A picture is worth a thousand words: visual tools and mental health

In this article, we talk to Terri Borschman, a mental health practitioner with expertise in Dialectic Behaviour Therapy (DBT)*, about how she works with people in a Secure Extended Care Unit (SECU) using DBT in conjunction with Innovative Resources’ card sets.

Despite her deep interest in and commitment to DBT, Terri said she found that many of the concepts in the DBT program were too complex for the people she was working alongside in the SECU. She decided to see if there was a way she could adapt the program to better meet their needs. She notes that most of the patients in SECU are managing challenging issues:

‘Here in our Secure Extended Care Unit, we have patients who are chronic and most have been diagnosed with schizophrenia. The issues around the diagnosis are complex and can include substance abuse, traumatic histories, intellectual disability and Autistic Spectrum Disorder (ASD), and forensic histories, all of which can impact on behaviour and make learning difficult.’

Using the book by Julie F. Brown, The Emotional Regulation Skills System for Cognitively Challenged Clients—A DBT-Informed Approach as a guide, Terri redesigned the skills training component of DBT so the content was delivered more slowly. She also reconceived the measures of success so that people participating in the program had more opportunities to feel a sense of achievement along the way.

Terri says one of the biggest challenges for patients was finding ways to express emotion and feelings:

‘Most of our patients don’t have the words to use for feelings. I use charts that include a range of feelings – more than just happy, sad and angry. I have also been using The Bears cards as they have a great range of emotions on their faces – this allows the patient to show me what they are feeling or how thinking about something/someone makes them feel. Without the basic knowledge of what feelings are, we can’t understand what to do with those feelings.’

Another change Terri made was to adapt the tools used in the program so that they were more visual and less text-based. As a result, she said, they can be used by people with different cognitive capacities and literacy levels. She notes that this can also help build rapport and connection:

‘By using pictures and cards, the program caters to cognitive impairment, intellectual disability and those that cannot read or write. It also makes one-on-one time with patients more interactive. The worksheet packs can be put together with the cards to plan for a review, debrief with a patient after an incident or if the patient is having difficulty working through a problem.’

While Terri says she likes to use the cards within a specific DBT program, she also finds them useful in other contexts:

‘The cards from Innovative Resources have been a great asset in my DBT program. The cards help people to be able to name the feelings they have and describe what those feelings are like inside their body. There are so many other packs of cards that are useful but I have The Bears and the Body Signals® cards in my bag every shift. Some patients come and ask me if they can do the cards with me. It opens conversations that can be hard to start as a clinician. I often find out things that I never would have known without using the cards.’

* DBT is a modified version of Cognitive Behavioural Therapy that also incorporates acceptance-oriented skills like mindfulness and distress tolerance and change-oriented skills like emotional regulation and interpersonal effectiveness. It usually runs as a 24 week program. www.sane.org

Useful resources:

The Bears 

Body Signals®