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

1. Dialectical behaviour Therapy for People with a Learning Disability: An overview Dr Lesley Leeds Senior Clinical Psychologist Learning Disability Services Betsi Cadwaladr University Health Board

2. 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

3. 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?

4. 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

5. 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)

6. People with PD are: Untreatable Manipulative Attention-seeking Selfish Draining “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” Who has heard this?

7. 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…

8. The first day of the psychology career… OMG!!! • Rapid intro to PD and heavy duty problems • Marsha Linehan became my bedtime reading.. • Desire to work ‘psychologically’ • Long and winding road…

9. 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……

10. Current position • Competence and confidence • One established DBT team • Delivering DBT in one community setting • ‘Seeding out’ of other teams

11. 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

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

13. So, what’s the big deal about DBT?

14. 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.

15. 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)

16. A note on the biosocial theory • Biological propensity some… • Temperament • Invalidation or • Abuse all? • Emotional layer of skin missing – everything little thing burns - sensitivity

17. 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

18. 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.

19. 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.

20. 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

21. 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

22. Why is DBT useful for people with learning disabilities? • 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

23. Why is DBT useful for people with learning disabilities? On a strategic level: • Costs the organisation less money • Keeps people in their community placement (and often out of hospital) • Increases workforce capability

24. 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 Lesley.Leeds@wales.nhs.uk

25. 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

26. Using and adapting DBT for people with Learning Disabilities The experiential bit

27. Core DBT skills • Mindfulness • Interpersonal effectiveness • Emotional regulation • Distress tolerance • Reducing vulnerability to emotion mind

28. Reducing vulnerability to emotion mind Sounds easy…..but we all fail at this from time to time

29. 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?

30. We are all vulnerable to emotion mind When you have emotional sensitivity and problems coping, this happens a lot more to you

31. So, what is emotion mind (or what we call Hot Mind?) Cool Mind Calm Mind Hot Mind

32. Hot Mind/Emotion Mind Hot Mind – this is when your emotions take control – when your emotions are in charge of your thinking and how you behave. This is the problem bit for all of us!!

33. In an ideal world…we would be here When you feel the emotion, but it does not take over Cool Mind Calm Mind Hot Mind

34. Reducing vulnerability to emotion mind Staying out of ‘Hot Mind’ Remember: say CHEESE

35. This comes from PLEASE MASTER emotional regulation skills (Linehan, 1993) Treat PhysicaL illness Balance Eating Avoid mood-Altering drugs Balance Sleep Get Exercise Build mastery – try to do one thing a day to make yourself feel competent and in control

36. For people with intellectual issues …not user friendly Even we could not remember this easily!

37. Staying out of ‘Hot Mind’C = ‘Can Do’ Every day do something you ‘can do’ - something you’re good at

38. Staying out of ‘Hot Mind’H = Health Take care of your body See a doctor if you are ill Take your medication Avoid drugs and alcohol

39. Staying out of ‘Hot Mind’E = Eating Eat the right amount of food Avoid ‘emotion’ foods

40. Staying out of ‘Hot Mind’

41. Staying out of ‘Hot Mind’E = Exercise Do some exercise everyday.

42. Staying out of ‘Hot Mind’ S = Sleep Get the right amount of sleep.

43. Staying out of ‘Hot Mind’E = Enjoy Do something everyday that you enjoy

44. Staying out of ‘Hot Mind’ Remember: say CHEESE

45. Of all the DBT skills taught.. This is the one the clients remember and use the most Such basic, yet important skills

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

47. The long and winding road

48. Thanks for listening Questions?