1. National High Secure Learning Disability Service I Can Feel Good Dialectical Behavioural Therapy Informed Adapted Skills Programme For People with Intellectual Disabilities Bridget Ingamells. Clinical Nurse Specialist.

2. Evidence Base Linehan’s original DBT was designed for relatively high functioning women. A number of studies have now described outcomes of adapted forms of DBT for people with intellectual disabilities in both forensic and non forensic settings. Largest (n = 40) and most comprehensive (Brown et al.,2013). Found significant reductions in challenging behaviour after 4 years of treatment.

3. The Setting - NHSLDS 54 beds in purpose built service Young – 65% under 30 Complex needs LD/PD/MI Mild ID – mean FS IQ 64 – range of 54/80 Over two thirds dx with personality disorder High risk – Challenging behaviour with more violence than self harm Long stay - mean length of stay 9.0 years

4. NHSLDS Adapted DBT 2004+ Not ‘adherent’– made a progressive and conscious drift from standard DBT. Some participants have full DBT: individual therapy and group skills training (no telephone consultation) and team consultation. Skills modules also accessible to other patients as part of their treatment pathway, dependent on formulation. Skills part Published as ‘I can feel good’ (Pavilion 2014). (©Nottinghamshire Healthcare NHS Trust).

5. Pilot Programmes in NHSLDS from 2004 findings Too much information – too complex Concept connections not clear – mnemonics Major finding of affect labelling deficits Identified high kinaesthetic learning style –’chalk and talk’ and written handouts ineffective Need to personalise situations – difficulties relating to generalisations Significant discrepancies – verbal expression & perceived understanding vs actual understanding Took three - four times as long !

6. Developments Core concepts prioritised, slow pace Sessions highly structured with repetition of previous session content High level of practical content Less focus on verbal reasoning/insight Reduction in number of skills and new names for skills Increased care staff involvement in place of telephone coaching Individual follow-up skill sessions Simplified and visual diary cards High tutor ratio

7. Where adapted skills programme fits in the high secure treatment pathway Sits within the second stage of the treatment pathway following motivation and engagement work. Focus is on emotional regulation, behavioural control and coping skills development before moving on to offence focussed work. Emphasis on practical skill application and generalisation.

8. The IGFG Skills Modules Mindfulness (In This Moment/Mindfulness) Emotion Regulation skills (Managing Feelings) Interpersonal Effectiveness (People Skills) Distress Tolerance skills (Coping In Crisis)

9. Core Concepts In this moment/Mindfulness Added introduction to thoughts feelings and actions. practice - walking the dog!!!! what and how skills Managing Feelings Greater emphasis on feelings identification and labelling. ‘feel good factor’, suit of armour. Coping in Crisis 9 Core skills: new acronym – D.I.S.T.R.A.C.T.S People Skills What and how core skills :Describe, ask, listen, negotiate (give and take), and ‘the Bees’.

10. In This Moment/ Mindfulness States of Mind Role play – 3 chair What and How skills Practice Practice Practice Being vs Doing modes Activities to fit the modules Wise Mind WARM Emotion Mind HOT Logical Mind COOL

12. Managing Feelings

13. High emphasis on emotion recognition and accurate labelling – –I’m angry – step back –I’m anxious – step forward Tools –composite character (‘Henry’), body map, picture descriptors, chain analysis of emotion development, silent role plays, black bag exercise… Exploring skills –Maintaining the ‘Feel Good’ factor –Building the skills of armour

14. Life-size suit of armour. Analogy of building an ‘armour’ of skills which is added to at each session. increasing ‘Feel Good’ factor increasing Positive Activities and Acts of Kindness increasing mindfulness to emotions building resilience to reacting negatively on their emotional experience

15. People Skills Explore the same material but in a different way – no acronyms. Basic descriptors –What we do – ask, describe, listen, negotiate (give and take). –How we do it – use the B’s – gentle, truthful, confident. Tools –Composite Character, Skills Cards prompters, Props. –Role play, role play and even more role play ! - Weekly skills diary cards.

17. Coping In Crisis Acronym DISTRACTS –Do something different –Imagine a safe place –Self talk –Thinking about something else –Resist your action urges –Acceptance –Count your blessings –Think about pros and cons of coping –Soothe yourself Tools –Composite character –Henry’s Head

19. Programme Delivery Two approaches – Modular and Individual. May access skills groups as stand alone. Less emphasis on theory – more on practice. Limited use of mnemonics. Extended module length – flexible time scales. Repetition of material – session structure High facilitator ratios. Generalisation of skills through ward based staff.

22. ICFG skills Also being used in… medium secure male low secure male locked rehabilitation female community female/male prison Evaluation within high, medium and low secure male services is underway

23. Thank You Bridget Ingamells Clinical Nurse Specialist bridget.ingamells@nottshc.nhs.uk bridget.ingamells@nottshc.nhs.uk Morrissey, C. and Ingamells, B.(2011)Adapted dialectical behavioural therapy for male offenders with learning disabilities in a high secure environment: six years on. Journal of Learning Disabilities and Offending Behaviour. Volume 2, issue1 January 2011.