Dialectical behaviour Therapy for People with a Learning Disability: An overview

Dialectical behaviour Therapy for People with a Learning Disability: An overview

Dr Lesley LeedsSenior Clinical Psychologist Learning Disability Services

Betsi Cadwaladr University Health Board

Plan

The problem How did we get a service going? What is DBT How can DBT be useful for people

with learning disabilities? Adapting and using DBT Experiential teaching – some

adapted skills on managing affect – just say CHEESE

The Problem & Context

Historically: People with learning disabilities (and those

working in services) excluded from research and practice

Limited evidence base for psychological interventions

Limited access to psychological therapies

Who actually gets any treatment? Can these treatments really work?

There is a clinical problem out there….

Placement breakdown Out of county placements Complex case list Staff burnout Competence issues Cost to organisation Cost to individual and their family

Every CLDT has people with complex emotional and behavioural problems

Some will end up with PD diagnosis or have traits of PD

What do we do to help them (and those around them)? Doubly untreatable? (double jeopardy

problems) Revolving door individuals (social

workers, nurses, doctors, therapists)

Who has heard this?

People with PD are:

UntreatableManipulativeAttention-seekingSelfishDraining

“There’s not much we can do to help”

“I don’t know how to help that person”

“These PD people are nothing but a drain on resources”

“I don’t like to work with people like that”

“It’s not within my skill base”

There are often assumptions that PWLD should somehow be more skilful

And wouldn’t be behaving like this if they didn’t have a learning disability!!

Not true!It is their learning and life experience that has led to

the problems…

The first day of the psychology career…

Rapid intro to PD and heavy duty problems

Marsha Linehan became my bedtime reading..

Desire to work ‘psychologically’ Long and winding road…

OMG!!!

A chance to do something proper..

Opportunities for DBT training in 2011 A small team formed (n = 4) Audit across BCUHB – yes the cases are

out there Management approval (no mean feat) Adapted materials (no mean feat either) Started delivering skills training in Jan

2012 The start of a small but strong service……

Current position

Competence and confidence One established DBT team

Delivering DBT in one community setting

‘Seeding out’ of other teams

The near future

Current Ongoing service development in BCUHB to bring equity in services

Further staff training in 2014

Increasing access to Psychological Therapies in North Wales for people with learning disabilities

UK Position

There are only 3 other community DBT teams in UK specific to LD (British Isles DBT data)

So, what’s the big deal about DBT?

Dialectical Behaviour Therapy: in a nutshell...

Designed to address severe and persistent problem behaviours; that arise due to emotional and behavioural difficulties experienced by an individual.

DBT focuses on the acceptance and changing of problematic thoughts, feelings and behaviours.

The person is encouraged to believe and make changes to build a life a worth living.

DBT can help treat self harm, suicide, violence, non compliance, substance abuse, food issues, severe emotional difficulties and post traumatic stress.

Where does this treatment come from?

DBT was originally used for the treatment of women diagnosed with Borderline Personality Disorder, that engaged in self harming and suicidal behaviours.

DBT was initially used in community settings, now is being implemented in inpatient and forensic settings.

DBT originated from the Bio-Social Theory of personality functioning

Building evidence base in LD

10 DBT treatment teams in LD services in UK (in and outpatient)

A note on the biosocial theory

Biological propensity some… Temperament Invalidation or Abuse all?

Emotional layer of skin missing – everything little thing burns - sensitivity

Philosophy of DBT

DBT is:

Dialectical Supportive Cognitive Behavioural Skill orientated Balances acceptance and change Requires a collaborative relationship

All the features of a therapy well suited to people with learning disabilities

Aims of DBT

DBT aims to decrease extreme emotions, thinking and behaviours into more balanced responses to current situations.

DBT teaches clients to develop and refine skills in order to change problematic behavioural, emotional and thinking patterns that are causing misery and distress.

Behaviours to decrease

Behaviours to increase

Self dysregulation

Core mindfulness skills

Interpersonal dysregulation

Interpersonal effectiveness skills

Emotional dysregulation

Emotional regulation skills

Behavioural and cognitive dysregulation

Distress tolerance skills

Four Main DBT Skills

Core Mindfulness: - Teaches attention to the present moment and self

awareness. - Helps people be in control of their mind, be aware of

their thoughts and feelings at any one time, and think things through properly before acting.

Interpersonal Effectiveness: - Teaches interpersonal skills, to help deal with conflict

situations and to get on with others, get what you want in a way that maintains self respect and build and keep effective relationships with others.

- Emotional Regulation: - Teaches how to identify and describe emotions, how to

reduce vulnerability to negative emotions and how to increase positive emotions.

Distress Tolerance: - Teaches strategies of how to tolerate distress, without

engaging in impulsive and self destructive behaviours. Focuses on distraction and self soothing techniques, and strategies to radically accept traumatic events in their lives.

How is our DBT programme made up?

Individual Therapy Focus on analysis of (and decrease) problem behaviours,

increase effective coping skills, focus on motivational issues and work towards defined treatment goals.

Weekly hourly sessions Skills Training Group Teaching of behavioural skills to increase capability Weekly sessions for two hours for one year

Consultation Meeting Supervision for therapists to support their practice A community of therapists treating a group of individuals

Support Worker skill strengthening Support workers attend group and reinforce and praise skill use

out of sessions In lieu of telephone out of hours service

Why is DBT useful for people with learning disabilities?

On an individual level:

A life saving and life enhancement treatment

Validates the person’s difficulties Teaches people skills to cope with and

change a range of problem behaviours Enhances capability Teaches people to accept things that

cannot be changed


On a team level:

Teaches the staff on the ground to model, encourage and praise appropriate skills

Gives a framework for professionals to cope with problem behaviours

Change in attitude about treatability


On a strategic level:

Costs the organisation less money Keeps people in their community

placement (and often out of hospital) Increases workforce capability

Adapting this treatment for our clients

DBT is a complex model for therapists and clients alike

Essential to make it accessible for those with learning disabilities

For more information, contact me directly on [email protected]

Doesn’t this just dilute the treatment?

The core model and principals are the same

What good is any therapy if the client has no idea what you are talking about?!! No matter how fancy it seems

Using and adapting DBT for people with Learning Disabilities

The experiential bit

Core DBT skills

Mindfulness Interpersonal effectiveness Emotional regulation Distress tolerance

Reducing vulnerability to emotion mind


Sounds easy…..but we all fail at this from time to time

How many of us have:

Shouted at someone else when tired?

Been grumpy because you missed lunch?

Not functioned well because you were ill?

Got hacked off because you were bored?

Felt that you were no good at something?

We are all vulnerable to emotion mind

When you have emotional sensitivity and problems coping, this happens a lot more to you

CoolMind

Hot Mind

Calm Mind

So, what is emotion mind (or what we call Hot Mind?)

Hot Mind/Emotion MindHot Mind/Emotion Mind

Hot Mind – this is when your emotions Hot Mind – this is when your emotions take control – when your emotions are in take control – when your emotions are in charge of your thinking and how you charge of your thinking and how you behave.behave.

This is the problem bit for all of us!!This is the problem bit for all of us!!

CoolMind

Hot Mind

Calm Mind

In an ideal world…we would be here

When you feel the emotion, but it does

not take over


Staying out of ‘Hot Mind’

Remember: say CHEESE

This comes from PLEASE MASTER emotional regulation skills (Linehan, 1993)

Treat PhysicaL illnessBalance EatingAvoid mood-Altering drugsBalance SleepGet Exercise

Build mastery – try to do one thing a day to make yourself feel competent and in control

For people with intellectual issues …not user friendly

Even we could not remember this easily!


C = ‘Can Do’

Every day do something you ‘can do’ - something you’re good at


H = Health

Take care of your body See a doctor if you are ill Take your medication Avoid drugs and alcohol


E = Eating

Eat the right amount of food Avoid ‘emotion’ foods



E = Exercise

Do some exercise everyday.


S = Sleep

Get the right amount of sleep.


E = Enjoy

Do something everyday that you enjoy


Remember: say CHEESE

Of all the DBT skills taught..

This is the one the clients remember and use the most

Such basic, yet important skills

DBT has been a valid and useful intervention for people with mild LD in North Wales

Reductions in:

Self harm/suicidal behaviours

Aggression/threatening behaviours

Over-eating Seriously destabilising

behaviours Hospital admissions

Increase in:

Client capability Staff capability Placement duration Availability of

psychological therapies for PWLD

The long and winding road

Thanks for listening

Questions?

Documents

Dialectical behaviour Therapy for People with a Learning Disability: An overview