1. DIRECT Training DBT Informed Risk Emotion & Crisis Therapy By Catherine Prentice - Advanced Nurse Practitioner & Dr Liz Halloran

2. Why? Journey of how we developed and simplified a complex treatment into a 3 day training package for multi-disciplinary clinicians.

3. Background Trust saw 50000 clients seen in 2014/15 (30000 of these in secondary care) Community DBT Team currently offer 8 CAMHS places and 18 adult places for the whole of this population DBT Service only able to offer an intervention for a very small number of clients.

4. “What?” Pre- 2008 first DIRECT (Inpatient) 4 day training. Lot of focus on DBT theory and concepts, awareness of the model to educate staff to be a ‘DBT friendly’ ward. 2010 – Reduced to 3 day ‘essential’ skills training, to generalise DBT informed skills to Inpatient and CMHT staff.

5. Who? Teams of qualified clinicians are prioritised so there is an increased chance of consolidation, reflection, discussion and generalisation of skills back into the work place. Application form, commitment, goal setting (to identify 2 clients with PD that they are working with). This parallels commitment work with clients.

6. “How?” Day 1 - Engagement Mindfulness Introduction to model Dialectical stance Observing limits Commitment strategies Validation strategies

7. Day 2 – Managing Crisis and Risk Behaviours. Being creative how to teach 6 months of skills in half a day? 6 different skills split up into tables ;  Mindfulness  Grounding (pulled together DBT skills (TIPP etc), using familiar language  Self sooth  Improve the moment  Distract with ACCEPTS Crisis planning and management Chain and solution analysis

8. Day 3 - Environment Homework/skills diaries! -‘fine tuning’, master classes/ supervision/ trouble shooting Behavioural theory to remind staff how we can (unknowingly) reinforce behaviours with our clients. Consult agreement- taking DBT consult principles and applying them to team working.

9. Polar ends of a skills dialectic? Crisis Skills Chain and Solution Analysis

10. Changes made.. Reduce to 3 day - less theoretical more generalised and applicable Break of two weeks to practice ‘generalise skills (instead of refresher day) Taken out crisis telephone coaching (audio inappropriate) anglicize role play

11. Current issues from evaluation Staff skill set and experience differ – a need to provide crisis skills training for HCA – how do we find a synthesis in the dialectic? How do we find the middle path? No charge - calibre and efforts reduced. Ltd feedback re-post (3mnth) evaluation – are skills being transferred into practice?

12. Questions? Thoughts Reflections Clarification