Promising preliminary results for DBT in a forensic psychiatric setting - CONCEPT Professional Training

Monica F. Tomlinson, The University of Western Ontario
Peter N. S. Hoaken, The University of Western Ontario

Dialectical behavior therapy (DBT) is designed to target maladaptive behaviors, such as aggression. The present pilot study assessed whether DBT reduces aggression, anger, and hostility in a forensic psychiatric sample (N D 15). A randomized waitlist control pre-post/follow-up crossover design was employed. Group-level findings indicated a reduction in hostility during and following DBT. Individual- level findings indicated some reductions in aggression during and following DBT. Individual-level findings indicated that participants in DBT improved more on measures of aggression compared to participants in treatment as usual. These results are preliminary. Implications and future directions in research are discussed.

Dialectical behavior therapy, forensic psychiatric patients, aggression, anger, hostility

“The forensic mental health care system in Canada is responsible for rehabilitating individuals who have engaged in criminal behavior and been found Not Criminally Responsible on Account of a Mental Disorder. Given that these individuals both suffer from severe mental disorders and have histories of criminal behavior, forensic psychiatric hospitals are tasked with the dual responsibility of treating their mental disorders and reducing their risk to society. Treatment in these settings primarily focuses on pharmacotherapy, which is less expensive, resource-intensive, and time consuming than psychotherapy. Pharmacotherapy also has more evidence than psychotherapy for treating primary psychotic disorders, which 70.9% of Canadian forensic psychiatric patients have as their primary diagnosis.” (p. 1)

“While pharmacotherapy is an evidence-based treatment for the primary psychotic diagnoses in these settings, there is little evidence that pharmacotherapy is effective in reducing antisocial behavior either in the hospital or out in the community. There is also little evidence that pharmacotherapy is effective for treating the secondary diagnoses that are equally prevalent among forensic psychiatric populations (e.g., personality disorders, substance use disorders). These secondary diagnoses are highly related to antisocial behavior both in the hospital and the community. The National Trajectory Project in Canada recently reviewed the diagnoses most related to recidivism among 1,800 forensic psychiatric patients and found that a primary psychiatric diagnosis had no influence on risk of recidivism, a substance use disorder increased risk by 1.41 and a personality disorder diagnosis increases risk by 1.48 (when the index offence was against a person as opposed to property). Therefore, the current pharmacotherapy focused approach to rehabilitation in forensic psychiatric hospitals is neither addressing the safety issues in these settings, nor is it addressing the diagnoses or behaviors most related to ongoing antisocial behaviors.” (p. 1)

“Recent research has suggested that evidence-based psychotherapeutic approaches which explicitly target aggressive behavior be incorporated into general psychiatric care in this population. Dialectical behavior therapy (DBT) has surfaced as among the most promising and theoretically appropriate group therapy programs for developing pro-social skills and decreasing antisocial behaviors.” (p. 2)

“DBT has been widely implemented with forensic psychiatric and correctional populations diagnosed with BPD and has been recently recommended to treat individuals with antisocial personality disorder, substance use disorders, and psychopathy. Importantly, DBT has also been deemed one of the most promising therapies for reducing treatment-interfering behaviors, such as physical aggression among individuals with BPD in forensic psychiatric and correctional settings.” (p. 2)

“The following study aims to provide initial evidence that offering a skills-only (i.e., without the individual therapy component) DBT group to a small, diagnostically diverse, forensic psychiatric sample can have both a statistically and clinically meaningful impact on reducing aggression. In this pilot study, the 1993 manual was closely followed. Typically, it takes approximately eight weeks to complete each of the four modules, and then all four modules are repeated. In this pilot, the DBT leaders covered all modules in 6 months (approximately 24 sessions), rather than the prescribed 32 sessions. The transition of patients into outpatient care happened too frequently to repeat all skills modules twice and still retain group members. Therefore, this pilot study will discuss the potential for a six-month, skills-only DBT group to reduce aggression in this sample.” (p. 3)

“Participants’ ages ranged from 28 to 63 years old. Twelve participants identified as Caucasian (80%), one identified as Aboriginal (7%), one as Asian/Pacific Islander (7%), and one as East Indian (7%). Participants had been under the supervision of the forensic mental health care system for an average of 3.6 years. Seven participants had less than a high school education (47%), five participants had a high school diploma (33%), and three participants (20%) had completed some post-secondary education.” (p. 6)

“While these data are preliminary, they demonstrate several interesting trends. First, among the participants who were improving during TAU, there is some indication that they either continued to improve during DBT or maintained their gains. Second, among the participants who were declining during TAU, many of them either continued to decline or moved into the “improvement” or “no change” groups during DBT. Third, among the individuals who remained stable during TAU, most of these individuals moved into the “improvement” group during DBT or remained stable throughout DBT. For example, the two participants who improved on anger during TAU moved into the “no change” group, and two of the three participants in the “no change” group moved into the “improvement” group and one stayed in the “no change” group during DBT. On the hostility measure, no patients improved in the six months before DBT, four patients remained stable, and three declined. During DBT, two patients moved into the “improvement” group, the majority remained stable, and one person continued to decline. During DBT, between 2 and 4 of the 13 participants clinically reliably improved on at least one measure.” (p. 8)

“Important trends were also noted in the six months following DBT. While the percentage of participants who improved was greater on most measures in DBT compared to TAU, it appears that the most improvements occurred in the months following DBT. For example, on impulsive aggression, no participants improved during TAU. In DBT, two participants improved, and during the six months following DBT, four participants showed clinically reliable improvement. In the six months following DBT, only one person declined on a measure of premediated aggression. No other patients declined on any of the measures in the six months following DBT. On measures of impulsive aggression, four participants from the “no change” group clinically reliably improved following DBT. These results suggest that the effects of DBT are most noticeable in the months following DBT, perhaps because patients are able to consolidate and synthesize their skills.” (p. 9)

“These preliminary findings offer an important starting point for future research. The paramount goal in forensic psychiatric hospitals is rehabilitation and successful, sustainable, reintegration back into society. This goal cannot be met with pharmacotherapy alone. Individuals in these settings need concrete skills with which to cope with the inevitable challenges of inpatient care and reintegration into society. Further, staff need evidence-based therapies for targeting behaviors that threaten safety within the hospital. Future research with larger sample sizes and a more stringent methodology are needed. With these very preliminary findings, the authors are hopeful that future, more methodologically rigorous studies, can help support the use of DBT for reducing aggression, anger, and hostility among forensic psychiatric patients both in forensic facilities and in society.” (p. 10)

“When comparing the TAU and DBT groups during the first six months of the study, there is some indication that participants are improving during DBT, or are maintaining their pre-DBT scores. Given that several participants declined during TAU and no participants declined during DBT in the first six months, these results provide no suggestion that DBT is harmful for patients who are declining during TAU. These are important trends that, with a larger sample size, may be detected using more traditional statistical analyses.” (p. 9)

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