Dialectical Behaviour Therapy (DBT) Siobhan Keating, Rebecca Ewing , Nadene O’Loan Colette Caldwell Garvin McKnight DBT is an integrated model combining a range of cognitive and behavioural approaches with aspects of Eastern philosophy (including mindfulness meditation) and dialectics What is dialectics? Weighing and integrating contradictory facts or ideas with a view to resolving apparent contradictions. The balance between acceptance and change strategies in therapy form the fundamental ‘Dialectic’ within DBT – encourages individuals to accept themselves as they are in present within the context of reshaping their cognitions and changing future behaviour The main target of DBT is to increase dialectical behaviour patterns of cognitive functioning whilst helping patients to change extreme behaviours into more acceptable responses.

What is DBT A cognitive behavioural treatment for difficult to treat mental disorders Originally for suicidal individuals with BPD DBT = specific type of CBT Designed by Marsha Linehan (1993) primarily to treat Borderline PD, She suggests it is primarily dysfunction of emotional regulation system which involves cognition, behaviour, interpersonal communication and self-identity. The model proposes that PD ARISES FROM A TRANSACTION BETWEEN BIOLOGICAL VULNERABILITY AND INVALIDIATING ENVIRONMENTS. IE emotional response systems which respons to stimuli with greater speed and strength than other individuals and have a slower return to baselline once stressor is removed. This dysregulation leads to LESS EFFECTIVE COGNITIVE P[ROCESSING DIFFICULTIES WITH PROBLEM SOLVING POOR ACESS TO COPING STRATEGIES LIMITED CAPACITY TO CONSIDER CONSEQUENCES Primary focus for DBT is recognising, accepting and moderating emotional responses.

Wider evidence base In- patient psychiatric settings (Linehan et al 2006) Eating disorders (Telch et al 2001) Addictions (Linehan et al 2002) In patient adolescents ( Trupin et al 2002) Forensic environment ( Evershed et al 2003) Learning Disability ( Lew et al 2006, Singh et al 2008) Rampton study – evidence from self-report and transfer to lower security ( Morrissey and Ingamells, 2011) Originally designed for out patient chronically suicidal individuals Lowe et al 2000– female, high secure Reductions in self harm incidents. Evershed et al 2003 - male, PD , high secure TAU control. Reductions in violent incidents; self and staff rated anger. Lew et al – inpateint LD adapted DBT – reductions in aggression and risk behaviour foll an initial increase in first 6 months Singh et al., (2003-11) – effective in reducing aggression, and problematic sexual behaviour in males mild to moderate disability Chilvers et al., (2010) – effective in reducing proxy measures of institutional aggression, female inpatients (n=15)

Our Service Sixmile Low Secure Forensic unit Males with a learning Disability – IQ 55-70 Complex treatment needs Belfast Trust No formal diagnosis – presenting problems

The Rampton Programme Contract with programme developers Catrin Morrissey Bridget Ingamells Provided training and Adapted materials

Core Skills group modules In this Moment Managing Feelings People Skills Coping in Crisis switching off / being in the moment- pig positive exp to save and use when needed high and low not sink In this moment = mindfulness Managing feelings – emotional regulation Coping in crisis – distress tolerance People skills – interpersonal effectiveness

DBT In Muckamore Skills group 1 – 1 session DBT consultation meeting Wider staff training

Current Group Adult males(6) – 21 – 55 years IQ range - 58 – 70 Other MH problems – Bi-polar, ADHD, Substance misuse Offence History – Violence, sexual violence, manslaughter, abduction of a child Legal status – both detained and voluntary

Outcomes Psychometrics : Mindfulness – 5 facets Mindfulness – CAMS – R Emotional regulation – ECQ Emotional recognition – TASIT Emotional control – STAXI Coping skills – CRI Behaviour monitoring – Nurse Observation Scale Goal Attainment Scale – All modules Weekly Behaviour monitoring

What we have learned? Increased insight into how difficulties impact on day to day lives Individualised targets on Diary Cards Visual props more effective e.g. Sponge and sieve M & Ms Insight – us and them

What we have learned -2 Further adaptation of materials / exercises for our client group Use of metaphors - careful consideration of literal meaning eg “Hot mind” Mindfulness – difficult concept to grasp - application to everyday lives All skills need specific work to connect to daily lives

Plans for the future Further training and input from Rampton Team Evaluation and use of psychometric data and incident recording Extending programme to include female in-patient population

Contact Rebecca.Ewing@belfasttrust.hscni.net Siobhan.Keating@belfasttrust.hscni.net