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Developing Dialectical Behaviour Therapy for Forensic Male Learning Disabilities

Background information. We arePart of Nottinghamshire Healthcare NHS Trust.Forensic Learning Disability Directorate. Rampton Hospital.The Learning Disability Directorate69 beds, male population.Five wards, two main wards three villasAll patients are detained under the Mental Health Act.Require treatment in a high secure service.The Treatment Aims To provide an individual treatment pathway which meets identified needs to enable safe management and risk reduction. .

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Developing Dialectical Behaviour Therapy for Forensic Male Learning Disabilities

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    1. Developing Dialectical Behaviour Therapy for Forensic Male Learning Disabilities Learning to be in control of your mind, not letting your mind be in control of you Good afternoon, do title. Man and dog is what dbt skills aims are put on next click. Present first then questionsGood afternoon, do title. Man and dog is what dbt skills aims are put on next click. Present first then questions

    2. Background information We are Part of Nottinghamshire Healthcare NHS Trust. Forensic Learning Disability Directorate. Rampton Hospital. The Learning Disability Directorate 69 beds, male population. Five wards, two main wards three villas All patients are detained under the Mental Health Act. Require treatment in a high secure service. The Treatment Aims To provide an individual treatment pathway which meets identified needs to enable safe management and risk reduction.

    3. Why DBT? Increase Interpersonal skills Emotional regulation skills Distress tolerance skills Core mindfulness skills Decrease Interpersonal dysregulation Emotional dysregulation Behaviour and cognitive dysregulation Self dysregulation Our patients have deficits in controlling emotions impulsivity which affect relationships,Dbt addresses this by+ -Our patients have deficits in controlling emotions impulsivity which affect relationships,Dbt addresses this by+ -

    4. Developing DBT. 2 nursing staff and 5 psychologists completed the Marsha Linehan intensive DBT training programme This involved two one week training sessions with a six month interval.

    5. Criteria for selection Identified criteria for selection 1+ areas of dysregulation. Meet diagnostic criteria for at least one personality disorder. No current active symptoms of mental illness. No history of severe head injury. Will remain within the service for at least 12 months to complete DBT course. Asked Clinical teams for referrals and received 23 referrals who met the selection criteriaAsked Clinical teams for referrals and received 23 referrals who met the selection criteria

    6. Selection process Referral from Clinical Team identifying areas of dysregulation and PD diagnosis 23 referrals for assessment All referrals underwent psychometric assessment process 7 patients identified for programme inclusion 7 identified for Treatment As Usual comparison group

    7. Assessment criteria The 23 Referrals were assessed using the following criteria Assessment of all 5 areas of dysregulation Used LD accessible tools Where possible we used tools with LD normative data Had some assessment tools in common with other directorate DBT programmes Administered assessment interviews with the aid of visual prompts Assesment criteria was agreed mainly by the psycholigistAssesment criteria was agreed mainly by the psycholigist

    8. Assessment tools used Self report General Psychological Distress / Symptoms Brief symptom inventory (BSI) Clinical Outcomes in Routine Evaluation (CORE) Emotional Dysregulation STAXI – current anger, general anger Emotional Control Questionnaire (ECQ) – emotion coping strategies, impulsivity, aggression control Interpersonal Dysregulation Inventory of Interpersonal Problems (IPP) – assertiveness, sociability, supportiveness, dependence

    9. Assessment tools cont Informant Report Psychiatrist Areas of Dysregulation DSM IV PD criteria structured checklist Nurse Behaviour rating scale - covers emotional, interpersonal and behavioural dysregulation DBT Therapist Violence Risk Scale - static and dynamic factors, emotional, interpersonal, behavioural and self dysregulation

    10. Information for patients 1-1 discussions 1-1 discussions took place between therapists and patients to discuss contents of the programme and the commitment that would be required. Information sheet To inform patients about DBT and to enable them to have a better understanding ,an information sheet was developed.

    11. DBT Information Sheet General Goal: To learn and practice skills to change our actions Learning how to control how we feel about things Learning how to change the way we think about things to make life better for us To lessen our pain and suffering, and to solve problems in everyday living. The specific goals are to: Increase Learning to feel better when we are feeling down, angry, tense, sad, or any other feeling that makes us unhappy Our ability to keep friendships and relationships – warts and all. Social skills – listening, negotiating and being assertive without exploiting others. Being aware of what is going on. Being focused on the here and now. Paying attention. Accepting things as they are. Improving quality of life and coping with everyday life and its problems by improving our environment DBT can help you become an effective tool in the shaping of your future Decrease Being controlled by our emotions and letting them run our life. Feeling tense, worried or down for long periods. To stop avoiding relationships when problems start to happen To lower the chance of fights, bullying and arguing. Distractions – letting other things interfere with what you are doing at the moment. To lower angry behaviours and reactions To lower impulsive behaviours and reactions. Informs of goals to increase decrease read out main aims open to door to a brighter dayInforms of goals to increase decrease read out main aims open to door to a brighter day

    12. Diary Adaptations Diary Cards Adapted for individual therapy sessions to Identify individual target behaviours Main Treatment Targets we Identified Physical and verbal aggression Dysregulation of emotion – particularly anger Impulsivity Self harm Offence and offence parallel behaviours

    13. Pictures self generated or from other therapiies, to help identify target behaviours numbers levels of intensityPictures self generated or from other therapiies, to help identify target behaviours numbers levels of intensity

    14. Skills group training Programme delivery Closed group Shorter session duration Enhanced number of therapists Extended number of skills group sessions

    15. Modifications Of Standard DBT Necessary for patients to comprehendNecessary for patients to comprehend

    16. Module Recognition Mindfulness Emotion Regulation People Skills Distress Tolerance switching off / being in the moment- pig positive exp to save and use when needed high and low not sinkswitching off / being in the moment- pig positive exp to save and use when needed high and low not sink

    17. Homework adaptations

    18. Review of the first six months 2 nurses and 5 psychologist attended the second and final week of training. Delivered Mindfulness and emotion regulation skills group training modules Introduced TASIT to measure the effectiveness of emotion regulation. All identified patients remain on the programme Consultation groups continue Communications with comparison group developed

    19. Developments over the last 12 Months Two therapists have left the service. One therapist is currently seconded onto another project. In the process of reviewing emotion regulation in order to evaluate using TASIT. Adherence at Consultation groups is not being given as high priority. Supervision continues but due to staff numbers input is reduced Completed all modules. Two patients have been discharged to environments of lesser security. Leaves 4 therapists and 5 patients, present we have two individual Leaves 4 therapists and 5 patients, present we have two individual

    20. Future of DBT Repeat the assessments for 21 patients to evaluate the effectiveness of the programme. Move towards providing rolling on / off sessions. Move towards individual modular sessions as a pre requisite for other therapies.

    21. Planning for the future More staff to access training in DBT Present trained staff to access adherence training. Adherence trained therapist to attend some consult meetings and provide supervision. Awareness training sessions for Clinical teams with regular up dates. Development of therapist and patient manuals in readiness for new groups. Presentation appear simple, but the developments to the complex manual have not been simple. Brid = questionsPresentation appear simple, but the developments to the complex manual have not been simple. Brid = questions

    22. Presentation Team Martine Lascelles martine.lascelles@nottshc.nhs.uk Bridget Ingamells bridget.ingamells@nottshc.nhs.uk

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