Background — There are ongoing debates in the DBT world about adapting the model for special populations. Here are samples of the points related to increasing accessibility of DBT for people with ID. How much adaptation is too much? Does the language make the treatment DBT? Do the foundational DBT principles make it DBT? If you have thoughts about DBT, please submit them to me and I will post them here.

“I think it is important to note that individuals with moderate and mild intellectual disabilities (ID) and co-occurring mental health problems (dual-diagnosis) often experience deficits in executive functioning, memory, receptive/expressive language, and attentional control that are barriers for both learning and generalizing DBT skills delivered via standard teaching.

Practitioners treating this population know that individuals with ID are shown to have higher rates of mental illness, trauma, social stigma, and challenging behaviors. Simultaneously, this group experiences mental health care disparities, due to a lack of availability of specifically-designed psychological treatments that supply ample treatment technology AND are accessible/generalizable. The lack of specifically-designed interventions is a serious problem because alternative treatments often involve intensive levels of supervision (1:1 and/or 24-hour supports) and/or polypharmacy, both of which have been shown to be associated with increases in challenging behaviors. The high costs and impacts of potentially iatrogenic “solutions” are seen/felt by these individuals (who have limited abilities to self-advocate) and the general public.

I believe that access to comprehensive DBT treatment is vital for this population. While few adaptations of standard DBT individual therapy may be necessary, the language and format of standard DBT skills are often a problem. For example, all current research articles addressing the effectiveness of using DBT with individuals who are diagnosed with ID all use “adapted” or “modified” versions of the standard skills.

I realize adapting teaching can transfer certain DBT concepts, I just don’t think it is adequate and/or optimal. Adjusting teaching strategies, potentially loses too much of what is essential in DBT. These people need all of it- or at least as much as possible.

In my opinion, there are ways to organize DBT concepts that do not water-down or dismember the treatment to the point where it loses its essence/integrity. Providing lily pads of chopped-up skills could be seen as an over-simplification of the complex processes involved in adaptive coping, providing messages of invalidation vs. functional validation. People with ID don’t need less sophistication of intervention- they need more. The structure has to carry the cognitive load- not fracture it into relatively impotent pieces that lack synthesis.

For people with significant learning barriers, it makes sense to explore using the Skills System as the skills training portion of DBT treatment for individuals with mild/moderate ID and/or autism spectrum disorder/high-functioning autism, because it is specifically designed for these populations. The DBT™-informed Skills System curriculum extracted core DBT principles and reconstructed the delivery system to provide cognitive scaffolding that facilitates learning and recall in context. There are nine core skills, simple terms (that reduce cognitive-load demands), and a framework that guides the individual to know what/how many skills to use in the current moment. It breaks down emotion regulation processes into micro-transitions that the individual can master and execute, even when experiencing emotional, cognitive, and behavioral dysregulation (key for generalization). The Skills System was review/approved by James Gross, PhD, the editor of the Handbook of Emotion Regulation. The pilot data (Brown, Brown, & DiBiasio, 2013) is available for download at http://skillssystem.com.

There are debates at the highest levels of the DBT world about what makes a treatment “DBT™” or “DBT™-informed”. The Skills System was deemed “DBT™-informed” because, while it was seen as being informed by DBT principles, the names of the skills were different than the standard versions. In my opinion, optimizing access to the intrinsic DBT principles out-weighs the value of the terms/format, especially given the serious ramifications of inadequate treatment solutions for this population. Perhaps a way to reach synthesis on this topic could be to teach the Skills System to vulnerable learners as a ‘pre-DBT’ curriculum that serves as a foundation upon which additional standard DBT skills can be added as capacities allow. This might offer the necessary scaffolding that could organize standard skills learning in ways that facilitate generalization. As the Skills System treatment developer/author, I need to disclose that I have a financial interest in this issue, because I receive royalties on book sales. In my role as a human being, my mission is to help this under-served, marginalized group of people who lack alternatives and access to effect treatments.” ​

Julie F. Brown, PhD

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