recently had the opportunity to ask Dr. Marvin Lew, psychologist, professor and author of Dialectical Behavior Therapy for Adults who have Intellectual Disability a chapter in Psychotherapy for Individuals with Intellectual Disability some questions about using Dialectical Behavior Therapy strategies with people who have intellectual disabilities. I’m happy to share with you, today, his experience.
Christy: You worked with people with intellectual disabilities for a number of years. What problems did you see that made you consider dialectical behavior therapy (DBT) for this group?
Marvin: This is true. I worked with people who have intellectual disabilities (ID) for fifteen years. I supervised many clinicians during that time and there was often a feeling that some individuals had so many complications in their lives that they may never get better. Sometimes it was felt that 10% of our case-load required 90% of our time.
Such individuals were challenges to their families, clinicians, and care providers. They had frequent difficulties with other people, had more than their share of community struggles such as loss of jobs, loss of housing, etc... and were often the genesis of burnout symptoms among their care providers. I'm sure I was not the only clinical supervisor who cringed at the sight of difficult to serve clients who had both ID and emotion regulation problems.
When Dr. Linehan's studies began to show success with a non-ID population, this was very encouraging as in some ways our population had similarities to hers especially with regards to the role of emotion regulation problems in their lives. Still, we knew this would require significant modification of her manualized treatment as many of our ID clients had specialized histories of invalidation, specialized biological vulnerabilities, histories of dependencies, histories of illiteracy, and histories of involvement with state and provincial care systems.
Christy: Why is DBT an appealing treatment for people with intellectual disabilities?
Marvin: DBT is an appealing treatment for people with ID who have emotion regulation difficulties. There is a long history of such individuals having been placed in institutions and long term care facilities for poor relationships, poor decisions and their medical/legal risk within the community. Often times, these people were placed in highly restrictive and expensive systems of care. Many individuals are difficult to treat resulting in discord, frustration, and burnout among providers. Many of these individuals have both psychiatric and medical problems resulting in crises, hospitalization, jail, and long-term care.
DBT represents a skills-based model that is consistent with the psycho-educational and habilitative treatment practices within the ID community. People who work in ID will be familiar with many DBT values and practices, including teaching skills associated with assertiveness, empowerment, and independence. Both clinical cultures are fundamentally positive and seek to reduce victimization and stigmatization of their clientele by improving their skills in negotiating the world.
Many care providers have learned that DBT offers a clinical option that is helpful for their charges, but also enhances their own clinical and spiritual lives. It does this through managing burnout and mastering important life skills such as mindfulness.
Christy: DBT is often considered a complicated treatment with multiple modalities and skills. How can the treatment be effective for an ID population?
Marvin: You are right Christy. DBT has lots of modalities and skills and can be a complicated treatment to master. As clinicians we did our best to expose our clients and groups to all the facets of Dr. Linehan's DBT skills. Typically people would hear about and practice the skills at least three times over an 18-month period. This is six-months longer than Dr. Linehan used for her groups, but ID people require more repetition.
Additionally, we included family or staff coaches who helped us generalize skills to the client's daily life. They themselves learn the skills along with the clients and helped them to practice both in and out of the group. We did not rely on DBT acronyms such as "DISTRACTS" since many of our clients could not read. Instead we relied more upon concrete and sensory- based experiential learning in the groups as well as structured oversight by family and team members of DBT oriented treatment plans. We were happy to identify 3-5 key skills that were meaningful for the client and could be integrated into treatment plans and thus practiced throughout lives.
Christy: Can you give a specific example of how you modified curriculum to make it more effective for people with intellectual disabilities?
Marvin: One modification of the curriculum that works nicely is to watch a clip of a movie which identifies a portion of skills such as differentiating "emotion mind" vs. reasonable mind" vs. "wise mind." A good example that I have used is the movie "Star Trek and the Wrath of Khan," but many other films offer a similar opportunity to evaluate the vignettes by stopping action and dispassionately observing and describing thoughts and behaviors associated with emotions.
One of the self-soothing skills that we often used was a "Distress Tolerance box" that includes an array of self-soothing choices that clients can use during stressed times such as when they are lonely, anxious, or angry.This is a helpful intervention because it is applicable to many different clients yet can be personalized for the individual. I wrote a chapter for Bob Fletcher's (2011) recent book on Psychotherapy for Individuals with Intellectual Disabilities in which these interventions are further described.
Christy: You co-wrote an article in 2006 with several colleagues (including myself) reporting on a DBT implementation with this population. Can you summarize some of the results from the data that you gathered?
Marvin: We did a study and wrote an article five years ago (Lew, Matta, Tripp-Tebo & Watts, 2006) on which you were a co-author. We presented some initial data on the effectiveness of DBT for an ID population. The results were for a cohort of 8 clients who were in the group because they were known for presenting community risks for safety, violence, harm to self, substance use and misuse, sexual risk, and eating disorders.
These were 8 individuals with mild intellectual disabilities (IQ=55-70) who all had multiple problems including dysregulated mood and personality disorders. These individuals spent 18 months participating in individual therapy and DBT skills training on mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.These individuals were found to have less risky behaviors after participation in the program. Though the results were for only a small group of clients, this was both encouraging and consistent with the DBT literature.
Christy: What recommendations would you have for someone who was considering DBT treatment for an individual with ID?
Marvin: First, I'd encourage them to explore the resources in the community that have experience with DBT as well as ID. I might consult with the Association for Behavioral and Cognitive Therapies or Behavioraltech which is a training facility for Dr. Linehan's group to determine if there is a DBT trained clinician or program near you. ID individuals are often served within standard outpatient programs and are often placed in groups along with non-ID individuals. In other cases there may be specially trained clinicians who work with this population. Many times family therapy is indicated and can be facilitative of learning DBT skills.
About Marvin Lew PhD ABPP
Dr. Lew, a licensed psychologist in Massachusetts and Florida, has held positions as a clinical director for a large mental health agency, has worked as a member of interdisciplinary teams addressing complicated-to-serve individuals in hospital settings and held an appointment as an Associate in Psychiatry at the U. Mass. Medical School from 1995-2007.
Currently he is in private practice, teaches and supervises students at The Center for Psychological Studies and Nova Southeastern University. Dr. Lew also provides consultation on the implementation of Dialectical Behavior Therapy.
Dr. Lew is co-author of the article DBT for Individuals with Intellectual Disabilities: A Program Description and author of Dialectical Behavior Therapy for Adults who have Intellectual Disability a chapter in Psychotherapy for Individuals with Intellectual Disability, he has presented on the application of DBT for individuals with ID on numerous occasions, most recently as part of the NADD Teleconference Series (The National Association for the Dually Diagnosed).
Photo by Hannah, available under a Creative Commons attribution license.