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Applications for I.D.
Jo-Anne Kens, December 2015
• Overview of DBT (Linehan)
• HBBS Experience/Adaptations for ID/DD population (M.Lew)
Dialectic view: challenges rigid black and white, all or nothing thinking.
• Synthesizes seemingly contradictory perspectives; Moves us from this or that….to
this and that
• Primary dialectic in DBT of acceptance and change
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Dialectical Behaviour Therapy
• Treatment developed for BPD
•Draws from CBT, ABA & Mindfulness
• Psychoeducational
•Validation and Acceptance
• Adolescents with parasuicidal behaviours
• Older adults with depression
• Adults with eating disorders
• BPD with substance abuse
• Applications for adults with I.D./D.D.
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Adopt or Adapt?
Adopt and Adapt?
Its success as an evidence based treatment is both
Benefit and Burden
• Brown, Brown and Dibiasio (2013)
• Dykstra and Charlton (2003)
• Lew, Matta, Tripp-Tebo, and Watts (2006)
• Sakdalan, Shaw and Collier (2010)
Should people with ID be denied access
to an effective evidence based treatment
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Aligned with existing approaches: • Person centred: validation, empowerment, independence
• Behaviour skills training/ psychoeducational approach
• Enhance capacity within DS sector (reduce burnout, shift perspective of client)
• Opportunity to collaborate with mental health providers to support dually diagnosed individuals
• High cost of crisis support•Hospital (emergency visits, admissions)
•Family physician
•Police
•EMS
•Homelessness and crisis shelters
$+$=$$$
• DBT is Complex - many acronyms and skills
• Cognitively challenging (e.g. literacy, memory, abstract concepts/metaphors)
• Long term commitment
• Generalization – must be supported and planned
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• Intense resources of clinical service
• Cost of training/Staff turnover
• Consultation Team with alignment to DBT: biosocial theory, dialectic stance, DBT assumptions, etc.
• Requires long term support
• Intensive resources of mediator/coaches (DS support agencies/other/family)
• Generalization – working with supports; teach people in system about DBT
• 2008 Network Specialized Care sponsored training for Ontario clinicians with Dr. Marvin Lew
• DBT-Adapted program; The Bridge of Central Massachusetts
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• 18 months in DBT (individual therapy and adapted DBT skills training group)
• Reduction in high risk behaviours after participation in the program.
Lew, Matta, Tripp-Tebo & Watts, 2006
Invalidating environments
Biological vulnerability
Clients…
• Are doing the best they can and need to do better
• Want to improve
• May not have caused their problems, but do have to fix them
• Deserve a life worth living
• Cannot fail at DBT (DBT can fail them)
• Treatment providers need support
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• Enhance client skills
• Enhance client motivation
• Ensure generalization
• Structure environment
• Enhance therapist skills
•Emotion Dysregulation
• Interpersonal Dysregulation
•Self-Dysregulation
•Behavioural Dysregulation
•Cognitive Dysregulation
• Skills Group
• Individual Therapy
• Telephone Consultation
• Consultation Team
• Structuring Environment
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DBT Skills Training group where skills are learned and practiced:
ACCEPTANCE ORIENTED SKILLS
• Mindfulness
• Distress Tolerance
CHANGE ORIENTED SKILLS
• Emotion Regulation
• Interpersonal Effectiveness
• Controlling your mind…instead of it controlling you.
• Learn to focus or direct your attention
• Awareness of the present moment….instead of the past or future
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• What Skills: What to do
• How Skills: How to do it
ObserveDescribe
Participate
Non-judgmentallyOne Mindfully
Effectively
Rational
Mind
Cool headed
Logic & reason
Emotion
MindHot headedEmotions in
Control
Acting on urges
Wise MindBalancedKnowing
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• Emotional distress can lead to problem behaviours
• Distress tolerance learning to manage distress skillfully without making things worse
• Pain vs. suffering
• Acceptance
• Self-Soothe through Senses
• Pros & Cons
• Distracting yourself - ACCEPTS
• IMPROVE the moment
Crisis Survival Skills
• Activities – do something different
• Contributing – to others
• Comparisons – with others
• Emotions – Distract with opposite emotions
• Pushing Away – take a time out temporarily
• Thoughts – focus thoughts on something else for now
• Sensations – distract with intense sensations
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• Imagery
• Meaning
• Prayer
• Relaxation
• One thing in the moment
• Vacation
• Encouragement
• Increase awareness of emotions
• Accept that emotions are part of life; gain some control over them
• Increase tolerance for difficult emotions
Reducing vulnerability to mood driven bx’s
• Increase wellness
• Increase positive experiences
• Not acting on negative emotions – use mindfulness to choose an alternate path
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• PL Treat Physical Illness
• E Balanced Eating
• A Avoid Mood Altering drugs
• S Balanced Sleep
• E Exercise
• Mastery: Build mastery and competence
• Assertiveness: Asking for what you want/Saying no DEAR MAN Skills
• Self Respect Skills: FAST Skills
• Relationship Skills: GIVE Skills
Getting your objectives met/Saying No
• Describe situation
• Express your feelings/opinions
• Assert by asking or saying no
• Reinforce person in advance
• Mindful of your objective
• Appear confident
• Negotiate solutions
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Getting/Keeping Important Relationships
• Gentle manner
• Interested in the other person
• Validate the other person without judging
• Easy manner – use humour
• Fair – to myself and others
• (no) Apologies – for asking, for opinion
• Stick to values
• Truthful – without excuses/exaggerating
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• Focus on specific client goals
• Review week through diary card
• Use chain analysis to identify triggers/skill opportunities/consequences
• Use validation and motivation strategies
• Review and rehearse skills
• Chain Analysis - contingencies
• Story of EmotionTriggering event
Thoughts
Body Sensations
Urge to Act
My Actions
After Effects
Vulnerabilities
High rates of Reinforcement:
•Validation, Cheerleading, Coaching
•Modelling
•Rehearsal (Role Play)
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•Connecting to client goals
•Devil’s advocate … why client shouldn’t
•‘‘Foot in the door” … start small & build
•‘‘Door in the face’’ … ask for the moon…then scale back
•Freedom to choose
• Homework practice
• Visuals (hand outs, power cards, etc.)
• Mediator support
• Telephone Coaching
• Coaching clients on how to
use skills to effectively cope with difficult situations (generalization)
• Clients can call between sessions to receive coaching.
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• Structure environments to ensure they respond in ways that validate and support skill use
• Be present: listening and observing
• Acknowledging and Confirming
• Empathy
• Validation based on clients experience
Finding the kernel of wisdom in clients’ behaviour or view (that makes sense based on..)
• Supports self-validation
(Validation doesn’t mean you agree)
Consultation Team
• Case discussion
• Peer supervision
• Ensure DBT adherence/dialectical balance
• Support and validation - Cheerleading
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• Ongoing consultation via VC lead by Dr. Lew to model a DBT consultation group as clinicians were developing their own adapted DBT-ID groups
• Training to residential supports/program staff/family/other key supports
• Crisis Plan – include DBT skills; Work with team around person
• Referral form
•Mild to moderate ID
• Persistent emotional dysregulation
•Group readiness
• Support available (coach/mediator)
• Logistics (transportation, schedule)
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• Sufficient stability to undertake commitment of DBT
•Attendance
•Participation
•Practice
•Homework
Attend at least 3 initial appointments prior to start of group
•Review client goals
•Enhance commitment
•Review group structure/expectations (homework practice, group rules)
•Sign agreements
• Introduce mindfulness
Each participant requires a mediator to:
• support learning during the group
• Model skills through participation in skills training (e.g. practice mindfulness)
• support generalization of skills across environments
• Support practice/homework completion
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• Overview of DBT
• Review Mediator Role
• Signed agreements
• Mindfulness 2 sessions
• Distress Tolerance 6 sessions
• Mindfulness 2 sessions
• Emotion Regulation 6 sessions
• Mindfulness 2 sessions
• Interpersonal Effectiveness 6 sessions
• Mindfulness 2 sessions
Different days of group
and individual sessions
e.g. Group on Tuesdays and Individual session on Thurs
to increase contact points to better support client with skills and motivation
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Weekly 90 minutes:
Mindfulness Practice 10 min
Check in/Homework Review 20 min
Break 10 min
Skills Training 30 min
Discuss Homework/Practice 10 min
Mindfulness Practice 10 min
• Mindfulness
• Review diary card – Check in
• Chain analysis (triggering events/maintaining behaviours?)
• Troubleshoot (Role play, problem solve, rehearsal, review skills from last group, etc.)
• Cheerlead, enhance motivation, validation
• Limited staffing resources (2 clinical staff)
• Act as both group facilitator and individual therapist
• Rotate roles
• Facilitator – skills training/prepare materials
• Support Role: Observer – post group review/if someone dysregulated and needed to leave room/etc.
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• Client DBT binderDiary Cards
Weekly skills handouts
• Power cards on rings or laminated visuals (individualized – portable skill reminders)
• Tracking sheet: paricipation/use of skills/therapy interfering behaviours
Use consistent symbols/icons across handout notes and diary cards
Wise Mind Mindful Non-Judgment
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Mon Tues Wed Thurs Fri Sat Sun
Mindfulness
Mindfulness (practice, focus on present) Pg __
What How Skills (observe, describe, non-judgmentally Pg __
Participate, one mindfully)
Wise Mind - Balance Hot and Cold Mind Pg __
Coping W
ith Stress
ACCEPTS Distraction Pg __
Activities, Comparisons, Contribute, Emotions Push Away, Thoughts Sensations
IMPROVE the moment Pg __
Imagery, Meaning Prayer, Relax, One thing, Vacation, Encouragement
Self Soothe with Senses (see, hear, feel, smell, taste) Pg __
Emotions
PLEASE – (Physical Health, Exercise Avoid substances, Sleep, Eating) Pg __
Opposite to Emotion Pg __
Build Positive Experience (do things you enjoy – Notice the joy)
Pg __
Master (do things you’re good at, challenge yourself) Pg __
Interpersonal Skills
FAST Fair, don’t‘ Apologize, Stick to values, Truthful Pg. ___
GIVE Gentle, Act Interested, Validate, Easy Manner Pg ___
DEARMAN Describe, Express, Don’t apologize Reinforce Pg __
Be mindful of goal, appear confident, negotiate
Using my senses: Today when I ________________ I focused my attention on the
present moment and
I saw
I heard
I smelled
I touched/felt
I noticed
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• Attendance
• Completed mindfulness practice/homework practice
• Willingness to try activities
• Participate – fully engaged
• Able to apply content to personal experience
• Maintained emotional control during group
• Listened to others, validated, turn taking, followed group norms/rules
ASSESSMENT
• Outlines target Bx (3 types)
• Commitment to Change
• Contingencies
TREATMENT
• Skill Areas individualized
• DBT Strategies to decrease target bx/address antecedents)
• Structuring the Environment/Team
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The mind is a source of great The mind is a source of great The mind is a source of great The mind is a source of great
happiness happiness happiness happiness andandandand a source of a source of a source of a source of
great unhappinessgreat unhappinessgreat unhappinessgreat unhappiness
Dysregulated thoughts
Dysregulated emotions
Reduced enjoyment
of the present
• Brief: Start with no more than 2-3 minutes
• Begin every activity with breathing, to settle the mind, calm the body and be present
• “Close your eyes if you like; Let’s take a few deep breaths, in….out……Notice the air going in and out, Notice your chest rise and fall”
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• Guided script – choice/voluntary
When (not if) your mind wanders…
Notice any tension in your body, try to let t
Notice distractions
Keep bringing your mind back to activity
No expectations…no right or wrong
Like every skill, improves with practice
Check in with everyone after each activity
•Ask how they found activity?
•Were they able to manage distracting thoughts/stay focused?
•Ask if this is something they could try at home?
•Validate responses
• Guided breathing/body scan
• Music – listening for instruments/tone/melody
• Popular music – count use of key word in a song
• Eating mindfully: Mints/popping rocks/raisin/
hot chocolate/ grapes/ blueberries
• Loving Kindness
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• Walking mindfully
• Balloon Toss
• Copy message with non-dominant hand
• Colouring Mandalas
• Marbles Rolling
• Scented play-doh or Hand Lotion
• Object – observe & describe
• (stone, leaf, feather, image, ocean in bottle, etc.)
• Unclear instructions – low level exposure
• Practice Non-judgment (describe w/out judgment)
• Listening (in the silence, describe what you hear)
• Visual imagery (e.g. beach)
• Recorded mindfulness
• Repetition, repetition, repetition
• Use concrete, simple language
• Reduce reading/limit text on handouts
• Adapt materials for the needs of each client (individualized)
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• Use concrete experiential activities to engage (visuals, auditory, tactile)
• Easy to link behaviours to DBT skills using
examples from clients and support people –“That’s a great example of a wise mind decision” “sounds like you used…”
• Make it fun (role play, films, food, laughter)
• Once comfortable, ask clients to lead mindfulness (plan ahead, practice & support)
• Encourage clients to validate each other
• Work closely with coaches/mediators who are part of generalization strategy
• Reinforce when you hear about examples of skills being used – Invite to share with group
• Playful….catch each other making judgments
• Identify key skills for each person, using their words (e.g. “focus on NOW”)
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• Sunflower Priestess Laughing meditation
• Spock Logical: Rational Mind – no emotion
• Legally Blonde “Liar” Self soothing after let down
• Video of waves, metaphor for emotions
Thanks for listening
Jo-Anne Kens
Behaviour Consultant
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• Brown J. (2011( The Skills System instructor's guide: An emotion regulation skills curriculum for all learning abilities. Bloomington, IN: IUniverse
• Dimeff, L.A., Koerner, K., (2007) Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. Guilford Press,
• Dykstra, E.J., & Charlton, M. (2003). Dialectical behavior therapy: a new direction in psychotherapy. Retrieved from
• http://www.nctsnet.org/nctsn_assets/pdfs/reports/dialectical_behavior_therapy_dykstra_charlton.pdf
• Feigenbaum, J Dialectical behaviour therapy: An increasing evidence base Journal of Mental Health February 2007; 16(1): 51 – 68
• Lew M., Matta C., Tripp-Tebo C., Watts D. DBT for individuals with intellectual disabilities: A program description. Mental Health Aspects of Developmental Disabilities. 2006;9(1):1–13.
• Lew, M. Application of DBT to Dually Diagnosed Individuals; Marvin Lew Presentation June 10 & 11, 2008 (Toronto,
ON)
• Linehan, M., (1993) Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guildford Press
• Linehan M. (1993)Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press
• Pederson, L.D., (2015) Dialectical Behavior Therapy: A Contemporary Guide for Practitioners. Wiley-Blackwell
• Swenson, C. (2012) Getting DBT…AND getting DBT into the real world. Retrieved from http://www.borderlinepersonalitydisorder.com/wp-content/uploads/2012/01/CharlieSwensonFeb262012.pdf
• Sakdalan J. A., Shaw J., Collier V. Staying in the here-and-now: A pilot study on the use of dialectical behavior therapy group skills training for forensic clients with intellectual disabilities. Journal of Intellectual Disabilities. 2010;54(6):568–572.[PubMed]
• Singh, N.M. Wahler, R.G. Adkins, A.D. & Myers, R.E. (2003( Soles of the Feet: A mindfulness based self control intervetnion for aggression by an individual with mild mental retardation and mental illness. Research in Developmental Disabilities, 24, 158-169.
• Verhoeven, M. (in Press). Journeying to wise mind: dialectical behavior therapy and offenders with an intellectual disability.
• Websites:
• www.Behavioraltech.com
• http://www.slideshare.net/tbrad0411/dbt-training-2-day-workshop?qid=90ac19f4-cd65-4bef-ab49-2dd5eb8d5545&v=default&b=&from_search=5http://www.dbtselfhelp.com/html/specific_goals_of_dbt.html
