Margaret Charlton, PhD, ABPP Aurora Mental Health Center
Dialectical Behavior Therapy (DBT), a treatment originally developed for individuals diagnosed with Borderline Personality Disorder, has been shown to be helpful in the treatment of clients with severe, complex trauma issues. In addition, DBT shows promise as a treatment for individuals with dual diagnoses (mental illnesses and developmental disabilities). Individuals with developmental disabilities are significantly more likely to experience traumatic events than the general population. These statistics vary depending on the type/severity of the disabling condition, the type of trauma being tracked,l and the method of obtaining the data. DBT also provides a method of helping the professionals involved in treatment to work together as a more effective team. This article will present an adapted model of DBT for use with children with developmental disabilities.
DBT is a comprehensive treatment program addressing deficits in emotion regulation, distress tolerance, and interpersonal relationships. It was originally developed by Marsha Linehan (1993a; 1993b) for the treatment of individuals diagnosed with borderline personality disorder. Since that time, its effectiveness has been demonstrated with a large variety of different disorders and age ranges of individuals, including suicidal adolescents (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997; Katz, Cox, Gunasekara, & Miller, 2004), clients with binge eating disorders (Telch, Agras, & Linehan, 2001), and group use in a residential program (Wolpow, 2000). DBT is now best described as being designed for the severe and chronic, multi-diagnostic, difficult to treat client with both Axis I and Axis II disorders.
Using DBT, therapists have five main tasks. They work to expand client capabilities, motivate the client to engage in new behaviors, generalize the use of the new behaviors, establish a treatment environment that reinforces progress, and maintain capable and motivated therapists (Linehan, 2000). These tasks are accomplished using three components: individual psychotherapy, skills training groups, and supervision/case consultation groups (Linehan, 1993a). Using these components, DBT provides strength-based instruction with specific training in concrete skills, utilizing a multidimensional and multidisciplinary approach.
In the past, it was believed that psychotherapy was not effective for people with developmental disabilities. In addition, many felt that people with developmental disabilities did not have the same need for psychotherapy as the general population. Today there is growing appreciation that individuals with developmental disabilities suffer from the same difficulties in life that the rest of the population encounters, such as feelings of anxiety and depression, grief, job stress, and so forth (Charlton, Kliethermes, Tallant, Taverne, & Tishelman, 2004; Butz, Bowling, & Bliss, 2000; Nezu & Nezu, 1994). Although there are a number of issues that must be addressed when providing psychotherapy to individuals with developmental disabilities and mental illnesses, many psychotherapeutic techniques, if suitably modified, are effective for people with developmental disabilities (Butz et al., 2000; Nezu & Nezu, 1994). Although more repetition is needed, once people with developmental disabilities make changes in therapy, the retention of the changes is similar to that displayed in the general population (Charlton et al., 2004).
To adapt psychotherapy for people with developmental disabilities, information should be provided in a variety of different modes, for example, using both auditory and visual information together (Spackman, Grigel, & MacFarlane, 1990). It is helpful to simplify language, structure the therapy session and use a more directive and active approach (Butz et al., 2000). Concrete activities such as modeling are useful with clients who have language deficits, as well as setting clear limits, maintaining structure and focus to the session, and allowing flexibility for the expression of thoughts and feelings (Szymanski et al., 1994). Suggestions for change need to be specific; time should be allowed during the session to practice different ways of handling the situation; and do not assume that information will generalize from the session into other situations, unless explicit practice is done to institute this change (Charlton & Tallant, 2003).
Method of Adaptation
There are many common characteristics between people with developmental disabilities and the populations for which DBT has been found to be effective. The populations for which DBT has been normed experience a higher incidence of trauma than the general population. They also display impaired impulse control, difficulty identifying and managing frustration appropriately, and problems with the regulation of emotions. In addition, they often lack effective methods of self-soothing. All of these characteristics are frequently displayed among people who have developmental disabilities. In addition, we know from the work on adapting treatment for people with developmental disabilities that DBT's focus on strength based instruction, concrete skill building, and built-in repetition of key information is particularly helpful for this population.
Once we determined that the philosophy and theory underlying DBT was likely to be effective for people with developmental disabilities, our adaptation efforts were made to language and presentation. The adaptation focused primarily on the handout materials associated with the DBT skills training groups. The work that is being presented here on adapting DBT skills training materials comes from Dialectical Behavior Therapy Skills Training: Adapted for Special Populations (Dykstra & Charlton, 2004).
We began with changes in language, so that individuals with developmental disabilities would be able to understand the concepts. Second, some of the concepts were paired down and/or simplified to allow for better comprehension and application of the material. Third, the handouts were rewritten and reformatted in order to increase attention and aid in understanding. Finally, client feedback, repetition and rehearsal have been incorporated into the therapy structure to aid in the learning, retention, and generalization process. (Dykstra & Charlton, 2003)
The process of adapting the DBT skills training materials is probably best understood through the use of examples. For emotion regulation handout 1, rather than talking about reducing emotional vulnerability, as in Dr. Linehan's handout, we worked on understanding how emotions affect us and on making good decisions when experiencing an emotion (Figure 1). We also used a visual presentation style that would make it easier for clients with developmental disabilities to absorb the information. This type of adaptation is illustrated in Figure 2, where we reduce the number of interactions attempted to teach, used more prominent arrows, illustrated the components with different shapes to make them easier to remember, and simplified the language. In Figure 3, we modified Linehan's (1993b) acronym "PLEASE MASTER" which addresses reducing vulnerability to negative emotions, to "SEEDS GROW" and discussed controlling emotions instead of reducing vulnerability. This modification allowed us to use simpler language that was already in our clients' vocabulary. It also provided another opportunity to emphasize that we control our emotions; they do not control us. (Dykstra & Charlton, 2003; Dykstra & Charlton, 2004)
We are in the process of conducting a pilot study in an effort to determine the effectiveness of our adapted version of DBT. The study is being conducted with clients in the day treatment program at Intercept Center. In the study, we are utilizing all three components of DBT, in addition to our normal milieu management techniques, so that clients are receiving DBT focused individual therapy, skills training groups using the adapted manual, and all of our treatment team staff members are participating in a DBT supervision/consultation group.
Thus far, we have collected observations of client behavior by staff, client outcome when leaving the program, and daily diary card information. We are using an adapted daily diary card, shown in Figure 4.
As with most pilot studies, there are many limitations to our data. We do not have a control group, as all of the youth participating in the day treatment program receive DBT. DBT is being used in conjunction with other techniques and we lack the ability to control many factors in the students' environment that influence their behavior. In addition, clients enter and leave the program at different times, so that the data we gather can be hard to interpret. Thus far the data we have collected is suggestive, but not in any way conclusive.
Our observational results indicate that clients are spontaneously using "DBT Language." They are displaying the skills they have been learning, both spontaneously and when cued by staff members. In addition, over time in treatment, our clients are becoming more insightful into situations, emotions, thoughts, and actions that are maladaptive, as evidenced by the greater ease they show in processing such incidents.
Table 1 illustrates the outcome when leaving the program for the students who participated in adapted DBT thus far. Three students left the program without completing any of the skills training modules (one on run; one incarcerated; and one placement disrupted). Two students completed one skills training module, but were moved to placements outside of our catchment area, so no outcome data is available. Of the remaining 11 students, two moved to more restrictive environments, three remained stable in the day treatment program and six moved to less restrictive environments.
Information from the daily diary cards is shown in Tables 2 (action items), 3 (thoughts), and 4 (feelings items). The action items (argued, tried to hurt self, attempted suicide, tried to hurt others and tried to avoid work) from the cards are dichotomous; answered either yes or no. In addition, yes responses did not occur very frequently, so it was hard to demonstrate change. In hindsight, we should have included measures of duration or intensity, since that appears to be where more change occurs. In contrast, for thoughts and feelings there was a positive trend in our data.
There is much more work to be done before we will be sure that adapted DBT is as effective as traditional DBT. However, there is a great need for the development of more effective treatment techniques to meet the needs of people with developmental disabilities. We know that people with developmental disabilities and mental health issues benefit from participation in psychotherapy, provided the psychotherapy is presented in a manner that is accessible to them (Szymanski et al., 1994). Much additional effort is needed to provide people with developmental disabilities the same range of options for treatment that the general population enjoys. The current effort to adapt DBT is just a beginning.
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