This feature by Dr. Nicole Kletzka is Part 1 of a two-part series about DBT in Forensic Settings. In part 1, Dr. Kletzka sets the stage by defining forensic psychology and beginning to understand how the model of DBT can be applied in forensic settings. We then take a closer look at the how the five functions of comprehensive DBT treatment specifically relate in forensic settings, beginning in Part 1 with the first function of client motivation.
Forensic psychology refers to the application of psychological principles within a legal context. Because of the prevalence of violence, aggression, and self-harm in these settings, treatment providers often seek out evidence-based treatment modalities to help clients gain behavioral control. DBT has strong evidence in support of its effectiveness in reducing suicide attempts, non-suicidal self-injury, anger, impulsivity, and substance use. It is not surprising that from almost the beginning of the development of DBT, the treatment has been implemented in forensic settings such as prisons, inpatient and outpatient court-ordered treatment programs, and inpatient forensic hospitals.
Individuals and researchers applying DBT within forensic settings hypothesize that the biosocial theory applies for individuals with antisocial personality disorder (ASPD) or psychopathy as well as borderline personality disorder (BPD). Researchers describe two different subtypes of ASPD patients: those with deficits in emotional regulation skills, and those with limited emotional arousal. For the first group, the biosocial theory would apply as it is described in standard DBT to treat individuals diagnosed with BPD. When individuals who are highly sensitive, react quickly, and have a slow return to baseline emotional functioning interact with an invalidating environment, a transaction can be created which exacerbates the individual’s reactivity and sensitivity. Over time, sensitive individuals may stop trusting their own internal reactions. They may not learn effective emotion regulation strategies and may therefore oversimplify emotion regulation processes. They may be reinforced for emotional escalation if people in their environment attend to their needs only if they lose control.
McCann and her colleagues hypothesize that children with biologically based limited emotional arousal may not respond to stress and anxiety in the same way other children react. They also may not experience shame as a behavioral inhibiting emotion. Applying the biosocial theory in this context, parents may react by employing harsh or coercive strategies to control disruptive behaviors, creating an invalidating environment for the child. Children may then react with increased opposition or defiance, continuing the cycle. These children may also engage in disruptive or sensation-seeking behaviors as a way of experiencing more emotions.
For some of these individuals, limited affect may not be just a biological disposition. Emotions can also be punished out of a person’s behavioral repertoire. For instance, if a young child approaches a parent crying and the parent hits them or otherwise punishes them for crying, the child may learn not to cry or display emotions. They may learn to avoid emotions such as sadness. In addition, children in punitive and coercive households may model their behavior after that of their parents.
With all this said, how does DBT treatment within a forensic population differ from standard DBT?
Unique challenges arise in forensic settings; however, keeping in mind that DBT is a principle-based treatment, the original model is easily applied within forensic settings. Standard DBT is an emotion regulation treatment which addresses five functions of comprehensive treatment: client motivation, skill building and capability, generalization of skills, structuring the environment, and support/skill building for the treatment providers.
The function of motivating clients is typically addressed in individual therapy sessions; however, in some forensic settings a lack of resources and competing administrative demands make it impractical to provide individual therapy for all patients. There is research that supports the efficacy of skills training alone for certain populations, although motivation for forensic clients can be especially challenging. These clients are typically mandated to treatment, and because of the court involvement, both administration and treatment providers have specific treatment goals that are imposed upon them by the legal system. Rather than being motivated by a need to find more effective strategies to reduce their emotional pain, forensic clients may feel that they are the victims of the system. Treatment is often a box to be checked off rather than a personal choice and investment. To increase commitment, it is important that clients be given the choice of participating in DBT programming, in keeping with the principle that DBT treatment is voluntary. This may involve educating administrators and courts about DBT. By doing so, programs provide clients with the freedom to choose in the absence of alternatives.
DBT clinicians also have to be creative to help clients identify life-worth living goals that will be motivating. It is often difficult to define realistic life worth living goals outside of release from the forensic setting. Many patients adopt the viewpoint that their lives will start once they are released from the hospital, and simultaneously it is often unclear what their lives will look like once court involvement ceases. Programs can find creative avenues to target these issues, such as adding orientation sessions, having case managers or frontline staff work with clients, or adding life worth living goal development as a part of skills training.
Response style also comes into play in forensic settings. At different phases in the legal process, clients’ response styles may vacillate. Early in the court process, they may be evaluated to see if they are competent to stand trial (if they are able to understand the court process and work with their attorney in a rational manner). At this stage, clients may exaggerate problems in order to avoid facing legal charges. If they are found not guilty by reason of insanity by a court, they may be more likely to try to minimize problems in order to facilitate a shorter sentence or inpatient stay. Therapy interfering behavioral targets may emerge for the providers or the clients, particularly when DBT providers overlap too closely with the court-ordered treatment.
Read here for part 2 of this blog, in which we will examine how the remaining four functions of DBT are applied in forensic settings, including the functions of skill building and capability, generalization of skills, structuring the environment, and support/skill building for the treatment providers.
Nicole Kletzka, PhD, DBT-LBC completed the Linehan Board of Certification process in 2015 and joined Behavioral Tech Institute in 2016. She has trained and consulted with several system implementation projects and specializes in working with inpatient, forensic populations. Nicole is the DBT Coordinator and a Consulting Forensic Examiner for Michigan’s Center for Forensic Psychiatry. She has expertise in DBT for patients with intellectual disabilities, and in trauma-informed treatment. Dr. Kletzka previously worked at Rady Children’s Hospital in San Diego with child trauma victims and has been an affiliate member of the National Child Traumatic Stress Network for over a decade.
REFERENCES:
Galietta, M., & Rosenfeld, B. (2012). Adapting dialectical behavior therapy (DBT) for the treatment of psychopathy. International Journal of Forensic Mental Health, 11(4), 325-335.
Ivanoff, A., & Marotta, P. L. DBT in Forensic Settings. In The Oxford Handbook of Dialectical Behaviour Therapy.
Kletzka, N., Lachat, C., Echols, S., & Witterholt, S. (2014, November). Structuring dialectical behavior therapy treatment in a forensic inpatient setting: Patient progress and staff perceptions. 19th Annual ISITDBT Conference. Philadelphia PA
McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). DBT with an inpatient forensic population: The CMHIP forensic model. Cognitive and Behavioral Practice, 7(4), 447-456.
McCann, R. A., Ivanoff, A., Schmidt, H., & Beach, B. (2007). Implementing dialectical behavior therapy in residential forensic settings with adults and juveniles. Dialectical behavior therapy in clinical practice: Applications across disorders and settings, 112-144.
Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient units. Dialectical behavior therapy in clinical practice, 69-111.
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