By Jack Carney, DSW, past Clinical Director,
Outpatient DBT Treatment for Forensic Clients
By Jack Carney, DSW, past Clinical Director,
FEGS Forensic DBT Program
FEGS (Federation Employment & Guidance Service, Inc.) celebrated the sixth
anniversary of its Forensic Dialectical Behavior Therapy (DBT) program in December
2003. Initiated as a demonstration project in 1997, the program was designed
to assist men and women who have serious mental illnesses, impulsive aggression
towards self and others and criminal justice histories, to access outpatient
clinical psychotherapy services. The majority of these individuals have long
histories of substance abuse as well. To date, the program has served over one
hundred and thirty persons, and continues as the only outpatient DBT program
for forensic clients in the United States.
Dialectical Behavior Therapy
DBT was the treatment selected since it is skills-based and appeared best suited
to address the two principal barriers blocking treatment access, i.e., psychotherapists’
apprehension at working with Forensic clients and their reliance on a deterministic
and ultimately exclusionary treatment approach. Linehan, who originated DBT
for her work with women with Borderline Personality Disorder, describes DBT
as an amalgam of traditional cognitive-behavioral therapy, of Eastern Zen philosophy,
and of the tension of the classic “change-no change” dialectic inherent
in all psychotherapy. These are resolved in DBT via the synthesis represented
in the concept of “radical acceptance”.
In accordance with Linehan, we view our Forensic clients, the majority of whom
are men, from a biosocial perspective which posits their impulsive aggression
as stemming from core biological deficits leaving our clients vulnerable to
“toxic” environments. These interactions result in severe emotional
“dysregulation”. The affected persons then seek to modulate this
via behaviors that are maladaptive and injurious to self or others.
FEGS Forensic DBT Program
To address this core emotional “dysregulation” in a holistic fashion,
we employ Linehan’s four main treatment modes: individual, group, telephone
consultations, and therapist consultation.
The DBT therapist and client work together in one-hour weekly sessions to identify
problem behaviors—those that are injurious to self, others, or interfere
with therapy, and that diminish client quality of life. In addition, they monitor
the client’s ability to substitute DBT skills for these maladaptive behaviors.
In groups, the skills of Emotion Regulation, Core Mindfulness, Distress Tolerance
and Interpersonal Effectiveness are taught in two-hour weekly meetings over
nine to twelve months. Therapists coach clients by telephone to apply DBT skills
in real-life situations. The Forensic DBT therapists meet bi-weekly in a supportive
setting to discuss client treatment problems and to improve their own treatment
skills.
We have also implemented a treatment protocol that conforms to the community-based
treatment model for mentally ill forensic clients proposed by Lamb and colleagues.
Treatment Outcomes
All 133 individuals admitted to the FEGS Program to date have a history of criminal
justice system involvement, serious mental illnesses, and evidence of problems
with impulse control, including self-injurious or assaultive behaviors. They
also rely heavily on intoxicants to regulate their powerful emotions. The majority
are victims, as well as perpetrators, of trauma.
Given the client’s histories, treatment engagement and retention have
been paramount clinical concerns. Of our 133 clients, 45% have either completed
at least one treatment cycle or continued in treatment. The average treatment
tenure for this cohort is approximately seven months. This compares favorably
to retention in most substance abuse treatment programs.
We have concluded that the two greatest barriers to treatment retention are
an increase in feelings of vulnerability, and their substance abuse “validation”
early in treatment. Major elements of the treatment protocol are also employed
to promote retention, particularly the development of a risk management plan,
criminal justice coordination, and clinical case management, which involves
referral to and collaboration with other community-based treatment providers.
Of particular help has been FEGS’s Project COPE, the MICA IPRT located
in Jamaica.
While in treatment with us, regardless of length of stay, little more than 6%
of our clients have been reincarcerated, only one for commission of a felony.
This compares favorably with histories of incarceration for 78% of all our clients,
64% of whom have felony convictions. Significantly, all these individuals were
reincarcerated for technical parole violations, marking these individuals as
among the most vulnerable we treat. Less than 2% of our clients, while in treatment,
committed acts of violence towards self, and approximately 10% committed acts
of violence towards others. This compares favorably with their histories where
43% committed acts of violence towards self and 63% towards others.
Systemic Barriers Require Resolution
Despite our equivocal outcomes regarding treatment retention, we believe we
have demonstrated that individuals with serious mental illnesses and criminal
justice histories, while in a treatment program that includes individual DBT
and Group Skills Training and that adheres to our treatment protocol, will learn
how not to do injury to themselves and others and how to avoid rein-carceration
and the commission of anti-social acts. Unfortunately, we have not had the resources
to compile post-treatment data, and so do not know the length of salutary treatment
impact on those of our discharged clients.
However, achievement of improved treatment outcomes and continuation, as well as possible expansion, of Forensic DBT and our treatment model, depend on the eventual resolution of several key mental health systems barriers and DBT program gaps.
Mental health provider agencies remain ill equipped to effectively address their
clients’ substance abuse disorders, and they have yet to adopt the explicit
goal of promoting the general commun-ity’s safety. Governmental commitment
to fund community-based forensic treatment and related services remains insufficient.
Indeed, psychiatrists remain reluctant to work with impulsively aggressive individuals,
particularly those with criminal justice histories. DBT itself requires further
study: to determine its adaptability to other treatment populations; its complementarity
with other approaches to address impulsivity and substance abuse; and its longitudinal
impact on clients’ long-range quality of life. For a detailed description
of DBT and outcomes research, see www.behavioraltech.com.r