1. 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.

2. 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.

3. 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 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., ( ) – 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)

4. 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

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

6. 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

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

8. 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

9. 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

11. 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

14. 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

15. 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

16. Contact Rebecca.Ewing@belfasttrust.hscni.net