1. DialecticalBehavior Therapy for Individualswith Intellectual
Disability: Adaptations & Outcomes
Michelle Shauger, MD; Kathleen Mohring, MA, LPC; Kenneth Antkowiak, MS, LLP;
Mark Mitchell, MSW; Kristen Barlow, MSW
Individuals with intellectual disability (ID) are likely to experience delayed development in
various domains (language, social, emotional, cognitive) that may result in immature or incompletely
developed personalities (Fletcher, 2007). Delaysin these areas can lead to frustration, isolation,
acting out, and other maladaptive behaviors, which may manifest traits or features of a personality
disorder (Dykstra & Charlton, 2004). Many of these traits are often found in the cluster B category
(borderline, antisocial, histrionic, narcissistic) of personality disorders. Additionally, the various
vulnerabilities that accompany individuals with ID, including experiences of abuse (from which
individuals with ID typically suffer four to ten times more than the general population), neglect, and
invalidating environments, can further complicate personality development. Multipleresearch
studies have indicated that anywhere from 7% to 31% of individuals in the community with ID may
have a personality disorder (Fletcher, 2007).
Historically, psychotherapy for individuals with intellectual and/or developmental disabilities
was often limited to behavior-modification strategies. More recently, a recognition of other types of
helpful psychotherapies has evolved, especially in individualswith less severe levels of intellectual
disability. Dialectical Behavior Therapy (DBT) is an empirically validated treatment modality which
balances therapeutic validation and acceptance of the person along with cognitive and behavioral
change strategies. It addresses skill deficits in mindfulness, emotion regulation, interpersonal
effectiveness and distress tolerance with which individualswith intellectual disability often struggle
(Dykstra & Charlton, 2004). DBT has recently begun to be used with individuals diagnosed with ID
and traits of borderline personality disorder (BPD) (Lew et al, 2006). However, recent professional
literature searches revealed an apparent paucity of research on the use of DBT with ID populations.
In the Spring of 2007, the Washtenaw County Community Support and Treatment Services
agency (CSTS) began to identify clients in their Developmental Disability (DD) program with the
combination of mild levels of ID and traits of BPD who could potentially benefit from DBT. In
anticipation of a pilot program for these clients, Master’s-leveltherapists underwent training in DBT
service delivery, including discussions on how this therapy would need to be adapted for clients with
intellectual disability, learning disorders, illiteracy, or other cognitive impairment. Recognizing that
some clients in the mental illness (MI) department of CSTS also suffered from such impairments,
therapists in the DD program partnered with colleagues in the Supported Living and Enhanced
Community Services (SLECS) program within the MI department for expansion of service delivery.
Service recipients within the SLECS program represent some of CSTS’ most severely mentally ill
clients, often having been stepped-down from years of being institutionalized in Michigan’s state
psychiatric hospital system to live in group homes or other supported-living settings, requiring
intense levels of support. Most of these clients suffer from refractory psychosis, with many also
having traits of borderline personality disorder. Some of these clients had previously tried standard
DBT treatment offered at different community mental health centers, but had difficulties
understanding the concepts due to the cognitive impairment symptoms of their schizophrenia. It
was thought that they may also be able to benefit from the adapted program which was being
developed within the Developmental Disabilities unit at that time.

2. In October 2007, the adapted DBT program was launched with an Orientation event for
clients, direct-care staff, family members and other CSTS staff interested in becoming more
educated. Information on the DBT program requirements, along with outlines and examples of the
four modules (mindfulness, emotion regulation, interpersonal effectiveness, distress tolerance), were
explained, including the 90-minute weekly group, homework assignments, and weekly individual
therapy sessions. Inclusion of family members and direct-care staff to help serve as coaches for
clients was also discussed. Of the ten clients who attended the initial orientation, nine decided to
sign the one-year contract (which would cover skills training in all four modules) to participate in the
program, comprised of six individuals from the DD unit and three from the SLECS unit. It was
believed that lack of better engagement may have played a role in the one client who decided not to
join, so “pre-DBT” motivational enhancement work subsequently became a regular focus of the
program. Additional clients continue to be identified on a regular basis and worked with around
motivational enhancement/engagement issues, with plans to join once the appropriate stage of
change is reached. As of April 2008, two additional clientsin the DD department were determined
to have met this stage of readiness, and subsequently joined the program at the six-month point
when the other nine clients were transitioning between the emotion-regulation and interpersonal
effectiveness modules.
The Washtenaw County CSTS DD/SLECS DBT team currently consists of three DBT trained
therapists, a psychiatrist who oversees medications for participating clients, a unit supervisor,
and a service coordinator/consultant with many years of experience working with clients with ID
and BPD traits in Michigan’s state psychiatric hospital system. The three therapists provide
individual therapy for the involved clients, and rotate (two at a time) to facilitatethe weekly skills
group. The entire team meets for an hour once per week for support and collaboration. As the team
has continued to research the area of DBT for individuals with ID, it was discovered that a group
from the Aurora Medical Center in Colorado (Dykstra & Charlton, 2004) was also providing DBT
for individuals with ID. Some communication and collaboration between the two groups ensued,
along with a sharing of information and resources. However, because of a dearth of printed
materials for ID-adapted DBT, the CSTS team has continued to devise original adapted content
handouts for each DBT module. Visual images are included to represent all major topics, so that
clients with literacy and reading comprehension difficulties may still be able to follow along and do
the homework. At the end of each group, a rating scale is filled out by the clients indicating the
usefulness of the current session, to help inform future adaptations.
Following the DBT model popularized by Marsha Linehan, the team started with
introducing the clients to mindfulness following the October 2007 orientation (Linehan, 1993).
Many clients did have some difficulty understanding certain concepts, especiallythose that were
more abstract. Repetition of ideas, use of pictures, frequent examples and role-playing by the
therapists and clients in group were often effective in helping clients grasp a better understanding.
Initially, the homework for participants was to learn to use an adapted diary card appropriately,
which the clients really seemed to enjoy. It appeared that well-defined and structured assignments
(such as filling out a diary card) were especially helpful. Additional homework assignments were
eventually added into the therapy. At the end of each module, the team developed a Jeopardy game
in order to help review and reinforce concepts before moving onto the next module, the playing of
which has come to be a favorite element of the group work. The clients have signed contracts and
agreed to have some of their groups and individual therapy sessions videotaped for the purposes of
informing further education and service development. Some of this video is being used during
subsequent training and information sessions for family and direct care staff. Given that invalidating

3. environments can often exacerbate the symptoms that DBT is trying to treat, the team has
recognized the importance of training the support persons in their clients’ lives on how to facilitate
more validating environments, and to serve as coaches to help clients use their skills when
symptoms are difficult to control. When word got out about the information session for supports,
many other employees of CSTS involved in clients’ care (nurses, support coordinators,
psychologists, vocational and integrated healthcare specialists) shared an interest in joining. In July
2008, an information session based on a recent training by Linehan on this very subject was offered
by the team to all the above mentioned individuals. Continuing to offer such sessions for feedback
and further adaptation have become part of program planning.
During the course of the DBT-ID program, data are regularly collected in multiple domains.
DD outcome scales that capture self-determination in the areas of work, community life,
relationships, housing, safety, and health and wellness are completed on a quarterly basis. Since the
initiation of the program, one client has been able to obtain and sustain employment, and another
has maintained the job she had previously obtained. One other client successfully moved out of her
parents’ home into an apartment with roommates. Another client is working toward the goal of
moving out of his supported living placement and in with his fiancée and child once his lease expires
at the end of summer of 2008. All of the participating clients have been attending to their physical
healthcare needs, taking medications as prescribed, and following up with appointments as
necessary. One client who had been on weekly medication boxes with nursing assistance due to
medication compliance problems, no longer requires that assistance. In the spring of 2008, the
program’s initial SLECS therapist left. This affected one client in particular, who also struggled with
dependent personality traits and who frequently seemed the most ambivalent of the group about the
DBT program. Team therapists are using Scott Miller’s (www.talkingcure.com) self-reported rating
scales at the end of their individual sessions, and while those working with this client saw objective
improvement during her time with DBT, she was unable to identify it. This client maintained in the
program with one of the other therapists for a couple of additional months after her initial
therapist’s departure in April. However, in July of 2008 there was also some reorganization at CSTS
in which the psychiatrist initially assigned to both the DD and SLECS units changed assignments,
leading to another “loss” for that client, and she has subsequently dropped out. A termination
session was done with the most recently assigned DD therapist, and although no longer participating
in skills group, the client is currently doing well and focusing her attention on a smoking cession
group she recently joined.
Washtenaw County CSTS uses an electronic health record (Encompass) that documents
medication changes and brief psychiatric rating scales at each medication review, along with
frequency of appointment attendances. After nine months of participating in the program, covering
the modules of mindfulness, emotion regulation, and interpersonal effectiveness, none of the nine
original members required an increase or change in medication. One was actually able to no longer
need her PRN benzodiazepine for anxiety, and subsequently had it discontinued. Of the two newer
members who joined in April, one did have a hospitalization for suicidality shortly after her entrance
into DBT, during which time a second antidepressant was added. Of the nine original members,
there were no hospitalizations or stays at the local crisis residential center dating from their
engagement in the program in October 2007. Looking at the year prior, there had been a total of 14
days of hospitalization and 14 days of crisis residential service use for this client cohort. For the one
new client who was hospitalized, it was believed that use of an outside therapist (she originally did
not have a therapist within the team) may have played a role, secondary to less available

4. collaboration and coordination, so this client has subsequently been assigned to a DBT therapist
within the team. Of the original nine members, the average frequency of appointments with the
CSTS psychiatrist who is part of the DBT team was bi-monthly for the three SLECS clients, and
monthly for the five DD clients (one DD client had been seeing an outside psychiatrist but planned
to switch to the CSTS psychiatrist assigned to the DBT team), prior to their engagement in the
program. Since their participation in the adapted DBT program, the frequency of psychiatrist
appointments has been able to be reduced to quarterly for the SLECS clients, and to either quarterly
or bi-monthly for the DD clients—and for one DD client, appointment frequency dropped to every
six months. There is consideration of allowing that client to see her primary care doctor for her one
antidepressant medication, perhaps after she “graduates” from the program in October 2008.
In conclusion, individuals with intellectual disability can and do suffer from traits and
features of personality disorder. Dialectical Behavior Therapy is well recognized as a first-line
treatment for individuals with borderline personality disorder. More recently it has begun to be used
in individuals with ID and traits of BPD. The Washtenaw County CSTS has developed a DBT team
who has been able to effectively adapt DBT for clients with traits of BPD and either intellectual or
cognitive disability. While still in their first year of the pilot program, early return data has shown
significant outcome success. The team has been discussing how to proceed with care for their clients
once they’ve completed their last skills module (distress tolerance), and effectively “graduate” from
learning the four modules. The idea of a graduate group, possibly co-facilitated by a peer support
specialist, has been discussed. Given the success of the current program, further clients have been
identified and referred for participation, and more therapists within the DD program are currently
being trained in DBT. As of October 2008, the team will have completed one full year of the
program and is looking forward to analyzing a year’s worth of data to evaluate the impact on desired
client outcomes, and to make any additional adaptations to better serve clients with features of
personality disorder, along with intellectualor cognitive disability.
REFERENCES:
Dykstra E., & Charlton M. (2004). Dialectical behavior therapy skills training: adapted for
special populations.
University of Denver, Colorado: Aurora Mental Health.
55
Fletcher R., Loschen E., Stavrakaki C., & First M. (Eds.)(2007). Diagnostic manual-intellectual
disability:
A textbook of diagnosis of mental disorders in persons with intellectual disability.
Kingston NY:
NADD Press.
Lew M., Matta C., Tripp-Tebo C., Watts D. (2006). Dialectical behavior therapy for individuals with
intellectual disabilities: A program description, Mental Health Aspects of Developmental
Disabilities. 9, 1-12
Linehan, M. (1993) Cognitive-behavioral treatment of borderline personality disorder. New
York: The Guilford
Press.