Companion website page for Matthews, S., King, C. M., Ossai, O., Vora, S., Gonzalez, K., Bomysoad, R. N., & Faust, T. (2023, March 16–18). Forensic Dialectical Behavior Therapy resources from a pilot telehealth skills training program [Poster presentation]. American Psychology–Law Society Conference. https://ap-ls.org/2023-apls-conference
Dialectical behavioral therapy (DBT) is a well-known cognitive-behavioral treatment for clients presenting with complex problems that are difficult to treat. The treatment was originally developed for persons presenting with chronic suicidality, and especially women with borderline personality disorder. However, DBT has since been adapted for a range of challenging clinical populations, including justice-involved persons. And studies of forensic adaptions of DBT to date have shown various indicators of promise.
Dr. King and his lab developed a relatively brief forensic outpatient telehealth DBT skills training program to assist persons reentering the community from prison. The program was established as a university-based training clinic, with clients referred by a reentry court. Dr. King is a psychologist trained in forensic and correctional psychology as well as DBT. However, neither Dr. King nor the MSU Telehealth DBT Individual Skills Training Program are certified by the DBT-Linehan Board of Certification. At the present time, the program remains in the pilot stages.
The program synthesizes DBT with concepts from the Risk–Need–Responsivity model (RNR) and Changing Lives Changing Outcomes correctional treatment program (CLCO). Dr. King trains and supervises doctoral student therapists and master’s student program staff, including via weekly DBT consultation team meetings, during which the student therapists rotate between meeting leader, note taker, and observer. Dr. King also completed DBT adherence measures for the program as a whole. Consultation for independent ratings of the program using these adherence measures is currently being sought.
All sessions are delivered using a telehealth modality. Clients complete an intake session, before and during which they complete an assessment battery, and a finite number of weekly individual DBT skills training sessions. Clients also complete an assessment battery upon completing the treatment program. Therapists also periodically complete DBT adherence measures for individual sessions, and a therapist interview measure upon completion of treatment with a client.
To date, the pilot program has appeared feasible, and was developed in anticipation of quality assurance activities and future research. While awaiting the results of such analyses, given the promise forensic DBT has shown in prior research, Dr. King and his lab hope that the resources provided below will be helpful to others interested in establishing similar programs elsewhere.
Note that owing to the program's commitment to quality assurance and improvement, the materials provided below are updated from time to time. Note also that not all of the below resources are to internally developed and hosted materials (marked below with an *), nor are all these materials available without cost. Some links are to proprietary access channels. Appropriate credit should be self-evident based on the links provided. For permission to use or cite internally developed materials, please contact Dr. King.
Finally, for program developers, note that the development of other materials will be necessary, including administrative memorandums of understanding, form templates, databases, trainings, etc.
Clients complete an intake session followed by 12 sessions of individual DBT skills training, covering orientation, dialectical thinking, mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation. Therapists variously seek to balance the dialectic presented by the structured program schedule (change strategy) and client’s individual needs from week to week (acceptance strategy).
Student therapists and staff members receive initial training from the supervisor in DBT and forensic adaptions of that treatment model. Trainees learn, among other things, about acceptance, change, and dialectical strategies in DBT; each of the DBT skills; RNR factors; and forensic syntheses (e.g., the prioritized treatment target of freedom-interfering behaviors alongside life-threatening, therapy-interfering, and quality-of-life targets). Trainees are also provided with a DBT self-care guide and recommended to utilize systematic measures of personal mindfulness.
- Ivanoff, A., & Marotta, P. L. (2018). DBT in forensic settings. In M. A. Swales, The Oxford handbook of Dialectical Behavior Therapy. Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198758723.013.14
- Kletzka, N. (2019, August 22). DBT in forensic settings (part 1). Behavioral Tech. https://behavioraltech.org/dbt-forensic-settings-part-1/
- Kletzka, N. (2019, August 31). DBT in forensic settings (part 2). Behavioral Tech. https://behavioraltech.org/dbt-forensic-settings-part-2/
- Linehan, M. M. (2015b). DBT skills training manual (2nd ed.). Guilford Press.
- Swales, M. A., & Heard, H. L. (2017). Dialectical Behaviour Therapy (The CBT Distinctive Features Series, 2nd ed.). Routledge.
- Tomlinson, M. F. (2018). A theoretical and empirical review of dialectical behavior therapy within forensic psychiatric and correctional settings worldwide. The International Journal of Forensic Mental Health, 17(1), 72–95. https://doi.org/10.1080/14999013.2017.1416003
Stylistic therapist video examples:
Skills Training Guide
Clients are provided with a program-specific DBT skills training guide, tailored for justice-involved persons and written at an accessible level (Flesch-Kinkaid Grade Level = 6.1). The guide includes recommended skill practice exercises for each module of skills. Student therapists work from this guide while teaching skills to clients during individual sessions.
- MSU Telehealth DBT Individual Skills Training Program - DBT Skills Summary and Practices for Clients*
Clients are encouraged to complete DBT diary cards every week to track, on a daily basis, relevant aspects of their functioning as well as skills usage. Program-specific diary cards were developed to be relevant to justice-involved persons and are available in both Excel and Word formats.
- MSU Telehealth DBT Individual Skills Training Program - Diary Card (Excel)*
- MSU Telehealth DBT Individual Skills Training Program - Diary Card (Word)*
Student therapists complete an intake report, session notes, and treatment summary report using program-specific templates. They also take turns taking consultation team minutes using a template.
- MSU Telehealth DBT Individual Skills Training Program - Treatment Intake Report Template*
- MSU Telehealth DBT Individual Skills Training Program - Treatment Summary Report Template*
- MSU Telehealth DBT Individual Skills Training Program - Clinical Session or Phone Coaching Note Template*
- MSU Telehealth DBT Individual Skills Training Program - Consultation Team Minutes Template*
Supplemental Applications and Media
Clients are recommended to utilize phone-based mindfulness applications, and to review supplemental DBT skills media (e.g., YouTube videos, podcasts).
- Mindfulness Coach, available for Apple (App Store) and Android (Google Play) (Direct clients to set up daily reminder in app.)
- DBT-RU YouTube channel
- BorderlinerNotes YouTube channel - The "Experts" - Linehan playlist
- Therapists in the Wild podcast
(Search the Internet for "DBT podcasts," several of which exist, and recommend one which you think the client may be most interested in.)
Assessment Tools for Clients, Therapists, and the Program
Upon intake, clients complete a self-report assessment battery consisting of the
- Attitudinal readiness for correctional treatment: Corrections Victoria Treatment Readiness Questionnaire (CVTRQ; see here)
- Effective skills use and ineffective coping strategies: DBT-Ways of Coping Checklist (DBT-WCCL)
- Antisocial personality pattern traits: Levenson Self-Report Psychopathy Scale (LSRP36; see here)
- RNR model factors from the client's point of view: Self-Appraisal of Risks and Needs Version 5: Short Form (SARAN V5: SF; experimental measure, contact Dr. King about)*
- Importance of and consistent action with personal values: Valued Living Questionnaire (VLQ)
Clients are readministered several of these measures upon completing the treatment program. Note that study of these measures and additional references are necessary for ascertaining comparison data, etc.
Trainees also interview clients at intake to complete the
- Demographic information: Demographic Data Scale (DDS)
- Criminogenic risk and needs: Level of Service/Case Management Inventory (LS/CMI) Section 1.
They also administer the Test of Premorbid Functioning (TOPF) [Estimated verbal abilities] for tailoring verbal and written delivery of the treatment.
In addition, student therapists periodically complete the Dialectical Behavior Therapy Adherence Checklist-Individual Therapy (DBT AC-I) Therapist Self-Report Version [Adherence within a session to the DBT model] and upon completing treatment with a client, the Therapist Interview-4 [Therapist perceptions about the treatment].
On behalf of the program, Dr. King has also completed the DBT Program Fidelity Checklist (DBT PFC; percent adherence = 100%) and Program Fidelity Scale (percent adherence = 85%). Independent ratings of the program by a professional with DBT expertise using the DBT PFC yielded a percentage adherence of 86%. The lower relative adherence percentage was due to the independent professional rating the pilot version of the program as not ensuring that skills coaching and crisis intervention was made available to clients at all times outside of scheduled sessions; and the pilot version of the program not making outreach to include caregivers (e.g., parents, other family members, or supportive individuals) in treatment, despite serving vulnerable adults. This feedback has been incorporated into program adjustments toward enhanced quality assurance/utmost DBT model fidelity.