Facilitator and Patient Reflections Implementation of the new DBT Skills Manual in a Medium Secure Services Facilitator and Patient Reflections Presented by: Zoe Otter (Forensic Psychologist) Kristy Summers (Forensic Psychologist in Training) Partnerships in Care Midlands

Outline DBT in PiC Midlands Who are we Introducing & implementing the new skills manual Outcome measures Preliminary findings Reflections from group members Reflections from facilitators Future directions

DBT programme PiC Midlands Group Skills Individual Sessions Weekly Consultation Team Meeting Telephone consultation: Replaced by Staff awareness training Established in 2005 2 groups currently running over 2 sites (MSU & LSU) Regular training opportunities for new therapists Implementation of the new skills manual in December 2014 at Calverton Hill (MSU)

Who are we? Currently 5 DBT Therapists working within the Female Medium Secure Service with a range of experience 2 Trained in 2008/2009 1 Trained in 2013/2014 2 Trained in 2016 Group delivered on a rota basis All have individual DBT patients

“New” Skills Manual Preparation Previous lead attended Marsha’s Linehan’s new skills training in Ireland Discussed in consultation team meetings Number of consultation meetings were spent reviewing the new material to become familiar with it New manuals purchased Consultation meetings – discussed concerns, acceptance, updated for a reason New manual – time spent reviewing the material

“New” Skills Manual Implementation Discussed new manual with existing group members Re-evaluated outcome measures Discussed and prepared to introduce orientation module Continuous review of Group members feedback

Outcome Measures Assessment Measures Borderline Symptoms List -23 (BSL-23) BPD Symptoms DBT Ways of Coping (DBT-WCCL) Current Skill Level Beck Suicide Scale (BSS) Suicidal Ideation STAXI-II Anger Dissociative Experiences Scale Dissociation Beck Hopelessness Scale (BHS) Hopelessness (relates to emptiness) Beck Depression Inventory (BDI-II) Depression (relates to emptiness) Barratt’s Impulsiveness Scale (BIS-11) Impulsiveness Pre-Post Programme AND Pre-Post Module Freiburg Mindfulness Questionnaire Mindfulness Difficulties in Emotion Regulation Scale (DERS) Emotional Response Distress Tolerance Scale (DTS) Current level of distress tolerance Inventory of Altered Self-Capacities Interpersonal skills Goal Attainment Scale* Overall use of skills The measures aim to assess change throughout the completion of the programme and also measure change following each module. The measures chosen map onto the criteria of BPD to assess change in BPD symptomology. All information will be recorded anonymously on the DBT assessment database. Outcomes will be reviewed after each module and after each individual cycle of DBT skills training.

Orientation & Mindfulness Interpersonal Effectiveness Programme Outline Rolling Programme Pre Therapy for 4-6 weeks before joining the group New intakes at Orientation & Mindfulness Orientation & Mindfulness   Distress Tolerance Interpersonal Effectiveness Emotion Regulation Assessments take place in pre therapy Orientation & mindfulness – 6 weeks DT – 10 weeks IE – 10 weeks ER – 12 weeks Once on the group 50 week skills training programme – 3 weeks break plus 2 over xmas

Preliminary Findings – Mindfulness (1)

Preliminary Findings – Mindfulness (1)

Preliminary Findings – Emotion Regulation

Preliminary Findings – Emotion Regulation

Preliminary Findings – Mindfulness (2)

Preliminary Findings – Distress Tolerance Distress Tolerance Scale (DTS) Measures current level of distress tolerance Goal Attainment Scale Interpersonal Effectiveness Inventory of Altered Self-Capacities – measures Interpersonal skills To complete:

Group Member Reflections The course was well presented and the facilitators were very knowledgeable in the subject Paper work – too much Not having paperwork clipped together was confusing Some sessions were a bit rushed because there was so much to get through The more they [facilitators] have done it the more they have got out of it too Sharing experiences of BPD has helped me to not feel alone in the difficulties I experience It was quite long. It took a while to get into. Length and content of the session – feedback was that there was too much material to get through in the sessions and it was feeling rushed. The group was extended by half an hour, received positively. The patients have reflected that the more familiar the facilitators are becoming with the new manual the better it has become Paperwork – some have found the new materials difficult to get their head around – Initially patients were given out the hand out for each session as we went along. Following the feedback patients were given all of the module paperwork all together. Further feedback resulted in us finding a way to secure the hand out into two separate packs for work sheets and hand outs. Length of the modules – the modules have felt to long for the patients with this first cycle of the new manual, now that we are familiar with the manual it is clearer how to get through the modules in a more timely manor. Patients have valued sharing experiences of BPD and the biosocial model, this has increased group cohesion.

Group Member Reflections Thank you for my certificate I can’t wait to do it again! It made me more aware of myself and how to facilitate what I want or need It has given me even more skills to use and practice to change my former unhelpful and destructive behaviour I hope I may be able to do mindfulness again when I have finished my DBT course because it is the one I really use every day It provided me with lots of new exercises that I can apply daily Received positively by patients, they have continued to be motivated to attend Certificates have reinforced the progress they are making They value to modules Programme helps changing behaviour

Our Reflections Inclusion of the Group members in the process Introduction of orientation module received positively Good additions to the manual – radical acceptance example Highlights DBT assumptions – does not treat individuals as fragile Extended time of the sessions Out of session work, links well to the structure of the session Could have been better Discussed changes with current group members Orientation module – sharing experiences of BPD and identifying with biosocial model very powerful, helped group cohesion Uses powerful examples Does not treat patients as fragile when exploring their own behavioural difficulties and reasons for this Found that extending the session has allowed for a smoother running of the programme

Our Reflections Preparation – JUST DO IT! Hand outs and work sheets – juggling act Currently have a low referral rate – high turn over on admission ward Nature of patients – many suited for an adapted version/too unwell Long! Preparation – reading of the manual could have been better – we went with JUST DO IT! Hand outs and work sheets can be difficult to navigate through for patients – introduction of sticky notes and tabs appears to have helped with this Number of admission who have quickly moved on back to home areas Number of MI patients admitted and acute admissions who are not yet ready First run through of the manual we ensured that we tried to deliver all of it to be familiar with the manual – we have now started to reduce this to get through the manual

Future Directions Increase out coming Presenting findings Continue to send others of full DBT training Develop a new staff awareness package

Questions?