Dialectical behaviour Therapy for
People with a Learning Disability:
An overview
Dr Lesley Leeds
Senior Clinical Psychologist
Learning Disability Services
Betsi Cadwaladr University Health Board
Plan
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The problem
How did we get a service going?
What is DBT
How can DBT be useful for people
with learning disabilities?
Adapting and using DBT
Experiential teaching – some
adapted skills on managing affect –
just say CHEESE
The Problem & Context
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Historically:
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People with learning disabilities (and those
working in services) excluded from research
and practice
Limited evidence base for psychological
interventions
Limited access to psychological therapies
Who actually gets any treatment?
Can these treatments really work?
There is a clinical problem out there….
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Placement breakdown
Out of county placements
Complex case list
Staff burnout
Competence issues
Cost to organisation
Cost to individual and their family
Every CLDT has people with complex
emotional and behavioural problems
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Some will end up with PD diagnosis
or have traits of PD
What do we do to help them (and
those around them)?
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Doubly untreatable? (double jeopardy
problems)
Revolving door individuals (social
workers, nurses, doctors, therapists)
Who has heard this?
People with PD are:
Untreatable
Manipulative
Attention-seeking
Selfish
Draining
“There’s not much we
can do to help”
“I don’t know how to
help that person”
“These PD people are
nothing but a drain on
resources”
“I don’t like to work with
people like that”
“It’s not within my skill
base”
There are often assumptions that
PWLD should somehow be more
skilful
And wouldn’t be behaving like this if
they didn’t have a learning disability!!
Not true!
It is their learning and life
experience that has led to
the problems…
The first day of the psychology
career…
OMG!!!
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Rapid intro to PD and heavy duty
problems
Marsha Linehan became my bedtime
reading..
Desire to work ‘psychologically’
Long and winding road…
A chance to do something proper..
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Opportunities for DBT training in 2011
A small team formed (n = 4)
Audit across BCUHB – yes the cases are
out there
Management approval (no mean feat)
Adapted materials (no mean feat either)
Started delivering skills training in Jan
2012
The start of a small but strong service……
Current position
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Competence and confidence
One established DBT team
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Delivering DBT in one community
setting
‘Seeding out’ of other teams
The near future
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Current Ongoing service
development in BCUHB to bring
equity in services
Further staff training in 2014
Increasing access to Psychological
Therapies in North Wales for people
with learning disabilities
UK Position
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There are only 3 other community
DBT teams in UK specific to LD
(British Isles DBT data)
So, what’s the big deal about
DBT?
Dialectical Behaviour Therapy: in a nutshell...
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Designed to address severe and persistent
problem behaviours; that arise due to
emotional and behavioural difficulties
experienced by an individual.
DBT focuses on the acceptance and
changing of problematic thoughts, feelings
and behaviours.
The person is encouraged to believe and
make changes to build a life a worth living.
DBT can help treat self harm, suicide,
violence, non compliance, substance abuse,
food issues, severe emotional difficulties
and post traumatic stress.
Where does this treatment come from?
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DBT was originally used for the treatment of women
diagnosed with Borderline Personality Disorder, that
engaged in self harming and suicidal behaviours.
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DBT was initially used in community settings, now is being
implemented in inpatient and forensic settings.
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DBT originated from the Bio-Social Theory of personality
functioning
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Building evidence base in LD
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10 DBT treatment teams in LD services in UK (in and
outpatient)
A note on the biosocial theory
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Biological propensity
Temperament
Invalidation
Abuse
some…
or
all?
Emotional layer of skin missing –
everything little thing burns - sensitivity
Philosophy of DBT
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DBT is:
Dialectical
Supportive
Cognitive
Behavioural
Skill orientated
Balances acceptance and change
Requires a collaborative relationship
All the features of a therapy well suited to people
with learning disabilities
Aims of DBT
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DBT aims to decrease
extreme emotions,
thinking and
behaviours into more
balanced responses to
current situations.
DBT teaches clients to
develop and refine
skills in order to
change problematic
behavioural,
emotional and
thinking patterns that
are causing misery
and distress.
Behaviours
to decrease
Behaviours
to increase
Self
dysregulation
Core
mindfulness
skills
Interpersonal
dysregulation
Interpersonal
effectiveness
skills
Emotional
dysregulation
Emotional
regulation
skills
Behavioural
and cognitive
dysregulation
Distress
tolerance
skills
Four Main DBT Skills
Core Mindfulness:
- Teaches attention to the present moment and self
awareness.
- Helps people be in control of their mind, be aware of
their thoughts and feelings at any one time, and think
things through properly before acting.
 Interpersonal Effectiveness:
- Teaches interpersonal skills, to help deal with conflict
situations and to get on with others, get what you want
in a way that maintains self respect and build and keep
effective relationships with others.
- Emotional Regulation:
- Teaches how to identify and describe emotions, how to
reduce vulnerability to negative emotions and how to
increase positive emotions.
 Distress Tolerance:
- Teaches strategies of how to tolerate distress, without
engaging in impulsive and self destructive behaviours.
Focuses on distraction and self soothing techniques,
and strategies to radically accept traumatic events in
their lives.
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How is our DBT programme made up?
Individual Therapy
 Focus on analysis of (and decrease) problem behaviours,
increase effective coping skills, focus on motivational issues
and work towards defined treatment goals.
 Weekly hourly sessions
Skills Training Group
 Teaching of behavioural skills to increase capability
 Weekly sessions for two hours for one year
Consultation Meeting
 Supervision for therapists to support their practice
 A community of therapists treating a group of individuals
Support Worker skill strengthening
 Support workers attend group and reinforce and praise skill
use out of sessions
 In lieu of telephone out of hours service
Why is DBT useful for people with learning
disabilities?
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On an individual level:
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A life saving and life enhancement
treatment
Validates the person’s difficulties
Teaches people skills to cope with and
change a range of problem behaviours
Enhances capability
Teaches people to accept things that
cannot be changed
Why is DBT useful for people with
learning disabilities?
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On a team level:
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Teaches the staff on the ground to
model, encourage and praise
appropriate skills
Gives a framework for professionals to
cope with problem behaviours
Change in attitude about treatability
Why is DBT useful for people with
learning disabilities?
On a strategic level:
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Costs the organisation less money
Keeps people in their community
placement (and often out of hospital)
Increases workforce capability
Adapting this treatment for our clients
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DBT is a complex model for
therapists and clients alike
Essential to make it accessible for
those with learning disabilities
For more information, contact me
directly on
Lesley.Leeds@wales.nhs.uk
Doesn’t this just dilute the
treatment?
The core model and principals are the same
What good is any therapy if the client has no idea
what you are talking about?!! No matter how fancy
it seems
Using and adapting DBT for
people with Learning Disabilities
The experiential bit
Core DBT skills
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Mindfulness
Interpersonal effectiveness
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Emotional regulation
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Distress tolerance
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Reducing vulnerability to emotion
mind
Reducing vulnerability to
emotion mind
Sounds easy…..but we all fail at this
from time to time
How many of us have:
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Shouted at someone else when tired?
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Been grumpy because you missed lunch?
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Not functioned well because you were ill?
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Got hacked off because you were bored?
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Felt that you were no good at something?
We are all vulnerable to
emotion mind
When you have emotional sensitivity
and problems coping, this happens a
lot more to you
So, what is emotion mind (or what we call Hot Mind?)
Cool
Mind
Calm
Mind
Hot
Mind
Hot Mind/Emotion Mind
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Hot Mind – this is when your emotions
take control – when your emotions are in
charge of your thinking and how you
behave.
This is the problem bit for all of us!!
In an ideal world…we would be here
When you feel the
emotion, but it does not
take over
Cool
Mind
Calm
Mind
Hot
Mind
Reducing vulnerability to emotion mind
Staying out of ‘Hot Mind’
Remember: say CHEESE
This comes from PLEASE MASTER
emotional regulation skills (Linehan, 1993)
Treat
Balance
Avoid
Balance
Get
PhysicaL illness
Eating
mood-Altering drugs
Sleep
Exercise
Build mastery – try to do one thing a day
to make yourself feel competent and in
control
For people with intellectual
issues …not user friendly
Even we could not remember this
easily!
Staying out of ‘Hot Mind’
C = ‘Can Do’
Every day do something you ‘can do’
- something you’re good at
Staying out of ‘Hot Mind’
H = Health
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Take care of your body
See a doctor if you are ill
Take your medication
Avoid drugs and alcohol
Staying out of ‘Hot Mind’
E = Eating
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Eat the right amount of food
Avoid ‘emotion’ foods
Staying out of ‘Hot Mind’
Staying out of ‘Hot Mind’
E = Exercise
Do some exercise everyday.
Staying out of ‘Hot Mind’
S = Sleep
Get the right amount of sleep.
Staying out of ‘Hot Mind’
E = Enjoy
Do something everyday that you
enjoy
Staying out of ‘Hot Mind’
Remember: say CHEESE
Of all the DBT skills taught..
This is the one the clients remember and
use the most
Such basic, yet important skills
DBT has been a valid and useful intervention
for people with mild LD in North Wales
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Reductions in:
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Self harm/suicidal
behaviours
Aggression/threatening
behaviours
Over-eating
Seriously destabilising
behaviours
Hospital admissions
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Increase in:
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Client capability
Staff capability
Placement duration
Availability of
psychological
therapies for PWLD
The long and winding road
Thanks for listening
Questions?