Patients with intellectual disability often have difficulty controlling their emotions, which is what leads to so-called “challenging behaviors.” These behaviors include a range of aggressive and impulsive interactions, such as assault to self or others, stealing, fire-setting, sexual offenses, and other problematic situations. These are, unfortunately, rather common among ID patients, and challenging behaviors are often associated with underlying mood disorders and psychosis, as well as with general difficulty modulating emotions.

Dialectical behavior therapy (DBT) has proven effective for helping patients to regulate emotions, with data for efficacy in borderline personality disorder, eating disorders, and others. My colleagues and I have adapted DBT specifically for ID, calling it the Emotion Regulation Skills System (Brown JF. Emotion Regulation Skills System for the Cognitively Challenged Client: A DBT™-Informed Approach. New York, NY: Guilford Press; 2016). In a pilot study of 40 patients with challenging behaviors engaging in DBT individual therapy and Skills System groups (DBT-SS), we found significant improvement in risky behaviors at both one-year and four-year follow-ups (Brown JF et al, J Ment Health Res Intellect Disabil 2013;6(4):280–303). These findings are encouraging and warrant further exploration of this technique.

In this article, I’ll summarize the key components of the Skills System, highlighting its simultaneous sophistication and simplicity. Although the full technique is best used by therapists with special training, psychiatrists might find some aspects helpful in their brief sessions with these challenging patients.

Core skills and categories
There are nine core skills in the Skills System. The skills are broken into two categories: All-the-Time skills (which can be used by clients at all levels of emotion, even very intense levels), and Calm-Only Skills (interactive skills that are best reserved for times when the client is in emotional control).

All-the-Time Skills
Clear Picture
On-Track Thinking
On-Track Action
Safety Plan
New-Me Activities

Calm-Only Skills
Problem Solving
Expressing Myself
Getting It Right
Relationship Care

Rating feelings
We teach clients how to rate their feelings on a scale from 0–5, defining the levels this way:

0 =       No feeling
1 =       Tiny feeling (I can think clearly and talk and listen to others)
2 =       Small feeling (I can think clearly and talk and listen to others)
3 =       Medium feeling (I can think clearly and talk and listen to others)
4 =       Strong feeling (I have fuzzy thinking and can’t talk or listen to others)
5 =       Overwhelming feeling (I am harming myself, others, or property)

Deploying emotion regulation skills
Depending on each client’s emotions, we teach them to use specific emotion regulation skills to better cope with situations. We make things very concrete by teaching a “Recipe for Skills,” which helps clients put together specific skills chains for different situations.

1. Clear Picture. “Getting a clear picture” is how we describe the skill of mindfulness, and we break this skill down into the following six self-checking processes:

• Notice breath


• Notice surroundings


• Do a body check


• Label and rate feelings (using the 0–5 scale as previously discussed)


• Notice thoughts


• Notice urges
  
  Example: Pat gets a Clear Picture when she thinks, “I see my housemate stealing my phone. I’m thinking, ‘He is a jerk.’ I am mad at a level 4. I notice my breath is shallow and my fists are clenched. I want to punch him in the face.”

2. On-Track Thinking. Once clients are aware of a negative urge, we teach them to “check it” and give it a “thumbs down” if it is off-track. The client then shifts the thought to one that is on-track.
   
   Example: Pat engages in On-Track thinking when she realizes, “Punching my housemate is a thumbs-down. If I punch him, I will get in trouble. I need to move away and go to my room and do my coloring. If I talk to him now, it won’t be good.”

3. On-Track Action. Taking an On-Track Action follows naturally from On-Track Thinking.
   
   Example: Pat takes an On-Track Action by stepping away from the housemate and walking to her bedroom.

4. Safety Plan. If someone engages in an off-track action (eg, going near risk or doing something dangerous), a Safety Plan can help the person get back on track. We break down safety plans into various categories—as an example, we teach three ways to handle risk: focus on New-Me Activities, move away, or leave the area.
   
   Example: Pat executes her Safety Plan when she moves away from the housemate and goes to her bedroom.

5. New-Me Activities. We distinguish four types of New-Me Activities: Focus, Feel Good, Distract, and Fun. Focus activities bring a person back into the moment and include things such as following step-by-step instructions, playing solitaire, or following a recipe. Feel Good activities are self-soothers, and include using the senses to enjoy pleasant things such as walking in a scenic area or using a pleasant-smelling hand lotion. Distract and Fun activities include watching TV, playing video games, drawing, reading, and talking to friends—anything to “turn the page” from what is bothering the person.
   
   Example: Pat goes to the bedroom, puts on some music (a Feel Good New-Me activity), and folds clothes (a Focus New-Me Activity).

6. Problem Solving. This Calm-Only Skill entails taking a step back, defining the problem, and fixing it.
   
   Example: On the following day, Pat asks to meet with her case worker to explore how to solve the problem related to her housemate stealing ­objects.

7. Expressing Myself. This Calm-Only Skill helps patients effectively share with others what’s on their minds and in their hearts. This sharing can happen face-to-face, on the phone, through video, or through sign language.
   
   Example: While talking with her case worker, Pat expresses concern about feeling unsafe in the home when her housemate steals her things.

8. Getting It Right. This Calm-Only Skill improves patients’ ability to effectively ask for something they want from somebody else. The sub-skills of Getting It Right are: Right Mind, Right Time and Place, Right Tone, and Right Words.
   
   Example: Pat consults with the case worker to set up a time to sit down and engage in Problem Solving about the housemate issue.

9. Relationship Care. This Calm-Only Skill helps the patient build on-track relationships and change those that are off-track.
   
   Example: Pat decides to use Relationship Care skills to improve her relationship with her housemate.

Practitioners may find aspects of the Skills System approach helpful when working with ID clients. For example, teaching a smattering of New-Me Activities can help clients regulate difficult emotions and can be a great adjunct to medications.

By helping to put this skill set into practice, you will have a valuable tool when working with ID patients. You can help them remain calm and stay out of behavioral danger—and you’ll be able to see the results.