services, or improved clinical outcomes.  At the same time, I also see how systems often fight a battle (or dance the dialectic) between mandates at the front door and treatment once the threshold is crossed.  System operations and clinical operations are often at odds with each other, especially when staffing is short, and need is high. 

I see so many systems work so hard to implement evidence-based practices, only to have well intentioned service oriented mandates undermine treatment provision once the client enters the “building”.  We are so focused on access to services that systems and clinicians are overwhelmed managing assessments and intakes that provision of a comprehensive treatment like DBT feels impossible.  I watch so many attendees at training “step out” to manage a crisis, which often serves to reinforce escalating behavior.  I hear so many administrators talk about the crushing impact of turnover when the provision of evidence based practices are treated like “treatment as usual” with little accommodation afforded to the clinician who is taking on more work with harder clients. 

DBT is not treatment as usual.  Crises and acuity will not go down without a comprehensive treatment intervention and a comprehensive treatment intervention cannot be learned without training, practice and time.  I see so many funders, administrators, teams and clinicians who are completely dedicated to evidence-based treatment and yet system constructs and expectations don’t allow for the learning or provision of comprehensive treatments like DBT.  So, what to do?

I’ll always defer to the basics as they tend to get us through the big stuff.  I would start with the idea that we are better off dedicating 15 minutes of training every day versus 2 hours once a week.  The 15 minutes can be all at once but might even be more manageable if broken into three 5-minute increments.  Either way, a little bit every day is more effective than 2 hours once a week.  Make a list of things to do and take them one at a time.  Start by employing skills in every way you can – both as an effective way to learn the skills and because the skills will help you effectively navigate your system.  Observe and describe one mindfully and non-judgmentally.  This will lead to a “to do” list and that will lead to action steps.  Find a white board, a pot of coffee and your tribe and start thinking out loud.  It is shocking how much can be articulated and accomplished with a small group of people working towards the same goals. Start using DEAR MAN in every situation and rely on the skill of broken record.  Both will do wonders to get the doors to open and to keep you walking towards your goals. 

As Marsha Linehan would often say, she never met anyone who woke up in the morning wanting to be a mental health patient.  Not one.  I’ve never worked with a system that works toward providing ineffective treatment.  Not one.  Behavior is reinforced and shaped over time.  Change is hard and takes time, but is always an option.  The most effective thing we can do to change the system is to change our thinking that our systems are unchangeable.  It takes time and it is always within our purview.  As the saying goes, the journey of a thousand miles begins with a single step.  Let’s start walking together.