Effective or Not Effective? Dialectical Behavioral Therapy Skills in a Correctional Facility

Effective or Not Effective? Dialectical Behavioral Therapy Skills in a Correctional Facility

An Examination of a Modified START NOW Dialectical Behavior Therapy-Based Intervention and a Behavioral Level System on Male Inmate Misbehavior, Aggressive Behavior, and Suicide Precaution Status | 2023, Vol. 22, No. 2, 116-127


Victoria DiSciullo; Department of Psychology, West Virginia University, Morgantown, West Virginia, USA

Elisa Krackow; Department of Psychology, West Virginia University, Morgantown, West Virginia, USA

Merideth Smith; Psi Med, Inc., Charleston, West Virginia, USA


This study employed a quasi-experimental design to evaluate the impact of a modified START NOW program + behavioral level system (BLS) in a self-contained therapeutic community (SCTC) on inmate misbehavior at a correctional facility. The SCTC included a modified START NOW manualized mental health treatment, recreation groups, process groups as needed, and a level system on which to base the attainment of privileges. Inmate data was evaluated at 3-months pre- and post-SCTC to determine if there were differences in the number of mental health referrals for misbehavior, referrals to the restrictive housing unit, write-ups, instances of spontaneous use of force by correctional officers, and placement on suicide precaution status compared with a control group of inmates who were placed in restrictive housing during the same time frame. Analyses examined differences between these two groups comparing variables from pre-intervention to post-intervention timepoints. Both the modified START NOW + behavioral intervention group and the control group improved significantly from pre-to-post intervention on the number of placements in restrictive housing and number of write-ups for misbehavior but did not significantly improve on the remaining outcome measures. Study strengths and limitations are discussed.



Incarceration; inmates; aggressive behavior; suicide precaution; psychological intervention

Summary of the Research

“A potential indicator of psychological distress may be aggressive or self-directed violence (also termed self-injurious behavior), which can lead to safety and security concerns in a correctional facility…When safety concerns arise, correctional officers generally choose to use punishment strategies rather [than] rehabilitative strategies…Inmates experience numerous mental health symptoms during restrictive housing…Given these high levels of psychological symptoms and/or the need to avoid placing inmates in restrictive housing for engagement in undesirable behaviors, there has been great recognition regarding the importance of mental health treatment within the correctional system. One program developed for the prison system is the START NOW program. START NOW is a 32-session, 75-minute, twice weekly group therapy, based on skills developed through Dialectical Behavior Therapy (Linehan et al., 1991; Sampl et al., 2008). The program includes four modules: interpersonal skills, understanding/coping with emotions, problem-solving, and future-oriented skills…The main goal of START NOW is positive behavior change for inmates through the development of skills, such as decision making and judgment, coping, emotion regulation, and recognition of emotion and social cues…” (p. 116-117).

“A unique opportunity was available to the authors to evaluate a modified START NOW intervention plus a behavioral level system compared to a no-intervention control group given that one facility has a combined program that focuses on an inmate population with a wide-range of security risks and who exhibit significant violent, aggressive, and disruptive behavior. The self-contained treatment community (SCTC) uses a modified START NOW intervention for mental health treatment, along with additional positive reinforcement to target inmate prosocial behavior (i.e., level system to obtain privileges). Therefore, the current study evaluated the impact of the modified START NOW intervention plus behavioral level system (BLS) on inmate disruptive, violent, and aggressive behavior at a correctional facility in a southern state…This study included data from 88 adult male offenders, 45 in the modified START NOW intervention group period…” (p. 117-119).

“In contrast to previous START NOW studies, the modified START NOW + BLS group was not significantly different from the control group on the outcome variables of placement in restrictive housing and write-ups. This may have been because both groups displayed a decrease in the outcome variables associated with behavioral dysregulation, with a medium effect size for write-ups and a large effect size for restrictive housing…Several possibilities exist as to why the control group improved. First, the facility in which the study took place is structured in such a way that the SCTC and restrictive housing units share correctional staff…Thus, it is possible that correctional staff may have adopted the SCTC’s rehabilitative approach in the general population…Second, the decision to require that the control group have experienced at least one placement in restrictive housing in the pre-intervention group and the fact that modified START NOW + BLS participants experienced at least one placement in restrictive housing…constrained the likelihood of finding significant differences…” (p. 124-125).

Translating Research into Practice

“Third, an unanticipated finding was that a majority of the outcome variables in the current study had a low frequency of occurrence (i.e., mental health referrals, use of force, and suicide precaution watch) which reduced the likelihood of significant differences emerging. This was surprising given that the inmates chosen for the SCTC are considered to be largely violent, aggressive, and disruptive. We hope that the infrequency of these variables might inform future research…Further research is necessary to determine whether the results found in the current study replicate” (p. 125-126).

Other Interesting Tidbits for Researchers and Clinicians

“Prior to the development of the START NOW program, negative behaviors (e.g., aggression, violence) were often reduced using token economies and other behavioral reward systems in various populations, including inmates…The SCTC’s level system was designed by Roush et al., 2012 and provided staff with a guide to the privileges and requirements of a correctional setting level system. The behavioral level system is observational in nature; both mental health staff and correctional officers observe inmate behavior to determine whether inmates advance levels. Participation in the modified START NOW sessions, including completion of practice exercises, was tied to inmate’s advancement in the behavioral level system. After inmates advanced to Level 4, over a course of two weeks, mental health staff prepared them for termination from the modified START NOW program and to return to a general housing unit” (p. 117-119).

Additional Resources

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