OCCUPATIONAL THERAPY DISTRESS TOLERANCE GROUP NADIA MACKINNON AND BRONWYN FONTAINE

OBJECTIVES OF TODAY’S PRESENTATION 1.Discuss observed gaps in programming from an OT perspective 2.Review the goals and structure of the Occupational Therapy DBT Informed Distress Tolerance Group 3.Provide an overview of what is currently happening in this group including client feedback 4.Discuss future plans and opportunities for interdisciplinary collaboration

DESCRIPTION OF THE PROBLEM Prior to the development of our group, PY2 and PX2 OT’s were running life skill groups on each of the units which covered a variety of topics including stress management, self esteem, relaxation, recovery planning etc. Groups were open to all individuals on the units with varying levels of acuity and levels of functioning, which made it challenging to facilitate effective skill development. Over the past year we have noticed an increase in acuity on the units and patients presenting with significant coping skill deficits that we were unable to address with the model of programming we were providing at the time. We also identified a service gap when patients involved in our programming were transitioned from inpatient to outpatient services.

WHAT DOES THE LITERATURE SAY? DBT Skills training has been identified in the literature as a way to “learn and refine skills in changing behavioral, emotional and thinking patterns associated with problems in living that are causing misery and distress” (Linehan, 1993). Formal DBT is resource and time intensive thus DBT informed or adapted versions have been developed particularly for delivery in inpatient hospital settings (DiGiorgio et al. 2010) (Hawton et al. 2009). Booth et al (2014) created an adapted version of skills training focused specifically on Distress Tolerance Skills, and found that this group significantly reduced participants’ reports of self harm, increased distress tolerance levels (sustained 3 months later), and reduced participants’ mean number of inpatient days over the following 2 years. Facilitators felt that the program served as a “pre-therapy intervention” and felt it may better equip participants to engage in individual therapeutic work at a later stage

OUR SOLUTION To create a DBT informed occupational therapy program to facilitate the development of basic emotion regulation and crisis survival skills beginning at an inpatient level. Provide a bridge for patients involved in the group during their transition to outpatient services. Our group is based on a model that was developed for distress tolerance skills training in an acute inpatient setting which was outlined and evaluated in an article entitled “Living Through Distress: A Skills Training Group for Reducing Deliberate Self Harm” (Booth, et al. 2014).

OBJECTIVES OF OUR PROJECT Primary Objective: Facilitate skill development specifically in the areas of distress tolerance and emotion regulation beginning at the inpatient level. Secondary Objective: Address the gap between inpatient and outpatient care during the acute stage of recovery

OT DISTRESS TOLERANCE GROUP 8 session group run twice a week over a four week period Groups are 1h in length and are facilitated in the OT department on the third floor Content is informed by DBT theory. While distress tolerance skills are specifically targeted there is also a focus on emotion regulation and core mindfulness skills throughout the program. Each session begins with a mindfulness activity Homework is provided on Friday’s and reviewed after mindfulness during Wednesday’s session. 1-2 skills are presented each session. The focus is specifically on crisis survival skills.

INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria Adults over 18 years of age with a commitment to learning skills to cope with intense emotions and begin to build a life worth living Exclusion Criteria Patients on Suicide Obs. or Restricted to the Unit (due to safety and AWOL risk) Outpatients who were not previously referred to the group as an inpatient or those who have completed the group previously Uncontrolled psychotic illness Acquired brain disorder Dementia Intellectual impairment or pervasive development disorders Organic brain disorders Aggression/safety risk to staff Antisocial PD with prominent externalization

REFERRAL PROCESS Eligibility and appropriateness for group is discussed at weekly team meetings Anyone on the treatment team can refer using a consultation form Facilitators review the case and meet with the patient to complete an initial interview, determine appropriateness and discuss involvement in the group Patients are provided with a handout outlining the goals and structure of group Progress is discussed on an as needed basis with the team

INTERDISCIPLINARY COLLABORATION Referrals are discussed with the interdisciplinary teams on the unit The group is open to observation by staff and students – we have had social work, med students, nursing students and OT students observe to date We liaise with outpatient teams as needed if participants transition out of hospital while they are in the group We are open to co-facilitation from other disciplines within the current model of the group

THE GROUP TODAY Since the creation of this group in November 2015 we have received 43 referrals Of the 43 referrals we identified 2 individuals that were unable to attend due to their level of acuity at the time of referral. Of the 41 who were appropriate, 23 individuals have completed the program (attending the majority of sessions), most completing the program as outpatients. 12 individuals attended consistently on an inpatient basis but were inconsistent in their attendance on an outpatient basis or could not attend as they did not have outpatient follow up at psych health. 6 individuals are currently in the program

OUTCOME MEASUREMENT Since the group began we have been tracking attendance and level of participation for each client. Participants who attend over the four weeks are provided with a feedback form to complete on a voluntary basis.

FEEDBACK FROM CLIENTS DisagreeDisagree somewhat Agree somewhat Agree I found the group sessions helpful The skills I learned continue to be useful I have noticed a positive change how I manage intense emotions/tolerate distress Other people in my life have noticed a positive change in my behavior I felt understood & respected by the group facilitators

FEEDBACK FROM CLIENTS CONTINUED When asked “how did you benefit from attending the DBT informed distress tolerance skills group” participants responded: Coming to group was most helpful and pushed me to get out of my safe bedroom and recover Gave me a sense of purpose and hope Learning to use more coping skills, making a daily list of distraction, I have them available and out in the open in case I am stuck I learned how to calm myself and try to control my thoughts Gave me some practical skills to practice as I was going through a very hard time, it also gave me something to look forward to every week I benefited from enjoying the time away from the ward and the relaxation of the group, plus it helped me with stress and other things in my life. Gave me the tools (suggestions) to deal with my anxiety

FEEDBACK FROM CLIENTS CONTINUED When asked to list behavioral changes they had made since attending the group, participants responded: I am more mindful of my thoughts and try to employ alternate techniques to avoid crisis moments Being somewhat more positive instead of negative I have tried to be more present with myself and my thoughts, it is a daily struggle but I am going to continue to work on it. I notice a change in expressing my emotions, I think about what I am going to say before I say it I am more observant of the situation I am able to cope during difficult times with distraction. I say or tell my husband how I am feeling no matter if it is good or bad

FEEDBACK FROM CLIENTS CONTINUED When asked “what did you find most helpful about the DBT informed distress tolerance group” Several participants discussed the benefits they found of being in a group, as well as the structure and routine that group provided “The interactions with others and the content discussed over the weeks helped me find new strategies to cope with crisis and situations leading up to it” “Learning new ways to distract myself, it is not the end of the world it is the beginning” “Working out crisis situations and how to cope when you are in a crisis” “Relaxation, soft voices of OT leaders” “The Friday homework, having to use the skills in every day life” “Attending every week, talking about emotions and learning new skills”

FEEDBACK FROM CLIENTS CONTINUED When asked if there was anything about the group that participants did not find helpful, or ways to improve the group, themes included: Did not enjoy specific mindful exercises (eating and breathing) Physical set up of the room (would like ergonomic chairs) Length of group (more sessions) Changes to homework review One participant identified that it was not helpful to hear about other participants situations

FUTURE PLANS Continue to collect data on the group (attendance and client feedback) Seek feedback from our teams regarding the group Continue to adapt the group based on client and team feedback Implement a consent form to collect data for research purposes Encourage and facilitate more involvement from other disciplines

QUESTIONS