from fixed to flexible: a thematic analysis of patient ... fixed to flexible... · marsha m.,...
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From Fixed to Flexible: a thematic analysis ofpatient experiences of an adapted RO DBT
Programme
17th International Conference on the Care and Treatment of Offenderswith a Learning and/or Developmental Disability
April 2018
Matthew McCourt, Higher Assistant Psychologist
Elena Gaga, Higher Assistant Psychologist
Dr Joanne Sharp, Highly Specialist Clinical Psychologist, DITT-S Lead, DBT & RO DBT Therapist
Dr Michelle Small, Highly Specialist Clinical Psychologist, DITT-S Lead, DBT & RO DBT Therapist
Tees, Esk & Wear Valleys NHS Foundation Trust
Overview
Forensic DBT service
What is RO DBT
And how it differs to standard DBT
How it looks in our service
Aims
Procedure
Results
Recommendations
Forensic DBT Service
Forensic DBT Services
Offender HealthForensic LearningDisability
Forensic MentalHealth
DBT for UnderControl (A LifeWorth Living)
Dialectical Intensive Therapies Team – Secure (DITTS)
DBT + PE forTrauma
DBT forSubstanceMisuse (ALife Worth
Living Sober)
RO DBT forOver Control(A Life Worth
Sharing)
DBT/ RO DBTInformed Offence
Programme(Making Wise
Choices – Sexual/Fire & Violence)
What is RO DBT?
RO DBT follows the same programme format at DBT(weekly skills lesson, weekly individual session)
DBT is for people who present with under-control
RO DBT is for people who present with over-control
In general terms, this is what we work increase
Receptivity and Openness
Flexible Control
Intimacy and Connectedness
With an aim to enable…
Open Expression = Trust = Social Connectedness
Difference to DBT
DBT Core problem
Emotion dysregulation, poorimpulse control.
Primary Therapeutic focus
Internal - emotion regulationskills, gaining behavioralcontrol and distress tolerance
Developed for undercontrolled clients
Cluster B ‘dramatic erratic’personality styles, mainlyborderline and antisocial PD.
RO DBT Core problem
Social signalling deficits, low openness,and aloofness.
Primary Therapeutic focus
External - social-signaling, openness,and social connectedness skills
Developed for over controlled clients
Clusters A and C ‘overcontrolled’personality styles e.g. avoidant,obsessive compulsive, paranoid andschizoid PD’s, but also chronicdepression and anorexia nervosa.
RO DBT Themes Inhibited & Disingenuous Emotion
Aloof and Distant style of relating
Rigid and Rule Governed
High Social Comparison with bitterness and envy
Hyper Detail Focussed and Overly Cautious
RO DBT in our service 5 trained RO DBT therapists
2 Clinical Psychologists, 2 Community Nurses, 1 Speech andLanguage Therapist
2 Assistant Psychologists
6 RO DBT Therapists to be trained in November 2018
One full completed programme
Weekly Skills Class + Weekly Individual Therapy Session
Making Wise Choices (Sexual, Fire & Violence)
Offence Programmes developed by the service
Using DBT and RO DBT skills and principles
Run by DBT & RO DBT Therapists
Existing Literature Base
Lots of research for the effectiveness of RO DBT
Chronic Depression
Anorexia
See last slides
None for the use of RO DBT with people with aLearning Disability and/or Autism
None regarding service-user experience of RO DBT
AimsGain an understanding of how patients with Learning
Disabilities, Autism and Forensic needs experienceRO DBT
Gain feedback on the RO DBT programme (to identifyareas for improvement)
Explore an under-researched area, adding to theevidence base
Address NHS targets (measuring and improvingpatient experience)
Participants
4 adult male patients (3 interviewed)
Varying diagnoses, all over-controlled
Full RO-DBT programme completed between March2017-November 2017
Inpatient: medium and low security
Procedure
Semi- structured interviews
30- 40 minute interviews
Following completion of the RO-DBT programme
The research team involved in the interview processcomprised of members of the psychology team thatwere not part of the RO-DBT programme
Interview Schedule
Sample Interview Questions
Group Prime- Thinking about the Skills Group on a Thursday
Tell me what it was like to be in the RO-DBT Skills Class.
What difficulties did you have in the Skills Class?
Individual Therapy Prime- You met with [therapist] once a week for yourindividual session. Thinking about your individual therapy
What was Individual Therapy like for you?
Which RO theme did you find most useful? Why?
Full Programme Prime- Thinking about RO-DBT all together, so your skillsgroup and individual therapy
You did RO DBT for 9 months. How did you get from start to finish?
Were there any times when you struggled with RO-DBT? / What got in the waywhilst you were doing RO-DBT?
Analysis
Thematic Analysis
Qualitative process used to identify, analyse and report themes andpatterns within data
Chosen due to the heterogeneity of the participants and the flexibility ofthe process
Followed guidance from Braun & Clarke (2006) and Boyatzis (1998)
Continued use of a reflexive journal, creating an on-going dialogue
Ensured that our epistemological position was considered throughout
Results
Development of sense of self
Openness to trying something new
Use of skills
Support
Further similarities
Noticed pattern in diary cards
Inhibited emotional expression theme
Intrinsic motivation to complete (possibly due to beingOC? Stubbornness? Striving? Perfectionism?)
Enjoyed it/ has learnt a lot
Recommendations
Check for any potential relational difficulties- (peer whoattacked other member)
Manual- Too wordy (more demonstration or skills orrole play)/ forced discussions
Shorter group sessions and longer individual
Final Thoughts
“I think it was very helpful and I’m glad I did it”
“It’s for people who…express one emotion on theoutside but they feel something else on the inside”
“It offers, like, a lot of different skills for likecommunicating with people and identifying what you’refeeling”
“It is helpful for people who want to be less restricted,less fixed and less closed”
“I learned that asking for help is not a weakness”
Contact Details
Dr Joanne Sharp, Highly Specialist Clinical Psychologist, DITT-SLead, DBT & RO DBT Therapist
Dr Michelle Small, Highly Specialist Clinical Psychologist, DITT-SSOTT Lead, DBT & RO DBT Therapist
Lynch References
Peer-reviewed papers Lynch, T.R., Whalley, B., Hempel, R.J., Byford, S., Clarke, P., Clarke, S., Kingdon, D. ,
O’Mahen, H., Russell, I. T., Shearer, J., Stanton, M., Swales, M., Watkins, A. andRemington, B. (2015). Refractory depression – Mechanisms and Evaluation of radicallyopen Dialectical behaviour therapy (RO-DBT) [REFRAMED]: protocol for randomisedtrial. BMJ Open, 5, e00885. doi:10.1136/bmjopen-2015-008857
Lynch, T.R., Hempel, R.J., Dunkley, C. (2015). Radically Open-Dialectical BehaviorTherapy for Disorders of Over-Control: Signaling Matters. American Journal ofPsychotherapy, 69(2), 141-162.
Chen, Eunice Y., Segal, Kay, Weissman, J., Zeffiro, Thomas A., Gallop, R., Linehan,Marsha M., Bohus, Martin, Lynch, Thomas R. (2014). Adapting dialectical behaviortherapy for outpatient adult anorexia nervosa—A pilot study. International Journal ofEating Disorders, Article first published online: 27 OCT 2014 (doi: 10.1002/eat.22360).
Lynch, T.R., Gray, K.L.H., Hempel, R.J., Titley, M., Chen, E.Y., O’Mahen, H.A. (2013).Radically Open-Dialectical Behavior Therapy for adult Anorexia Nervosa: Feasibility andoutcomes from an inpatient program. BMC Psychiatry, 13, 293.
Lynch TR, Cheavens JS, Cukrowicz KC, Thorp SR, Bronner L, Beyer J. (2007).Treatment of older adults with co-morbid personality disorder and depression: Adialectical behavior therapy approach. International J of Geriatric Psychiatry, 22(2), 131–143.
Lynch TR, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy fordepressed older adults: A randomized pilot study (2003). American J of GeriatricPsychiatry, 11(1), 33–45.
Chapters Lynch, T.R., Hempel, R.J., Clark, L.A. (2015). Promoting Radical Openness and Flexible
Control. In John Livesley, Giancarlo Dimaggio, & John Clarkin (Eds.), IntegratedTreatment for Personality Disorder. New York: Guilford Publications, Inc.In John Livesley,Giancarlo Dimaggio, & John Clarkin (Eds.), Integrated Treatment for PersonalityDisorder. New York: Guilford Publications, Inc.
Lynch, T.R., Seretis, D., & Hempel, R.J. (in press). Radically Open-Dialectical BehaviourTherapy for Overcontrolled Disorders: including Refractory Depression, AnorexiaNervosa, and Obsessive Compulsive Personality Disorder. In Alan Carr & MuireannMcNulty (Eds.). Handbook of Adult Clinical Psychology, 2nd edition