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THE USE OF DIALECTICAL BEHAVIOR THERAPY WITH FORENSIC CLIENTS WITH AUTISM SPECTRUM DISORDER DR JOSEPH ALLAN SAKDALAN AND SABINE VISSER CLINICAL FORENSIC AND NEUROPSYCHOLOGIST (NZ) APRIL 2018

THE USE OF DIALECTICAL BEHAVIOR THERAPY WITH FORENSIC ... · DIALECTICAL BEHAVIOR THERAPY •Dialectic Behavior Therapy (DBT) is a cognitive behavioral treatment originally designed

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Page 1: THE USE OF DIALECTICAL BEHAVIOR THERAPY WITH FORENSIC ... · DIALECTICAL BEHAVIOR THERAPY •Dialectic Behavior Therapy (DBT) is a cognitive behavioral treatment originally designed

THE USE OF DIALECTICAL BEHAVIORTHERAPY WITH FORENSIC CLIENTSWITH AUTISM SPECTRUM DISORDER

DR JOSEPH ALLAN SAKDALAN AND SABINE VISSER

CLINICAL FORENSIC AND NEUROPSYCHOLOGIST (NZ)

APRIL 2018

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OUTLINE OF PRESENTATION

• Introduction and Background

• Current Literature on the Treatment of ASD issues and Challenges

• Use of DBT with other populations

• Utility of DBT with ASD

• Applications of DBT with Forensic client with ASD

• Conclusions and Future Directions

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ASD DIAGNOSISA. Persistent deficits in social communication and social interaction across

multiple contexts, as manifested by the following, currently or by history

(examples are illustrative, not exhaustive; see text):

• Deficits in social-emotional reciprocity, ranging, for example, from abnormal social

approach and failure of normal back-and-forth conversation; to reduced sharing of

interests, emotions, or affect; to failure to initiate or respond to social interactions.

• Deficits in nonverbal communicative behaviours used for social interaction, ranging,

for example, from poorly integrated verbal and nonverbal communication; to

abnormalities in eye contact and body language or deficits in understanding and use

of gestures; to a total lack of facial expressions and nonverbal communication.

• Deficits in developing, maintaining, and understanding relationships, ranging, for

example, from difficulties adjusting behaviour to suit various social contexts; to

difficulties in sharing imaginative play or in making friends; to absence of interest in

peers.

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ASD DIAGNOSISB. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested

by at least two of the following, currently or by history (examples are illustrative,

not exhaustive; see text):

• Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor

stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

• Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal

or nonverbal behaviour (e.g., extreme distress at small changes, difficulties with

transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same

food every day).

• Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong

attachment to or preoccupation with unusual objects, excessively circumscribed or

perseverative interests).

• Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the

environment (e.g., apparent indifference to pain/temperature, adverse response to

specific sounds or textures, excessive smelling or touching of objects, visual fascination

with lights or movement).

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ASD DIAGNOSISC. Symptoms must be present in the early developmental period (but may not

become fully manifest until social demands exceed limited capacities, or may be

masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or

other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual

developmental disorder) or global developmental delay. Intellectual disability and

autism spectrum disorder frequently co-occur; to make comorbid diagnoses of

autism spectrum disorder and intellectual disability, social communication should

be below that expected for general developmental level.

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CURRENT PSYCHOLOGICAL/PSYCHIATRICTREATMENT/INTERVENTIONS FOR ASD

• Cognitive Behavioural Therapy (CBT)

• Behavioural interventions

• Social Skills intervention

• Sensory based therapies

• Psychiatric medications

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DIALECTICAL BEHAVIOR THERAPY

• Dialectic Behavior Therapy (DBT) is a cognitive behavioraltreatment originally designed by Marsha Linehan (1993) as anoutpatient treatment for people diagnosed with BorderlinePersonality Disorder (BPD).

• The DBT approach balances therapeutic validation andacceptance of the person along with cognitive and behavioralchange strategies.

• Controlled outcome trials have shown that DBT has beeneffective in reducing self-injurious behaviors and inpatientpsychiatric days in women diagnosed with BPD. It has also beenshown to be helpful in reducing anger and improve socialadjustment.

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DIALECTICAL BEHAVIOR THERAPY

• The use of DBT has recently been expanded to populationswith additional diagnoses such as substance misuse, eatingdisorders, depression with co-morbid personality disorders.

• It has also been used in additional settings such as forensicservices and mental health inpatient units.

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BPD AND ASD

• Issues around emotion dysregulation

• Impulse control problems/emotional reactivity

• Cognitive Rigidity

• Poor interpersonal skills/poor problem solving skills

• Poor coping skills

• Poor distress tolerance and self-harm behaviours

• Some problems with empathy (?)

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Biological Dysfunction in the Emotion

Regulation System

Invalidating Environment

BIOSOCIAL THEORY OF BPD

Pervasive Emotion Dysregulation

(Linehan, 2005)

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CORE STRATEGIES IN DBT

Problem Solving Validation

(Linehan, 2005)

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VALIDATION AND PROBLEM SOLVING

• DBT strives to avoid having the client/patient see the therapist asan adversary rather than an ally in the treatment of psychologicalissues.

• In DBT the therapist aims to accept and validate the client’sfeelings at any given time while nonetheless informing the clientthat some feelings and behaviours are maladaptive, and showingthem better alternatives

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BALANCING THE SKILLS

Acceptance Change

Self-Regulation

EmotionRegulation

Mindfulness

DistressTolerance

InterpersonalEffectiveness

(Linehan, 2005)

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MINDFULNESS IS ….• Observe things as you experience it without adding constructs or

interpretations to it

• Participate by entering completely into the experience of the currentmoment

• Non-judgementally (no right or wrong)

• One mindfully (doing on thing at a time)

• Effectively – decide to do what works

(Linehan, 2005)

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MINDFULNESS

RationalMind

WiseMind

EmotionalMind

Taking Control of Your Mind = Being in your Present Mind

RiskyMind

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MINDFULNESS SKILLS

• Improve ASD clients' ability to 'ground' themselves; the ability to revert back

to or orientate to the present moment without having judgement about

themselves or a given situation. → identify problems with ASD clients where

they are very reactive/impulsive, cognitively rigid, tend to feel overwhelmed

about making judgements around their views, thoughts and feelings.

• A lessening of sensitivity to their environment. While people who have ASD

will possibly cope sufficiently in low- stress environments, the level of sensitivity

to sensory stimulation (sounds, light, textures, etc.) → be able to process

sensory stimulation better via mindfulness skills

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MINDFULNESS SKILLS

• Mindfulness might be able to assist ASD clients with moving towards their

Wise Mind i.e. not becoming too rational or becoming impulsive and engaging

in self-destructive behaviours → Emotional Mind.

• Also help to filter or modulate their sensory input to reduce being mentally

overloaded → that’s good!

• Being able to stay in the “here-and-now” rather than ruminating or being

preoccupied with the the past and the future

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DISTRESS TOLERANCE

•Crisis Survival Strategies – tolerating short term

distress/stress

•Accepting Reality – tolerating long term

distress/stress

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DISTRESS TOLERANCECRISIS SURVIVAL STRATEGIES

• Distraction (Forget about it for now!)

• Self-soothing (Calming the senses!)

• Improve the Moment (Making it better!)

• Pros and Cons (Good and Not-so-Good)

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DISTRESS TOLERANCE

• Activities

• Contributing (Help)

• Comparisons

• Emotions (Different Feelings)

• Pushing away

• Thoughts

• Sensations

Wise mind ACCEPTS

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CALMING THE SENSES

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DISTRESS TOLERANCE

• Imagery

• Meaning

• Prayer

• Relaxation

• One thing at a time

• Vacation

• Encouragement

IMPROVE the Moment

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RADICAL ACCEPTANCE

• Practice of accepting life on its own terms and finding effectivestrategies to cope with whatever is happening.

• It does not mean being passive but accepting “what is” with theunderstanding that you have the power of choice.

• Radical acceptance is a choice that can ease stress anddepression and enhance your quality of life.

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DISTRESS TOLERANCE SKILLS• Individuals with ASD are prone to anxiety, depression and other mental health

issues with a high prevalence of completed suicide.

• DBT skills are behaviourally based and can be tailored to ASD. A focus

placed on distraction techniques and implementing improved adaptive coping

skills would aid ASD- based sensory overload.

• The value of radical acceptance → accepting that some things are beyond

their control/they can’t control their environment

• Using of soothing activities → utilises sensory processing → useful with ASD

clients

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EMOTION REGULATION

• Understand emotions

• Reduce emotional vulnerability

• Decrease emotional suffering

• Change by acting opposite to painful emotions

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EMOTION REGULATION

Reduce emotional vulnerability

• Eat right

• Sleep Well

• Exercise

• Don’t take drugs and alcohol

• See your doctor and take your medications if sick

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EMOTION REGULATION

Steps for Increasing Good Emotions

• Attend to relationships

• Focus on positive things that happen

• Stop thinking about worries

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EMOTION REGULATION

Changing your emotions

• When afraid face your fears

• When sad, do things to make you feel good

• When angry, talk about your feelings

• When ashamed, stand tall and take responsibility

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EMOTION REGULATION SKILLS• It is crucial for ASD individuals to learn how to regulate their

emotions.

• They tend to have difficulty understanding their emotions and

emotional state, and treatment should include improving their

ability to identify different types of emotions.

• Improve their understanding of the effects of biological factors

(e.g., lack of sleep, substance use) may affect them and what

sensitivities they may have to them.

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INTERPERSONAL EFFECTIVENESS SKILLS

• Individuals with ASD generally have difficulties with social

interactions and have social skills deficits.

• These deficits impact to varying degrees the effectiveness of

interpersonal relationships or interactions.

• Social skills are usually limited and DBT can help develop effective

behavioural abilities.

• Teach them interpersonal skills, problem solving, negotiating,

assertiveness skills i.e. DEAR MAN skills

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INTERPERSONAL EFFECTIVENESS

• D = describe specifically the situation

• E = express how you feel

• A = ask or assert

• R = reinforce the other person

• M = mindfully

• A = appear competent;

• N = negotiate, if necessary.(Linehan, 2005)

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FORENSIC CLIENTS WITH ASD

• Assaultative behaviours due to emotion dysregulation

• Inappropriate social/sexual behaviours → poor understanding of

social norms/behaviours;

• Preoccupations/fixation → can lead to issues around sexual or

violent offending (e.g. obsession with children’s feet or certain

sexual activities, stealing specific objects, etc.)

• Substance misuse issues particularly for individuals with ASD who

‘self-medicate’ to manage their anxiety problems and other mental

health issues

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USE OF DBT WITH FORENSIC CLIENTSWITH INTELLECTUAL DISABILITIES

• Current research suggests that DBT holds promise in effectively reducing emotiondysregulation and challenging behaviours with adults with intellectual disabilities(Brown, et al., 2013; Morrisey & Ingamell, 2011; Sakdalan et al., 2006).

• A pilot study carried out by Sakdalan and colleagues (2006) involved sixoffenders with intellectual disability who completed a 13-week adapted DBTgroups skills training program. The study result showed a decrease in level ofrisks, increase in relative strengths and general improvement in overallfunctioning (Sakdalan et al., 2006).

• Morissey and Ingamells (2011) have evaluated a DBT program for maleoffenders with ID in a high secure facility. A total of 24 men had completed thegroups skills and they also received individual therapy. Preliminary outcomes ondata for six men found significant reductions on the Global Severity of DistressScale of the Brief Symptoms Inventory but no significant differences in incidentsof aggressive behaviour.

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• A more recent study which involved 40 adults with developmental disabilities

(most of whom had intellectual disabilities) and challenging behaviours,

including histories of offending behaviours.

• A large reduction in challenging behaviours were observed during the four

years while they were attending a DBT group and individual therapy (Brown

et al., 2013).

USE OF DBT WITH FORENSIC CLIENTSWITH INTELLECTUAL DISABILITIES

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DOES DBT ADDRESS ‘CRIMINOGENIC NEEDS”?• DBT targets criminogenic needs such as substance abuse, poor

problem solving, antisocial peers, anger, poor self management,emotional dysregulation, and antisocial beliefs.

• It directly addresses dysfunctional behaviors, including problemsinvolving emotional regulation, problem solving, self-management,and substance abuse, whilst simultaneously increasing thebehavioral skills and motivation needed to replace problembehaviors and increase more functional behaviors.

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CONCLUSIONS AND FUTURE DIRECTIONS

• DBT can be considered promising in addressing challenging and forensic

behavioural in individuals issues with ASD

• Provides a more integrated approach to treatment to individuals ASD to

address risk issues /problems associated

• Adapting DBT for ASD → use more concrete examples and less abstract;

focus on behavioural skills; more repetition and visuals → adapted DBT skills

training for forensic clients with ID (e.g. Sakdalan et al., 2010) may be a

good starting point

• Important to link DBT interventions to address dynamic risk factors → become

treatment targets

• Further research on the use of DBT with forensic clients with ASD is

recommended.

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ACKNOWLEDGMENTS

• Sarah Mason who helped with this presentation