Objectives Describe common problems among homeless youth which can - PDF document

APNA 29th Annual Conference Session 4036: October 31, 2015 Dialectical Behavior Therapy Skills Training: Its Impact on Resilience in Homeless Young Adults Linda Grabbe PhD, FNP ‐ BC, PMHNP ‐ BC School of Nursing, Emory University Connie Buchanan, MS, NP ‐ C, FNP Community Advanced Practice Nurses, Inc. Kristy Martyn, PhD, CPNP ‐ PC, FAAN School of Nursing, Emory University This research was partially funded by the Community Engagement Research Program • Dissemination Micro Grant from the Atlanta Clinical & Translational Science Institute (Morehouse School of Medicine, Emory University, Georgia Tech) The speaker has no conflicts of interest to disclose • The Resiliency Model and the Distress Cycle image are used with permission • Objectives • Describe common problems among homeless youth which can interfere with their ability regulate emotions • Describe the core concept which underlies the emotion regulation, distress tolerance, interpersonal skills in DBT skills training • Describe how the concept of wise mind applies to DBT skills training and developing resilience • Explain the difficulties in measuring resilience in this population Common Problems and Risks among Homeless Youth Dysregulation of Trauma • • emotions  Complex Depression •  Cumulative Anxiety  Developmental • Self ‐ harm behaviors • Insecure or disorganized •  Suicidality attachment  Substance abuse Developmental delays, • Impulsiveness aggression, dissociation, • somatization, distrust, Mistrust of mental • shame, relationship health system problems, and low self ‐ No health insurance • worth (Limandri, 2014; Wheeler, 2014) Grabbe 1

APNA 29th Annual Conference Session 4036: October 31, 2015 Research Purpose • To pilot an abbreviated group Dialectical Behavior Therapy (DBT) skills intervention to increase emotional regulation and resiliency in this high ‐ risk population www.shutterstock.com Community Resiliency Model (CRM) (Karas ‐ Miller, 2015) Grabbe 2

APNA 29th Annual Conference Session 4036: October 31, 2015 Community Resiliency Model (CRM) (Karas ‐ Miller, 2015) Methods • A concentrated DBT skills training program • Location: a large Atlanta shelter for 18 to 21 year old homeless youth • Open, rolling entry into group sessions • Sessions rotated over time • Biweekly initially  weekly • Same nurse providing intervention throughout the year • IRB approval; informed consent Methods Phase I Fall 2014: Baseline data on resilience and mental health problems • with post ‐ test after 8 sessions Findings ‐‐ inadequate numbers to do post ‐ test after 8 sessions; too rapid turnover of shelter residents; unpredictable length of stay; 4 sessions was maximum attended by most youth Phase II Winter/Spring 2015: Repeated weekly resilience measures using • five key resilience variables Findings —minimal improvement on resilience measure; youth personal situations possibly too unstable to be impacted by one hour of DBT per week Phase III Fall 2015: specific pre ‐ and post ‐ 4 session depression, anxiety, • anger, somatic symptom measures (PROMIS measures) with resilience measure; participants will receive incentive after 4 sessions (Study not yet started) Grabbe 3

APNA 29th Annual Conference Session 4036: October 31, 2015 Measures Phase 1 • The DSM5 Level I Cross Cutting Measure (American Psychiatric Association, 2013) • The Connor Davidson Resilience scale (Connor & Davidson, 2003) Phase 2 Five items from the Connor Davidson Resilience Scale Phase 1 and 2 Qualitative data from the participants Sample Characteristics for Phase 1 and 2 187 young adults attended at • • Age: range 18 ‐ 21 least 1 session 21 attended 4 or more sessions • Not a therapy group • Average group size: 6 • • Race/Ethnicities:  Caucasian  African ‐ American  Hispanic  Native American addiction.lovetoknow.com Dialectical Behavior Therapy (DBT) Skills Training • Evidence ‐ based skills training for individuals with suicidality, self ‐ injury, borderline personality disorder, emotion dysregulation ( Linehan , 1993, 2015; Valentine et al., 2015) • Purpose of DBT: Develop emotional stability, distress tolerance, and interpersonal skills through mindfulness • Standard DBT = group + individual therapy x 24 weeks Grabbe 4

APNA 29th Annual Conference Session 4036: October 31, 2015 • DBT skills training research Skills training as stand alone treatment – Adolescents leaving state custody or in corrections – Brief forms of group skills training – Beneficial treatment for African ‐ American women – (Katz, Cox, Gunasekara, & Miller, 2004; Rizvi & Steffel, 2014; Shelton et al., 2011; Meaney ‐ Tavares, 2013; Creswell, 2014; Andrew et al., 2014; Valentine et al, 2015) No research on DBT for homeless individuals – • Mindfulness/meditation training of homeless youth (at least 4 of 8 sessions; no control group) – significant increase in resilience, spirituality, well ‐ being – significant decrease in somatic, depression, anxiety symptoms (Grabbe et al, 2011) Connor ‐ Davidson Resilience Scale (2003) 5/25 items 0 ‐ 4 not true at all to nearly all of the time 11. I believe I can achieve my goals even if there are obstacles. 14. Under pressure, I stay focused and think clearly. 19. I am able to handle unpleasant or painful feelings like sadness, fear, and anger. 21. I have a strong sense of purpose in life. 22. I feel in control of my life. Reliability data for Visit 1 Cronbach's Alpha=0.793 Inter ‐ item correlations were > 0.34 N=184 DSM ‐ 5 Level 1 Cross Cutting Measure 23 questions covering 13 mental health domains • Depression, anger, “mania,” anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts/behaviors, dissociation, personality function, substance use (www.psychiatry.org) 2 PTSD Questions added • Serious attack or threat in the past • Flashbacks of the event (Anxiety and Depression Detector: Means ‐ Christensen et al, 2006) Grabbe 5

APNA 29th Annual Conference Session 4036: October 31, 2015 Baseline Resilience Scores – 70% of the youth had high resilience scores. Subjects with higher scores at baseline were more likely to come back for 5+ sessions Phase 1 DSM ‐ 5 Level 1 Cross ‐ cutting Measure n= 137 Phase 1 DBT components and examples Mindfulness: attention to the present moment to develop self ‐ • awareness and regulation Interpersonal effectiveness : how to communicate what you want • or need; saying “no;” and validation Distress tolerance: strategies to tolerate distress, without making it • worse (by engaging in impulsive and self ‐ destructive behaviors) – Distraction; self ‐ soothing techniques; interrupting emotions – “Radical acceptance” Emotion regulation: identifying and describing emotions, • increasing positive emotions; analyzing harmful behaviors Grabbe 6

APNA 29th Annual Conference Session 4036: October 31, 2015 3 states of mind: youtube (hear the song!) Typical Session • Mindfulness practice, usually focus on breath • Wise mind • Skill instruction with handouts • Practice Atmosphere • Attachment ‐ and trauma ‐ informed • Playful • Accepting • Validating • Some self ‐ disclosure www.trengovestudios.com Mindfulness www.planet ‐ science.com; http://4.bp.blogspot.com; http://artdrum.com/IMAGES Grabbe 7

APNA 29th Annual Conference Session 4036: October 31, 2015 Type over and name slide Youth comments on changes due to DBT • Sitting outside and looking at what is going on in the nature …you watch a squirrel or something….your still doing DBT and that is kinda cool….. • These exercises help me stay calm and focused; www.helpingservices.org more in control More comments on change How to slow my reactions • Breathe slowly if you are • arguing with someone to Use these strategies before calm down • my emotions become Being active can help with • unbearable sadness Turn bad emotions into good • emotions I will validate others/my • children I’m not going to be that • street thug any more, with no regard for human life www.shutterstock.com Grabbe 8

APNA 29th Annual Conference Session 4036: October 31, 2015 Change in mean resilience score over 5 sessions Phase 2 (Example ‐‐ Item 19 of CD Risc: I am able to handle unpleasant or painful feelings like sadness, fear, and anger: 14/20 stayed the same or improved) Changes in weekly resilience scores over 5 sessions Phase 2 Conclusions Limitations • High rates of both distress • Reality of instability in the and resilience youths’ lives • Youth are responsive to the • Necessarily a limited DBT skills training skill training program • A large number of high ‐ risk • Sessions are not necessarily youths may be reached sequential • Program may need to be • Highest ‐ risk youth more more intensive likely to be discharged from the shelter • Include the Community Resilience Model (Miller ‐ Karas, 2015) www.psychologytoday.com Grabbe 9

APNA 29th Annual Conference Session 4036: October 31, 2015 Plan • 4 critical DBT sessions (see poster at this meeting) • Better ways to capture evidence of impact through problem scenarios • Email and possible telehealth contact • Pre ‐ and post ‐ test with control group using the 10 ‐ item CD ‐ Resilience Scale and 4 brief measures: depression, anger, anxiety, somatic symptoms (NIH PROMIS measures : https://www.assessmentcenter.net/Manuals.aspx Somatic Symptom Scale: Gierk et al, 2014) Grabbe 10