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Adapting Dialectical Behavior Therapy for Justice-Involved Individuals

A treatment adaptation is warranted when a clinical problem is identified within a given community with specific risk and resilience factors. 

Adapting Dialectical Behavior Therapy for Justice-Involved Individuals

Deinstitutionalization

Deinstitutionalization, the emptying of state mental hospitals, was a well-intentioned but poorly planned social change in the United States beginning in the 1950s. This movement was a product of the overcrowding and deterioration of mental health hospitals, new medications that significantly improved the symptoms of about half of the patients, and a failure to understand that many of the sickest patients were unable to make informed decisions about their own need for medication. However, by the early 1970s, it was becoming apparent that the emptying of the state mental hospitals had resulted in a marked increase in the number of mentally ill individuals in jails and prisons. 

Due to deinstitutionalization, there are more than three times more seriously mentally ill individuals in United States jails and prisons than in mental health hospitals. In addition, 40% of individuals with serious mental illnesses have been in jail or prison at some time. Therefore, it is apparent that the need for appropriate mental health treatment for individuals in the United States criminal justice system is paramount.

Adapting Mental Health Treatment

It is not difficult to imagine effective mental health treatment for forensic populations differs from other clinical populations. For example, individuals with mental health problems who enter the criminal justice system have a particularly challenging time adjusting to the rules and routines of correctional settings, leading to high disciplinary consequences while incarcerated. These “violations,” e.g., verbal threats, self-harm, disorderly conduct, and property violation, indicate emotional, behavioral, and cognitive difficulties. And without appropriate treatment, these problems will likely persist, causing additional stress to the individual and the environment.

Developmental, environmental, and social risk factors have been found to increase the use of less adaptive coping skills (e.g., aggressive or antisocial behavior). For example, growing up with low socioeconomic status or in large, aggressive families with poor parenting skills, maltreatment, and emotional deprivation are all associated with a risk for antisocial behavior.

Other risk factors for antisocial and delinquent behavior:

  •  Low IQ
  • Language development delays
  • Hyperactivity
  • Antisocial beliefs
  • Greater negative emotionality
  • Substance abuse

Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) was developed to treat individuals with high-risk behaviors with poor prognoses. Since its development, efficacy studies have indicated that DBT is an effective and flexible treatment for individuals with complex behaviors and high rates of comorbidities; therefore, DBT has been adapted for other populations. Recently, there has been a surge of interest in the application of DBT for individuals within a correctional setting.

 

Adapting Rather than Adopting

Adapting DBT requires modifying the content of the treatment to fit the incarcerated population better (e.g., treatment targets and skills training examples). In addition, engagement strategies have been developed to improve treatment efficacy for incarcerated individuals. 

Researchers have argued several points for adapting DBT for justice involved individuals:

  • The high prevalence of personality disorders within forensic populations
  • DBT is a comprehensive cognitive-behavioral therapy (CBT) with a rigid behavioral hierarchy, and research has suggested that CBT successfully reduces recidivism
  • Managing life-threatening and aggressive behavior is paramount in forensic populations
  • DBT can address and reduce staff burnout by decreasing stress related to challenging individuals who maintain severe behavioral dyscontrol

When using DBT with this population, clinicians must adjust treatment targets:

  • Life-threatening targets: violent behaviors, urges, and thoughts
  • Therapy interfering targets: lying, contraband, and engaging in rule infractions
  • Quality of life targets: reducing behaviors that create current suffering and increasing behaviors to develop a noncriminal life

Treatment Barriers

Individuals who are incarcerated with severe personality disorders often engage in a higher volume of disciplinary incidents than their non-personality-disordered peers and end up in segregation. As a result, these individuals are hopeless, unmotivated for treatment, and dangerous.

Treatment programs are designed to reduce the likelihood of an individual continuing to engage in problematic or illegal behavior. While an important aim, treatment endeavors related to rehabilitation alone are unlikely to accomplish their objective without actively engaging clients in the process. 

Good time, level systems, and daily incentive programs have been developed to address barriers to treatment engagement.

  • Good time: encourages participation and graduation from the DBT program to have segregation time vacated.
  • Levels system: increased privileges for individuals who attempt skills and even more privileges for individuals who model skillful behavior and coach others. This helps individuals overcome the feeling of authoritarian control.
  • Daily incentive program: operant principles are used in various ways to shape behavior. Extra phone minutes or recreation time are effective incentives and reduce low-level problem behaviors.

Adapted Interventions for Individuals Involved in the Legal System

Adaptation must be related to the presenting problem in the targeted community. For example, novel treatment components may be added, or pre-existing elements may be altered to target specific symptom presentations requiring particular interventions.
 
The principles and structure of DBT treatment have consistent positive outcomes for suicide, self-harm, aggression, and other quality-of-life behaviors. Therefore, adaptations to DBT have been developed to target the impairments in executive cognitive functioning that play a crucial role in developing violent and aggressive behavior.
 
The average reading level of an individual involved in the legal system is considerably lower than that of the general public; therefore, it is necessary to simplify the language of written material and examples. Tomlinson (2018) examined 34 international forensic DBT programs and found that programs that adapted the content of DBT to target criminal needs and maintained higher fidelity to the treatment structure produced the most significant reduction in violent/aggressive behavior and recidivism. 

Tomlinson’s systematic review found that including examples relevant to the individual’s life makes the material more salient and better understood – leading to more productive treatment gains.

  • The Emotion Regulation module was adapted to increase empathy and understanding of consequences by teaching a new skill named “Random Acts of Kindness.”
  • The “Myths about Interpersonal Effectiveness” handout was modified to target antisocial attitudes and beliefs.

The Egregious Behavior Protocol

The egregious behavior protocol (EBP) was developed to address behavioral dysfunction typically resulting from the stress of being incarcerated coupled with limited coping skills. 

The EBP accommodates distinct contextual factors related to the presenting problem, enables structure in the environment, and provides a systematic approach to manage and treat severe self-harm behaviors, physical aggression, or destruction of property without profoundly disrupting others. One research study found it harmful to talk about self-harm in groups; therefore, EBP and target behaviors are not discussed in skills groups.

Clinical Implications

It is unwise and unethical to suggest that a personality disorder is a direct link to criminal conduct; however, the overrepresentation of persons with personality disorders in the prison population suggests they have an increased risk of criminal behavior. Additional research has indicated that aggression is enhanced in individuals with specific personality disorders (i.e., borderline personality disorder) compared to controls. Treatment that mitigates symptoms of personality disorders will likely amend problematic and illegal behavior. Therefore, it is not surprising that research has found that DBT modifications demonstrated effective treatment results with several populations at risk of committing violence in recent years.
 
The United States Department of Justice reported that only 60% of incarcerated people with mental illness receive mental health treatment. The lack of appropriate psychiatric treatment among incarcerated individuals can lead to various concerns. For example, safety within correctional institutions, successful reintegration into the community upon release, and a reduction in recidivism depend on the appropriate treatment of this population.
 
The treatment standard of care should be the same for individuals in the community and those incarcerated. We are ethically obligated to treat individuals with serious mental health needs. Therefore, the adaptation of evidence-based treatments is necessary. We can address human rights concerns intertwined with detaining and isolating individuals in correctional facilities and provide care to the most complex individuals while incarcerated.

Conclusion

Although it is in its infancy, research demonstrating the effectiveness of adapting DBT for use with individuals involved in the legal system is growing. DBT with these individuals is challenging; it is a delicate balance between adequately addressing internal and external needs. For example, increasing the mental well-being of an individual involved in the legal system without addressing their level of risk can result in a happy but dangerous individual. Alternatively, managing risk without addressing personal well-being can result in a disengaged and hostile individual. However, the potential to change lives, even the lives of the most “difficult” individual in custody, is possible and exciting. Not just individuals involved in the legal system, forensic psychologists, and criminal justice officials can significantly benefit from well-developed and well-executed DBT programs.

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