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How to Successfully Implement Adapted Dialectical Behavior (DBT) Programs for the Intellectually

Disabled Diversified Finance & Health Services, Inc. 2015

Kelly M. Shuler, MSW, LMSW, CHt, QIDP Mark Mitchell, MSW, LMSW, QIDP

Diversified Finance & Health Services, Inc. 2015

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Mindfulness Exercise

Diversified Finance & Health Services, Inc.2015

What is DBT?

• Dialectical Behavior Therapy: Handout

• Popularized by Marsha Linehan, PhD (1993, Cognitive Behavioral Treatment of Borderline Personality Disorder, New York: Guilford Press)

• Combines therapeutic validation and acceptance of person along with cognitive and behavioral change strategies.

• Biosocial Theory of BPD: Handout


DBT • Addresses skills deficits in Mindfulness, Emotion Regulation,

Interpersonal Effectiveness, and Distress Tolerance

• More recently expanded to treatment of other populations (eating disorders, substance abuse, Child/Adolescent, sex offenders)

• Studies in consumers with ID

• 2004 (Dykstra & Charlton)

• 2006 (Lew et al)


First Objective: 1. Identify ways in which an

Adapted Dialectical Behavior Therapy (DBT) program can

positively impact organizations.


How can a DBT program positively impact your

organization? • Group discussion:


Agency Cost Reduction • Reduction in Hospitalizations Costs • Decrease Staff Turnover and Burnout • Decrease Overall Care Costs (i.e. – CLS Hours, Staff Ratios,

Emergency Care Expenditures) • Reduction in Vocational Support Costs • Decrease in Crisis Intervention Costs • Increase in Natural Supports • Decrease in Housing Subsidies and Related Costs • Decrease in Revenue Expenditures Related to Lower Incarceration

Rates • Decrease in Costs Related to Alternative Placements • Decrease in Utilization of Psychiatric Services • Decrease in Administrative Involvement with Crisis Issues


Person Receiving Services • Mental Health Stabilization/Medication Management • Employment Stabilization • Improved Family/Interpersonal Relations • Skill driven • Stable Housing/Decrease in Homelessness • Less Staff/Provider Turn-over • Decrease in Legal Issues • Reduce School Integration Issues • Decrease in Suicide Ideation/Attempts • Improved Quality of Life


Develop measureable outcomes

• Now that you have identified areas of change. Develop measureable outcomes and collect data to share with administration.


Second Objective:

2. Describe the basic process of developing and providing an Adapted DBT Informed program.


Adapted DBT Manual • Stays true to Linehan’s philosophy

• Maintains fidelity to original material – Workbook/video tapes

• Concrete vs Abstract Materials

• Feedback from group members

• Review your manual for updates and adaptations yearly to reflect lessons learned and process improvements

• Personalization of manuals and diary cards


Identify Team Members • Psychiatrist

• Consultant

• Clinical Supervisor

• DBT therapist (2-4), LMSW, LLP, LPC


Weekly Consultation Team Meeting

• Ring mindfulness bell to begin

• Mindfulness exercise

• Assign roles within meeting

• Discussion of previous weeks group and individual therapy sessions including DBT target stages

• Review issues and concerns with consultant

• 30 minutes of preparation for next group

• Develop group therapy agenda


Training for Staff • Read Marsha

Linehan’s Books • Review Marsha

Linehan’s videos • Attend a 5-day

training • Utilize a consultant:

Diversified Finance & Health Services (Mark Mitchell and Kelly Shuler)


Identifying Group Members

• Identify participants through referral from psychiatric services

• Request for referrals from Supports Coordinators/Case Managers

• Attend staff meetings and present criterion for eligibility

• Identify between 14 – 16 possible candidates as some people do not choose to participate


PRE-ENGAGEMENT PHASE • Therapist is assigned and establishes contact

for initial appointment

• During initial appointment, therapist assesses appropriateness and willingness to commit to the process

• Individual objectives are identified and contracts are signed

• Provide flyer for orientation session and discuss who to invite (eg. family, staff, supports)


DBT Orientation Agenda • Sign In Sheet

• 1. Welcome: introduce DBT Team. Discuss the use of the bell.

• 2. Mindfulness: mindfulness exercise

• 3.Biosocial theory of Borderline Personality Disorder

• 4. DBT Overview: * Skills you will learn are:

a. Mindfulness b. Emotional Regulation

c. Distress Tolerance d. Interpersonal Effectiveness.

• 5. Expectations:

• a. There is a one year commitment

• b. Group to meet x1 weekly every Tuesday from 2:30-4:00pm/break included

• c. Participate in 1:1 counseling sessions x1 weekly

• d. Call your therapist if you are not able to attend group or 1:1 session.

• e. Missing 4 session in a row will be cause for termination from the program

• f. You will need to practice outside of group by completing worksheets that the therapist provides.

• g. You will receive phone coaching as needed

• 6. Video

• 7. Pizza and Pop

• 8. Q & A session


Group Therapist Roles • Mindfulness role – Runs mindfulness

exercise; observer group dynamics; takes notes; leads wind down

• “Good” Cop – Teaches the lesson; engaging all group members; cheerlead group members and provide validation

• “Bad” Cop – Reviews weekly worksheets; asks if group members want praise, validation or problem solving from other group members; watch for therapy interfering behaviors; rings bell to refocus group


Group Rules Each group works toward developing their own rules – the following rules are important to any group: Turn off cell phones. Allow others to finish speaking. Be respectful. No side bar conversations. No cursing or swearing. What is said in DBT stays in DBT. Dress appropriately for group. Show up on time. No drugs or alcohol is to be used in group. No outside relationships with group members. No weapons. Bring completed worksheet assignments with you for therapy sessions each week. Bring your book to group each week. No pictures taken in group.


Weekly Individual Therapy: 45-60 minutes

• Finalize Goal and Objectives

• Diary Cards lead individual session

– Stage 1 targets

– Do they understand the materials?

• Chain Analysis if indicated

• Stages 2, 3 and 4 – applying new skills to life issues


Group Feed back and Graduation

• feedback


Linehan, Marsha (2014). DBT Skills Training Manual, Second Edition, Guilford Publishing.

Burdick, Debra (2013). Mindfulness Skills Workbook for Clinician and Clients. PESI Publishing & Media.

Dykstra and Charlton, (2008). Adapting DBT for Special Populations.

Michelle Shauger, MD; Kathleen Mohring, MA, LPC; Kenneth Antkowiak, MS, LLP; Mark

Mitchell, MSW, LMSW; Kristen Barlow, MSW: “Dialectical Behavior Therapy for Individuals with Intellectual Disability: Adaptations & Outcomes.”

Linehan, Marsha (1993). Cognitive Behavior Treatment of Borderline Personality

Disorder. New York: Guilford Press.

Bibliography


Diversified Finance & Health Services, Inc.

• Questions and

• Answers


Contact Information • Diversified Finance & Health Services, Inc.

• Kelly M. Shuler, MSW, LMSW, CHt, QIDP

• President/Executive Director

• 517-304-7561 (cell)

• 517-262-6966 (office)

• Email:[email protected]

• AND

• Mark Mitchell, MSW, LMSW, QIDP

• Independent Consultant

• 734-223-8084 (cell)

• 517-262-6966 (office)

• Email:[email protected]

Address: P.O. Box 312, Pinckney, MI 48169
