THE USE OF DIALECTICAL BEHAVIOR THERAPY WITH FORENSIC CLIENTS WITH AUTISM SPECTRUM DISORDER

Transcription

1 THE USE OF DIALECTICAL BEHAVIOR THERAPY WITH FORENSIC CLIENTS WITH AUTISM SPECTRUM DISORDER DR JOSEPH ALLAN SAKDALAN AND SABINE VISSER CLINICAL FORENSIC AND NEUROPSYCHOLOGIST (NZ) APRIL 2018

2 OUTLINE OF PRESENTATION Introduction and Background Current Literature on the Treatment of ASD issues and Challenges Use of DBT with other populations Utility of DBT with ASD Applications of DBT with Forensic client with ASD Conclusions and Future Directions

3 ASD DIAGNOSIS A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

4 ASD DIAGNOSIS B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text): Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

5 ASD DIAGNOSIS C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

6 CURRENT PSYCHOLOGICAL/PSYCHIATRIC TREATMENT/INTERVENTIONS FOR ASD Cognitive Behavioural Therapy (CBT) Behavioural interventions Social Skills intervention Sensory based therapies Psychiatric medications

7 DIALECTICAL BEHAVIOR THERAPY Dialectic Behavior Therapy (DBT) is a cognitive behavioral treatment originally designed by Marsha Linehan (1993) as an outpatient treatment for people diagnosed with Borderline Personality Disorder (BPD). The DBT approach balances therapeutic validation and acceptance of the person along with cognitive and behavioral change strategies. Controlled outcome trials have shown that DBT has been effective in reducing self-injurious behaviors and inpatient psychiatric days in women diagnosed with BPD. It has also been shown to be helpful in reducing anger and improve social adjustment.

8 DIALECTICAL BEHAVIOR THERAPY The use of DBT has recently been expanded to populations with additional diagnoses such as substance misuse, eating disorders, depression with co-morbid personality disorders. It has also been used in additional settings such as forensic services and mental health inpatient units.

9 BPD AND ASD Issues around emotion dysregulation Impulse control problems/emotional reactivity Cognitive Rigidity Poor interpersonal skills/poor problem solving skills Poor coping skills Poor distress tolerance and self-harm behaviours Some problems with empathy (?)

10 BIOSOCIAL THEORY OF BPD Biological Dysfunction in the Emotion Regulation System Invalidating Environment Pervasive Emotion Dysregulation (Linehan, 2005)

11 CORE STRATEGIES IN DBT Problem Solving Validation (Linehan, 2005)

12 VALIDATION AND PROBLEM SOLVING DBT strives to avoid having the client/patient see the therapist as an adversary rather than an ally in the treatment of psychological issues. In DBT the therapist aims to accept and validate the client s feelings at any given time while nonetheless informing the client that some feelings and behaviours are maladaptive, and showing them better alternatives

13 BALANCING THE SKILLS Emotion Regulation Mindfulness Acceptance Change Interpersonal Effectiveness Self-Regulation Distress Tolerance (Linehan, 2005)

14 MINDFULNESS IS. Observe things as you experience it without adding constructs or interpretations to it Participate by entering completely into the experience of the current moment Non-judgementally (no right or wrong) One mindfully (doing on thing at a time) Effectively decide to do what works (Linehan, 2005)

15 MINDFULNESS Taking Control of Your Mind = Being in your Present Mind Risky Mind Rational Mind Wise Mind Emotional Mind

16 MINDFULNESS SKILLS Improve ASD clients' ability to 'ground' themselves; the ability to revert back to or orientate to the present moment without having judgement about themselves or a given situation. identify problems with ASD clients where they are very reactive/impulsive, cognitively rigid, tend to feel overwhelmed about making judgements around their views, thoughts and feelings. A lessening of sensitivity to their environment. While people who have ASD will possibly cope sufficiently in low- stress environments, the level of sensitivity to sensory stimulation (sounds, light, textures, etc.) be able to process sensory stimulation better via mindfulness skills

17 MINDFULNESS SKILLS Mindfulness might be able to assist ASD clients with moving towards their Wise Mind i.e. not becoming too rational or becoming impulsive and engaging in self-destructive behaviours Emotional Mind. Also help to filter or modulate their sensory input to reduce being mentally overloaded that s good! Being able to stay in the here-and-now rather than ruminating or being preoccupied with the the past and the future

18 DISTRESS TOLERANCE Crisis Survival Strategies tolerating short term distress/stress Accepting Reality tolerating long term distress/stress

19 DISTRESS TOLERANCE CRISIS SURVIVAL STRATEGIES Distraction (Forget about it for now!) Self-soothing (Calming the senses!) Improve the Moment (Making it better!) Pros and Cons (Good and Not-so-Good)

20 DISTRESS TOLERANCE Activities Contributing (Help) Comparisons Emotions (Different Feelings) Pushing away Thoughts Sensations Wise mind ACCEPTS

21 CALMING THE SENSES

22 Imagery Meaning Prayer Relaxation One thing at a time Vacation Encouragement DISTRESS TOLERANCE IMPROVE the Moment

23 RADICAL ACCEPTANCE Practice of accepting life on its own terms and finding effective strategies to cope with whatever is happening. It does not mean being passive but accepting what is with the understanding that you have the power of choice. Radical acceptance is a choice that can ease stress and depression and enhance your quality of life.

24 DISTRESS TOLERANCE SKILLS Individuals with ASD are prone to anxiety, depression and other mental health issues with a high prevalence of completed suicide. DBT skills are behaviourally based and can be tailored to ASD. A focus placed on distraction techniques and implementing improved adaptive coping skills would aid ASD- based sensory overload. The value of radical acceptance accepting that some things are beyond their control/they can t control their environment Using of soothing activities utilises sensory processing useful with ASD clients

25 EMOTION REGULATION Understand emotions Reduce emotional vulnerability Decrease emotional suffering Change by acting opposite to painful emotions

26 EMOTION REGULATION Reduce emotional vulnerability Eat right Sleep Well Exercise Don t take drugs and alcohol See your doctor and take your medications if sick

27 EMOTION REGULATION Steps for Increasing Good Emotions Attend to relationships Focus on positive things that happen Stop thinking about worries

28 EMOTION REGULATION Changing your emotions When afraid face your fears When sad, do things to make you feel good When angry, talk about your feelings When ashamed, stand tall and take responsibility

29 EMOTION REGULATION SKILLS It is crucial for ASD individuals to learn how to regulate their emotions. They tend to have difficulty understanding their emotions and emotional state, and treatment should include improving their ability to identify different types of emotions. Improve their understanding of the effects of biological factors (e.g., lack of sleep, substance use) may affect them and what sensitivities they may have to them.

30 INTERPERSONAL EFFECTIVENESS SKILLS Individuals with ASD generally have difficulties with social interactions and have social skills deficits. These deficits impact to varying degrees the effectiveness of interpersonal relationships or interactions. Social skills are usually limited and DBT can help develop effective behavioural abilities. Teach them interpersonal skills, problem solving, negotiating, assertiveness skills i.e. DEAR MAN skills

31 INTERPERSONAL EFFECTIVENESS D = describe specifically the situation E = express how you feel A = ask or assert R = reinforce the other person M = mindfully A = appear competent; N = negotiate, if necessary. (Linehan, 2005)

32 FORENSIC CLIENTS WITH ASD Assaultative behaviours due to emotion dysregulation Inappropriate social/sexual behaviours poor understanding of social norms/behaviours; Preoccupations/fixation can lead to issues around sexual or violent offending (e.g. obsession with children s feet or certain sexual activities, stealing specific objects, etc.) Substance misuse issues particularly for individuals with ASD who self-medicate to manage their anxiety problems and other mental health issues

33 USE OF DBT WITH FORENSIC CLIENTS WITH INTELLECTUAL DISABILITIES Current research suggests that DBT holds promise in effectively reducing emotion dysregulation and challenging behaviours with adults with intellectual disabilities (Brown, et al., 2013; Morrisey & Ingamell, 2011; Sakdalan et al., 2006). A pilot study carried out by Sakdalan and colleagues (2006) involved six offenders with intellectual disability who completed a 13-week adapted DBT groups skills training program. The study result showed a decrease in level of risks, increase in relative strengths and general improvement in overall functioning (Sakdalan et al., 2006). Morissey and Ingamells (2011) have evaluated a DBT program for male offenders with ID in a high secure facility. A total of 24 men had completed the groups skills and they also received individual therapy. Preliminary outcomes on data for six men found significant reductions on the Global Severity of Distress Scale of the Brief Symptoms Inventory but no significant differences in incidents of aggressive behaviour.

34 USE OF DBT WITH FORENSIC CLIENTS WITH INTELLECTUAL DISABILITIES A more recent study which involved 40 adults with developmental disabilities (most of whom had intellectual disabilities) and challenging behaviours, including histories of offending behaviours. A large reduction in challenging behaviours were observed during the four years while they were attending a DBT group and individual therapy (Brown et al., 2013).

35 DOES DBT ADDRESS CRIMINOGENIC NEEDS? DBT targets criminogenic needs such as substance abuse, poor problem solving, antisocial peers, anger, poor self management, emotional dysregulation, and antisocial beliefs. It directly addresses dysfunctional behaviors, including problems involving emotional regulation, problem solving, self-management, and substance abuse, whilst simultaneously increasing the behavioral skills and motivation needed to replace problem behaviors and increase more functional behaviors.

36 CONCLUSIONS AND FUTURE DIRECTIONS DBT can be considered promising in addressing challenging and forensic behavioural in individuals issues with ASD Provides a more integrated approach to treatment to individuals ASD to address risk issues /problems associated Adapting DBT for ASD use more concrete examples and less abstract; focus on behavioural skills; more repetition and visuals adapted DBT skills training for forensic clients with ID (e.g. Sakdalan et al., 2010) may be a good starting point Important to link DBT interventions to address dynamic risk factors become treatment targets Further research on the use of DBT with forensic clients with ASD is recommended.

37 ACKNOWLEDGMENTS Sarah Mason who helped with this presentation