“Julie, thank you so much for your thoughtful description of the origins of the Skills System, and the clear way in which you outlined the debate about what is DBT (I don’t know how to add the TM like you did), and what is DBT-informed rather than “adapted,” though I would like to add another term of “DBT-infused,” which is what I think your program is. I agree with your comments about the needs of ID clients, and the many, many, many complications there are in getting adequate services for them. I did my Master’s practica with autistic individuals who were functioning in the ID range, and then worked for nearly 30 years in various state hospital programs – the first 10 years in state hospitals for ID individuals, and then 19 in another state hospital that also included some individuals with ID. One of the psychiatrists I worked with many years ago said that ID individuals with mental health issues were not twice as complicated, they were exponentially more complicated. You are absolutely correct that to simply teach the skills as they are, using simpler language, is not usually enough for these ID individuals – even though they may learn the list of the skills, they may not understand the purpose of them and how to apply them in specific situations, or why to pick one skill over another. They don’t always get the “elegance” of the skills.

I don’t think the Skills System should just be used for ID folks, though. I have often said that the “habilitation” model of treatment for individuals with ID is better suited for the treatment of individuals with BPD than the “rehabilitation” model that is used for most mental illnesses. In the rehab model, the assumption is that the person had skills/abilities, became mentally ill and lost some of the abilities, and with rehabilitation, they will be restored in their functioning. In the habilitation model that we used for ID individuals, we assumed that the person did not have the skill, unless and until we saw it performed consistently in various settings. Most of the individuals with BPD have been raised in such chaotic environments, that they often have huge gaps in their skill sets, and thus as as clinician, I am much less likely to get “fooled” by the apparent competence if I can maintain my stance in the habilitation model – I don’t care what the person says, I need to see the behavior demonstrated (or described in such detail that I can “see” it) before I know that they have mastered the skill. This is one of the things I love about your Skill System – it helps me when I have a client, regardless of IQ, who just is not getting what to do when. I don’t have to keep going over the specific skill (you know, like saying it over and over, and maybe a little bit louder is going to make the person understand 😉 ), but can back up and give the person more cues and in a different context. I have said before that even with my incredibly bright clients, I use the 0-5 scale that you illustrated so well in one of your handouts, and they seem to “get it,” viscerally. It is like watching a light bulb go on.

Yes, you have to, I suppose, disclose that you get royalties. However, as I have heard you talk about your work, it is clearly a work of love for these individuals. Thanks again for all your work. Bev

Beverly Long, PsyD, LP
Assistant Professor, Department of Psychiatry
University of Minnesota