from fixed to flexible: a thematic analysis of patient ... fixed to flexible... · marsha m.,...

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

Joanne.sharp4@nhs.net

Dr Michelle Small, Highly Specialist Clinical Psychologist, DITT-SSOTT Lead, DBT & RO DBT Therapist

Michelle.small2@nhs.net

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