Comparison to other forensic/correctional DBT programs

Bomysoad, R. N., King, C. M., Gonzalez, K., Vora, S., Faust, T., Ossai, C., & Matthews, S. (2023, March 16–18). Comparison of prior forensic Dialectical Behavior Therapy approaches to a pilot telehealth program [Poster presentation]. American Psychology–Law Society Conference.

Individuals reentering the community from prison present with varied criminogenic and non-criminogenic needs, some of which can be addressed via cognitive-behavior therapy (CBT). One type of CBT, Dialectical Behavior Therapy (DBT), has shown promise for forensic and correctional populations. Traditional DBT entails weekly group and individual sessions, phone coaching as needed, and regular consultation team meetings; and includes skills training in mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance, toward fostering better regulation of emotions, cognitions, behaviors, and interpersonal functioning. When adapted for forensic and correctional populations (forensic/correctional DBT), DBT is often employed to reduce criminogenic risk, among other treatment targets (e.g., reduce important non-criminogenic needs, such as self-harm).

MSU Telehealth DBT Individual Skills Training Program

The pilot program was developed by Dr. King, who has training in forensic and correctional psychology and DBT, and is licensed in both the states where the clinic was located and where the referred clients reside. He trains all program staff and serves as leader of weekly DBT consultation team meetings.

The program consists of a remote intake session (during which clients complete several standardized measures concerning background history, Risk-Need-Responsivity model (RNR) factors, personal values and consistent action, and skillful and ineffective coping strategies; and an evaluator-rated risk–needs assessment tool is completed) and 12 remote weekly sessions of individual DBT skills training conducted via telehealth (videoconference). Many of the baseline measures are readministered to clients at the completion of treatment. Sessions are delivered by doctoral student therapists, who periodically complete a treatment adherence measure for individual sessions, as well as a debriefing measure at the conclusion of treatment with a client. Master’s students serve as administrative staff persons. All staff meet with Dr. King weekly for consultation team, with the students rotating among the positions of meeting leader, observer, and note taker, and the latter recording minutes using a consultation team meeting template. Individual supervision is also provided as needed.

In addition to the traditional DBT treatment target hierarchy of life-threatening, therapy-interfering, and quality-of-life behaviors, the pilot program also incorporates the concept of freedom-interfering behaviors. The latter are conceptualized as problem behaviors relevant to criminogenic needs, thought of in terms of “criminalness” indicators as conceived in the Changing Lives Changing Outcomes (CLCO) correctional treatment program. Program-specific diary cards and a client skills training manual with suggested skills practice assignments (Flesch-Kinkaid Grade Level for readability = 6.1) were developed and employed with clients. Phone-based mindfulness applications and DBT media (e.g., YouTube videos, podcasts) are also recommended to clients. Student therapists document their treatment using program-specific intake report, session note, and treatment summary report templates.

Comparison to Other Forensic/Correctional DBT Programs

A literature search was conducted for reports describing adaptions of DBT for forensic outpatient and inpatient populations, as well as correctional populations, to which the pilot program was compared. Forty articles were identified for review, which detailed forensic/correctional DBT programs for justice-involved adults with or without mental health needs. The majority of programs were rendered in secure settings, including forensic inpatient hospitals and correctional facilities.

Seventeen articles described the use of DBT in secure inpatient forensic settings. While several reports did not specify adaptions made to traditional DBT, these programs typically included group sessions, with some also incorporating individual sessions. When reported, the programs varied in length from 7 to 72 weeks. Phone coaching was often omitted, as this modality was often deemed not to be a good fit in many secure settings. Other noted adaptions included reducing the complexity of vocabulary, mnemonic devices, and written materials; and increasing the use of pictures and setting-relevant examples. Various specialty populations were served, including individuals with intellectual disabilities, learning disabilities, substance abuse problems, and personality disorders (antisocial personality disorder and borderline personality disorder [BPD]). The programs addressed various treatment targets, including emotion dysregulation and impulsivity more broadly, and co-occurring disorders, including psychosis. More specific treatment targets included symptoms of psychopathology, coping skills, and risk for harm to self or others, including anger, verbal hostility, and physical aggression.

Seventeen articles described DBT programs rendered in adult correctional settings (i.e., jails or prisons). Two reports discussed DBT-Corrections Modified (DBT-CM), with specific adaptations for vocabulary and visual aids, and tailored examples from the DBT-CM manual. Treatment targets included increasing general skillfulness. Or tailoring for women with mental disorders and parasuicidal behaviors; adults with personality disorders (e.g., BPD, psychopathy); persons presenting with medium to high risk for reoffending or specialty offense histories (e.g., stalking); or persons with intellectual disabilities, severe mental illness, or impulsivity and aggression. Treatment durations varied from 4 to 60 weeks.

Six articles described utilization of DBT in outpatient or community settings. These programs predominantly utilized group sessions, though some incorporated individual sessions, and addressed a variety of treatment targets, including criminogenic risk, psychopathology, substance misuse, and skills usage generally. Treatment duration ranged from 16 to 48 weeks. One modification, DBT for justice-involved veterans (DBT-J), included the use of teleconferencing in light of the COVID-19 pandemic.

Similar to prior forensic/correctional adaptions of DBT, the pilot program includes population-specific adaptions such as attending to criminogenic risk and development and use of population-tailored treatment materials. It is also comparable to some of the briefer forensic/correctional DBT programs evident in the literature, and those focused on a relatively “general” correctional population. However, the pilot program is notable for its relatively novel use of telehealth for outpatient treatment; conceptualization and prioritization of targeting freedom-interfering behaviors; and use of individual skills training sessions only. Planned quality assurance activities will help determine the data-driven merit of the pilot program’s approach.