# Helping Give Away Psychological Science/Autism Speaker Series/DBT Skills Training with Autistic Adults

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# DBT Skills Training with Autistic Adults

Brenna B. Maddox Ph.D: Assistant professor, UNC Department of Psychiatry. Implementation scientist, TEACCH Autism Program
Lorie A. Ritschel Ph.D- Associate Professor, UNC Department of Psychiatry. Trainer and Consultant, Behavioral Tech, LLC. Private Practice, Triangle Area Psychology Clinic

## Learning objectives:

* Describe the Mental health needs of autistic adults and the barriers preventing them from achieving effective mental health care
* Provide an overview of dialectical behavior therapy skills training
* Discuss the benefits of using DBT skills training with autistic adults.

## Autistic adults

* Autism is not only a childhood condition
* In the next decade over 700,00 autistic teens will enter adulthood
** This is problematic because all of these individuals who are receiving treatments and interventions through school based programs will no longer have access to the mental health care that they need
* On average autistic individual will spend the majority of their lives as adults
* Co-Occurring psychiatric conditions
** This occurs at very high rates in ASD adults
** There is a great deal of difficulty when it comes to accessing treatment called the services cliff after high school.
*** These individuals no longer have access to the healthcare options that they were given through schools, and with the help of parental guidance and insurance programs.
** Negative outcomes of untreated psychiatric conditions
* Many clinicians do not feel confident about working with autistic adults.
** An individual with ASD who also has anxiety maay reach out to get mental health services to help treat their anxiety. Upon calling a clinician they say “Hey I need treatment for anxiety” and they will say okay, we can do that. However, when the patient says they also have ASD they are referred to ASD specific psychiatrists who do not have training in anxiety.
** Most evidence based practices were not designed for autistic people in the community mental health setting.
** The mental health and developmental disabilities systems are disconnected
*** This causes many autistic adults to be turned away from treatment because the psychiatrists that they are reaching out to for treatment have not been trained to work wiht individuals who are autistic.

## Making a path forward

* Evidence based treatments adapted for autistic adults
* Feasible and sustainable community settings
* Meaningful partnerships with autistic adults

### Goals of treatment

Teach emotion regulation
* Decrease emotional arousal
* Re-orient attention
* Inhibit mood-dependent action
* Organize behavior in the service of effective goals
5 functions of comprehensive treatment include
* Improved motivation
* Enhance capabilities
* Ensure generalization of skills to the natural environment
* Structure the environment
* Enhance therapist motivation and capabilities

### Standard DBT treatment modes

* Individual therapy weekly
* Group therapy weekly
* Coaching calls as needed
* Consultation team weekly

## Problem areas and skills modules

Emotional dysregulation
* Rapidly shifting feelings and moods
* Problems with anger
** Try emotion regulation
Self dysregulation
* Fluctuating or absent sense of self
* Feelings of emptiness
** Try mindfulness
Interpersonal dysregulation
* Chaotic relationships
* Fear of being left alone or abandoned
** Try interpersonal effectiveness
Behavioral dysregulation
* Self harm or suicidal behaviors
* Impulsivity
** Try distress tolerance
Cognitive dysregulation
* Slowed, confused or paranoid thinking
** Try middle path

## Stages of treatment

One: severe behavioral dyscontrol.
* Goal: behavioral control
Two: quiet desperation
* Goal: Non-anguished emotional experiencing
Three: problems in living
* Goal: ordinary happiness and unhappiness
Four: incompleteness
* Goal: Capacity for joy and freedom

### DBT individual treatment targets

* Behaviors to decrease include
** Suicide and NSSI (thoughts, urges, and actions)
** Therapy-interfering behaviors
** Quality of life interfering behaviors
* Behaviors to increase
** Core mindfulness
** Distress tolerance
** Dialectical thinking
** Interpersonal effectiveness
** Emotional regulation

### The DBT skills training group format:

* Length is 1.5 hours
* 5 minutes mindfulness
* 40 minutes Homework review
* 10 minutes break
* 30-40 minutes skills training
* Assign Homework, and wind down last 5 minutes
* Empirical support for DBT as a standalone treatment
** Personality disorders, mood disorders, binge eating, bulimia, intellectual disability, ODD, ADHD, incarcerated individuals, people caring for adults with dementia
** Considerable variability across studies, most contained modifications to training
** Methodological limitations
** Conclusions general support skills training alone for patients without personality disorders

## TEACCH DBT timeline training

* June 2016- basic DBT overview
* March 2017- 2 day in person training
* August 2017- consultant calls started
* February 2018 1 day skills reboot
* January 2020 2 day in person training

## The Current Study

Data collection: Goals and measures
* Assess the feasibility of conducting DBT skills training in a group format with adults with ASD and without ID
* Gather data about potential changes that need to be made standard DBT curriculum or handouts to make the treatment more effective or accessible to an ASD population
** Attendance and attrition
** Patient satisfaction
** Therapist recommendations

### Methods

Participants
* Chronological age 18 years or older
* All diagnosed with ASD
* Completion of high school or regular education diploma
* No co-occurring diagnosis of ID
Treatment
* Groups met weekly for 1.5 hours for 24 weeks using the standard adult DBT handouts and worksheets
* Other interventions were uncontrolled

### Results

* Retention 81.25%
* Attendance 87.54%
* Overall patient satisfaction
** Satisfaction with the DBT skills group was high
** Satisfaction with the group procedures was also high and ranged from 3.64 to 4.64, with all scores above 4 except perceived utility of homework
** Self-related outcomes ranged from 3.73 to 4.45 making them also high.
* Therapist suggestions included
** Use of visuals
** Encourage repeated skills
** Simplify the handouts

### Issues

* Consistent with other DBT groups
** Billing and insurance coverage
** Therapy interfering behaviors
*** Inattention
*** Homework non completion
*** Off topic commentary
** Skills generalization

### Unique to TEACCH

* No individual DBT
** Managing safety concerns
** Managing TIB
* Group leader coverage
** Summer training
** Licensing
* Different contingencies
* Involving parents
* Interpersonal effectiveness skills
* Skills training suggestions
** Have large post it note display to show skills on the wall
** Small post its for people to write homework assignments on them
** Ask participants to all pull out calendars at the end of class to write down important due dates
** Include optional handouts

## Future Directions
### Suggested modifications

* Use written/ printed agendas for each group
* Make things more visual
* Choose videos and self-soothe activities that are better suited for clients with ASD
* Chain analyses with different colored strips of paper

### Next steps

* Ongoing data collection
* Adding groups in Charlotte
* Turning every skill into a visual experience
* Consider the role of caregivers in skills training
* Adding the middle path skills
* Adding training in individual DBT
* ↑ Ritschel, Lorie A.; Guy, Lisa; Maddox, Brenna B. (2021-09-23). "A pilot study of dialectical behaviour therapy skills training for autistic adults". Behavioural and Cognitive Psychotherapy: 1–16. doi:10.1017/S1352465821000370. ISSN 1352-4658. https://www.cambridge.org/core/product/identifier/S1352465821000370/type/journal_article.