JULIE F. BROWN, PHD
Developing the Skills System; my twenty-year journey.
The Treasure Hunt
This adventure began shortly after I graduated from Boston University with my MSW. I was working as a clinician in a behaviorally based 25-bed residential school for intellectually disabled, emotionally disturbed adolescent males and females in Massachusetts. One day, a youth who had a significant history of committing sexual offenses, setting fires, treating animals cruelly, and assaulting others was sitting in my office. We were discussing his latest incident of aggression toward a staff member. I posed questions, trying to elicit alternative behaviors to smashing a staff member in the head with a padlock. The young man was unable to generate useful options; thus, I suggested that he play the card game Uno instead.
In the midst of suggesting he play Uno, I experienced an epiphany. This boy had suffered numerous traumas and inflicted even more, and my solution was Uno! While pulling this suggestion out of my eclectic bag of therapeutic tricks, I suddenly became keenly aware that this isolated activity was a woefully inadequate intervention. The card game may have been a piece of a coping puzzle, yet the problem was that I did not have an adequate, synthesized framework or system to teach coping to this individual in a form that he could understand, apply, and generalize. If I did not have a comprehensive representation of a coping map, there was no way that this intellectually disabled adolescent was going to integrate my random teaching into a technically strong, yet flexible model that could help him manage the challenging internal and external factors he faced on a daily basis.
I possessed no vision about the path ahead, but the journey to find the Skills System had begun.
I spent the next 3 years immersed in treating this diverse and challenging population of youth within the residential setting. I combed the literature for insights; I found more tiny puzzle pieces but still no map: no comprehensive tools to help youth with numerous mental health diagnoses integrate the necessary skills to reduce the need for supervision; no models complex enough yet simple enough to assist individuals who struggled with effects of neglect, violent behavior, physical abuse, sexual victimization, and/or social stigmatization. I could not find a program that could help these youth reduce the need for multiple antipsychotic medications, antidepressants, mood stabilizers, and other drugs to control behavior. Although the well-structured token economy within the facility was helpful, it was not sufficient to teach these children, who had complex needs, the necessary skills to regulate their reinforced patterns of dyscontrol in settings beyond residential care. Somewhere there had to be a better solution.
During a monthly consultation in 1997, a well-regarded trauma specialist recommended I find out more about dialectical behavior therapy (DBT; Linehan, 1993a, 1993b, 2015a, 2015b). Initially, I asked myself, “How could a treatment for women with borderline personality disorder [BPD] who demonstrated suicidal and parasuicidal behaviors apply to my clients?” During my initial phases of DBT training, I discovered that although few of my clients were formally diagnosed with BPD, many experienced the BPD behavioral patterns of emotional, cognitive, and behavioral dysregulation described by Linehan. I was cautiously optimistic that DBT would prove to be a piece of the treasure map.
While it was clear that the DBT technology was helpful in improving self-management capacities, accommodations were necessary to allow cognitively impaired individuals to learn and generalize new adaptive coping skills.
By 1999, I was fortunate enough to have received intensive DBT training and created Justice Resource Institute’s (JRI) Integrated Clinical Services (ICS) in Rhode Island. ICS provided outpatient therapy services for adults with mild and moderate intellectual disabilities who experienced intense behavioral control problems. Standard DBT individual therapy, skills training groups, consultation team, and phone skills coaching were key ingredients of the ICS program. The comprehensive DBT treatment model was designed to help people change highly reinforced, long-term patterns of behavior associated with impaired emotion regulation. While it was clear that the DBT technology was helpful in improving self-management capacities, accommodations were necessary to allow cognitively impaired individuals to learn and generalize new adaptive coping skills. Adherence to the DBT model was paramount; our challenge was to make DBT technology accessible to cognitively impaired clients without reducing the therapeutic viability of the empirically validated treatment.
Surprisingly, the individual therapy aspects of DBT (Linehan, 1993a) required minimal adaptation for this population. While learning to do DBT individual therapy and treating cognitively impaired people is intellectually demanding for the therapist, participation in the treatment as a client is relatively straightforward. Unfortunately, the skills component (Linehan, 1993b) was a more complex problem. During the first year, we followed the standard DBT skills manual, adjusting teaching strategies to help improve comprehension of the information. The concepts contained in the mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance modules (Linehan, 1993b) were vital, yet the language and format were barriers for the clients. Despite my enthusiasm, many participants struggled to pronounce, remember, and understand several standard DBT skills terms and were therefore unable to recall and utilize the concepts within the context of life when emotionally dysregulated.
The DBT skills curriculum did not provide individuals diagnosed with intellectual disabilities, who often experience executive functioning deficits, a framework that facilitated transitions from one skill to the next within complicated contexts that required multiple skills. I continually felt that my clients’ reaction to the information in skills training group was like mine when I played the game 52 Pickup as a child. As a group leader, I felt as if I were my mean older sister, who would invite me to play cards and then scream, “Fifty-two pickup!” as she squeezed the deck, gleefully sending the 52 cards into the air and all over the floor for me to pick up. Just as I had been overwhelmed by the cards strewn all over the floor, the participants seemed to stare, dazed and confused, at the divergent information, without even knowing which skill (or card) to pick up first.
While I was driven to maintain adherence to the DBT model, I had a clear sense that I needed to present the DBT concepts in a more accessible way if my clients were going to grasp the essential principles. I began creating step-by-step progressions that the participants with intellectual disabilities could learn and utilize. I knew that I had to find a simple system that offered participants a template to use skills dynamically in a self-generated way that integrated information from both the internal and external experience within each moment. While it was critical that the concepts be uncomplicated, the function had to be highly complex to synthesize these elements. The system had to help the individual be mindful of the current moment, mobilize Wise Mind (Linehan, 1993b, 2015a, 2015b) in a consistent way, cultivate effective planning, and embody both the simplicity and the sophistication required to help the person handle life’s most abstract and demanding events. I spent months working and reworking these concepts to piece together this intricate puzzle.
One day, as I was driving, merging into a high-speed lane at 60 miles per hour, I noticed the core idea of the Skills System passing through my mind. It was so simple and so complicated at the same time—how dialectical! The treasure had emerged, and I was lucky enough to have noticed it careening through my mind. Fortunately, I didn’t know at that moment how exciting this gift was, because I probably would have driven off the road.
Since that day on Route 195, my clients, team, and I have grappled with DBT concepts and emotion regulation principles to develop this version of the Skills System. Over time and through years of collaboration, the Skills System has become a simple, yet sophisticated emotion regulation road map for youth and adults. The nine skills and three System Tools provide a useful structure that helps the individual make effective choices in service of personal goals.
Over time and through years of collaboration, the Skills System has become a simple, yet sophisticated emotion regulation road map for youth and adults.
The Skills System Instructor’s Guide: An Emotion-Regulation Skills Curriculum for All Learning Abilities was self-published in 2011. This platform allowed the material to be protected, disseminated, and improved. The Emotion Regulation Skills System for Cognitively Challenged Clients is the latest version, the culmination of over two decades of work.
Despite this long history, the empirical validation process is still in its infancy. In 2013, the JRI ICS pilot data were published in the Journal of Mental Health Research in Intellectual Disabilities (Brown, Brown, & Dibiasio, 2013). This single-group, longitudinal study examined reductions in negative behavioral outcomes of the 40 individuals with intellectual disabilities over a 4-year period who participated in DBT individual therapy and Skills System skills group. The findings indicated statistically significant reductions in low-, medium-, and high-risk challenging behaviors. Although this was not a randomized controlled trial, it is my hope that the findings encourage other professionals to explore use of the Skills System.
A DBT-Informed Approach
The Skills System is designed to be a set of skills for challenged learners. The skills are built from DBT concepts and in many places are direct adaptations of the standard DBT curriculum. DBT practitioners: Be prepared—the surgery to reconstruct and improve accessibility may seem radical. Upon reading this book, the naive DBT clinician may say, “Where are all of then DBT terms?”, while the seasoned veteran will see how certain DBT skills are deconstructed and repackaged to meet the needs of vulnerable learners. Most adaptations for people with intellectual disabilities politely add clipart and simplify through elimination. I tried that; it was insufficient and failed to meet the needs of this population adequately.
The reconstruction of the DBT skills had to be done carefully and effectively. Three key elements were integral in this process: (1) the work of James Gross, PhD, in emotion regulation; (2) cognitive load theory (Sweller, 2010); and (3) ongoing collaboration with my clients at ICS. It was necessary to keep DBT concepts intact, while simultaneously ensuring that the alternatives offered effective emotion regulation strategies in a user-friendly format consistent with DBT principles.
More specifically, the standard DBT skills modules format was replaced by a Skills List and System Tools that are used in a type of skills algorithm or dynamic formula that guides the individual to create adaptive skills chains. The Skills System framework helps the individual know which skills to choose and how many to implement given his or her level of emotion in each diverse situation. Although the nondisabled learner may be able to pick and choose skills effectively from the vast skills menu presented in the standard DBT skills manual (Linehan, 2015a), the vulnerable learner, with memory and executive functioning impairments, becomes overwhelmed. Certain DBT terms were retained, while others required adaptation. The language had to maximize recognition and recall of DBT concepts to facilitate generalization. Additionally, key skills concepts such as mindfulness (Wise Mind, Participating, and Acting Effectively), Check the Facts, Pros and Cons, and Cope Ahead had to be integrated as the base of every skills chain (Clear Picture, On-Track Thinking, and On-Track Action). An adapted DBT skills curriculum must provide functional validation to this population by presenting a maximum number of DBT concepts in ways that are accessible.
From my 26-plus years serving this population, I believe that in order to teach an individual who has moderate/mild intellectual disabilities to regulate emotions using a dialectical perspective, the skills framework must offer a structure that provides cognitive support—scaffolding— to perform high-level tasks, given that the individual has impairment in those functioning areas. Complex needs require enhanced intervention. To treat these people with more intense needs, DBT practitioners working with this population need to be bilingual, able to speak the standard DBT skills and Skills System languages.
Today I may recommend playing Uno to a given client; however, I can be confident that the individual knows several other emotion regulation skills, when to use each skill, how many skills to utilize, and how to implement the skills as a result of Skills System training. For example, recently in a skills group, one client, who was diagnosed with an intellectual disability of moderate severity, recounted a stressful situation she had managed successfully during the previous day. She described first getting a Clear Picture of the situation. She stated she was mad at a Level 4. Her staff members were not listening to what she was saying. She reported having strong urges to scream at the staff. Immediately my client stopped and stepped back. She used On-Track Thinking to reflect on whether these urges were helpful in reaching her goal. Knowing that she wanted to increase her independence and improve her relationships, she determined that screaming was not helpful. Realizing that she was too upset to use Express Myself or Problem Solving at that time (although she had urges to!), my client decided to do a Safety Plan and go to her room. She then reported doing an On-Track Action by calmly informing the staff members that she was going to her bedroom. While in her room, she did a few New-Me Activities (listening to music and drawing) that helped her think clearly, feel better, and relax. My client stated that later during the shift, she did her Clear Picture skill again and determined that she was feeling much calmer. She used On-Track Thinking to make a skills plan to talk to the staff members about the problem. Because she was calm and focused, she was able to discuss and solve the problem with the staff members.
As I listen to my clients recount detailed and effective skills usage as a part of skills training group, I periodically think of that boy with the padlock so many years ago. I think about how grateful I am to him for showing me my inadequacies. It has been a privilege working with many dedicated people—both group members and co-therapists— to improve the Skills System over the years.