Dialectical Behavioral Therapy within the Risk Need Responsivity Framework Reduces Recidivism

Monica F. Tomlinson, Department of Psychology, The University of Western Ontario, London, Ontario Canada

Cognitive-behavioral programs which are structured, skills-based, and risk-focused have been found to reduce recidivism rates by up to 55%. Dialectical behavior therapy (DBT) exemplifies all of these components, and has been rapidly adapted and implemented in correctional and forensic psychiatric facilities worldwide to reduce recidivism. Regrettably, the widespread implementation of adapted DBT has outpaced the research on its effectiveness for this purpose. Thus, it is currently unclear whether these programs are meeting the rehabilitation needs of these systems. In the following article, a qualitative systematic literature review of all DBT programs within forensic psychiatric and correctional populations using the PRISMA statement guidelines is presented, along with a detailed exploration of how these programs align with best practices in offender rehabilitation, and whether they are effective in reducing recidivism risk. Results offer very preliminary evidence that DBT has the potential to reduce recidivism risk in criminal justice systems if applied within a Risk-Need-Responsivity framework.

Criminal justice policy, dialectical behavioral therapy, DBT, offender rehabilitation, systematic literature review

“Prototypical programs designed to reduce recidivism in adolescent and adult forensic populations include Reasoning and Rehabilitation, Moral Reconation Therapy, and Aggression Replacement Training. These interventions focus on restructuring cognitions related to antisocial behavior…and introducing morally-based, pro-social ways of thinking and behaving…Meta-analytic findings from methodologically rigorous outcome studies on these (and other similar) interventions indicate that CBT programs are significantly more effective in reducing recidivism when they have additional program elements to standard CBT…and when they include higher numbers of sessions…While there is strong evidence for the continued success of these programs…researchers have also been cognizant of rapid developments in third-wave approaches, such as Acceptance and Commitment Therapy and Dialectical Behavior Therapy (DBT)…DBT already includes several of the additional components of effective CBT programs…and it has shown its effectiveness among difficult-to-treat populations…Personality disorders and substance use disorders are specifically important to treat in forensic settings…as they are significantly associated with recidivism” (p.72-73).

“Although this connection has not been made explicit in the literature, DBT also theoretically aligns with the most prominent and evidence-based risk reduction model in the recidivism literature, the Risk-Need-Responsivity (RNR) model. The RNR model posits that offenders should receive interventions that target the most acute risk factors for crime, that are matched in intensity to the person’s level of risk, and that are responsive to their individual needs…given the significant adaptations made to these programs, a quantitative review of current findings continues to be premature. As a result, a systematic qualitative review of DBT programs within forensic and correctional facilities is needed to determine whether the DBT programs currently in existence are being implemented within best practices for forensic rehabilitation, according to the RNR model, and whether there is any evidence that these programs are successful in reducing criminogenic needs, and subsequently, recidivism” (p.73-74).

“Alterations made to DBT programs within forensic settings included changes to the length of the program, the components of DBT used…and the materials presented during the skills training sessions…Arguably the most significant changes discussed in extant implementations of DBT within forensic settings pertained to the changes in skills training materials…For practical reasons, many implementations changed the wording of the skills manuals to have simpler language…less jargon…more gender neutral language…and more activities that apply to a custodial environment…Many implementations integrated crime review or crime cycle analysis components where participants would specifically discuss the factors that contributed to their past crimes…These additions to the DBT protocol were aimed at understanding what risk factors related to criminal behavior and how to ensure that crime is prevented in the future” (p.82).

“…The emotion regulation and distress tolerance modules also have theoretical support for targeting the criminogenic need, substance use. These modules specifically teach individuals to develop healthy patterns of reducing heightened emotionality and self-soothing, which may lower their propensity to use substances as a way of managing heightened emotions through self-medication…Reducing these needs may increase the chances that individuals will engage in prosocial activities, maintain employment, and seek further education, thus reducing the criminogenic needs lack of academic achievement and antisocial leisure activities…There is some evidence to suggest institutions are being sensitive to the gender-specific criminogenic needs of women in forensic populations, but not necessarily to those of men. The ‘responsivity’ principle of the RNR model asserts that rehabilitative programs should be tailored to the individuals’ learning styles, motivation, strengths, and abilities…The present literature on DBT programs within forensic settings suggests that programs are being adapted to better target criminogenic needs and are generally being delivered within an RNR framework” (p.88-89).

“There is also some evidence that program fidelity was related to reduction in criminogenic needs. Across studies, the programs that adhered more faithfully to the program elements of DBT (e.g., skills training, individual counseling, consultation groups, and between-session coaching) were more effective in reducing criminogenic needs, such as poor impulse control, hostility, anger, emotional dysregulation compared to programs that did not implement all program elements of DBT. Furthermore, the programs that were applied faithfully within an RNR framework…were associated with reductions in institutional defiance and aggression more than programs did not adhere to the RNR framework” (p.90).

“…Overall, the findings from this review provide some indication that adapted implementations of DBT are able to reduce both risk and recidivism, and that programs which most successfully accomplish this goal adhered closely to standard DBT protocol (in terms of their program components) and fit within an RNR network” (p.90).

“…Thus, information on individuals’ risk level should be used to determine who participates in DBT, and to adapt programs to correspond with the varying needs of individuals with different risk levels…The present review of DBT programs within forensic settings demonstrates that forensic institutions and evaluating their programs. Organizations…have written extensively on their standardized adaptations and preliminary evaluations. Many of these organizations have developed their own DBT manuals to better meet the needs of their populations. These manuals have integrated best practices for offender rehabilitation and incorporated the wealth of research on risk and rehabilitation…These evaluations could also evaluate the theoretical ‘active ingredients’ or ‘mechanisms of change’ in forensic populations” (p.87-90).

“Future research in this area is needed to improve the quality of studies, the size of research samples, and the fidelity with which programs are implemented. Such research can help lead criminal justice policy into an ear of prison reform that has the unprecedented luxury of standing upon empirically supported approaches to offender rehabilitation” (p.91).

“While all existing studies on DBT in forensic settings focused on emotional dysregulation, it is important to note that Dr. Thomas Lynch and colleagues have recently proposed a new form of DBT called Radically Open DBT (RO-DBT) for emotional overregulation. These researchers have adapted the biosocial theory to suggest that gene-environment interactions causing heightened threat sensitivity and diminished reward sensitivity lead some individuals to view mistakes and intolerable and unwavering self-control as necessary…RO-DBT focuses on increasing emotional expression, increasing disinhibition, increasing interpersonal experiences (including healthy interpersonal conflict), and decreasing behaviors associated with perfectionism” (p.91)

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