DBT in Forensic Settings (Part 2)

August 31, 2019

This feature by Dr. Nicole Kletzka is Part 2 of a two-part series about DBT in Forensic Settings. In part 1 (read it here), Dr. Kletzka set the stage by defining forensic psychology and beginning to understand how the model of DBT can be applied in forensic settings, and she focused on that application as it relates to the first of five functions of comprehensive DBT treatment: client motivation. 

In this part two, 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. 

In terms of skill building and capability, clients in forensic settings often present unique challenges.  Clients hospitalized because they are incompetent to stand trial or not guilty by reason of insanity often also carry diagnoses of schizophrenia, schizoaffective disorder or bipolar disorder.  When initially hospitalized, they may be acutely psychotic and unable to learn new skills until they are appropriately medicated.  Even with psychotropic medications, a subset of forensic clients continues to experience treatment-resistant psychotic symptoms or delusions.  In fact, this is often the basis for continuing hospitalization.  For these patients, the DBT clinician’s ability to validate the valid and invalidate the invalid is crucial.  Reality acceptance skills can also be central to helping them accept both their mental illness and their legal situation.  At times some forensic clients have used radical acceptance to help them make peace with their hallucinations.

The ability to learn new information is often a challenge in these settings.  Medication side effects, the long-term impact of substance use, traumatic brain injuries, psychosis and other challenges may impair forensic clients’ ability to learn.  In addition, concrete thinking is often associated with diagnoses of ASPD.  DBT clinicians must find creative, simple ways to distill the complex DBT skills in a way that works for these patients.  Repetition, including visual representations of skills, and adding many active learning strategies can be incorporated into groups to help facilitate this process. 

In standard DBT, phone coaching helps clients generalize their DBT skills to their everyday environments.  In inpatient forensic settings and prisons, the milieu staff fulfill this role.  This can be an asset in situations in which the individual is placed on a fully DBT unit.  DBT-trained milieu staff have the potential to dramatically increase the speed at which inpatients learn skills because they are available 24 hours a day, 7-days a week, for on-the-fly coaching.  This is not, however, often the case.  In big institutions such as prisons and forensic centers, administrative and funding concerns frequently require that staff be moved from unit to unit to meet coverage needs.  Staffing turnover presents a challenge in terms of adequately training staff.  In addition, front line staff often have schedules that do not permit them to leave the unit in order to learn DBT skills or participate in DBT Team Consultation meetings.  Challenges also arise with changes in administration disrupting efforts to create, structure, and support DBT programs appropriately so that they can effectively help forensic clients generalize their skills. 

Forensic DBT practitioners have devised a variety of different strategies to address these concerns.  Some facilities include line staff as skills training co-leaders, to allow them to learn skills, and to provide them with support.  Other creative strategies include assigning DBT clinicians to work with line staff and creating staff diary cards to help the staff learn the DBT skills, practice them, and teach them in an inpatient setting. 

In terms of structuring the environment, recent research suggests that hospitalizing individuals who are suicidal is iatrogenic.  In forensic settings, individuals are institutionalized for long periods of time.  This often serves to worsen individuals’ symptoms and problems rather than help them.  DBT clients are also prone to engage in behaviors that keep them institutionalized longer.  Even when clients maintain behavioral and emotional control, the systems may not reinforce them for their positive behaviors.  In many systems across the country, there is inadequate housing to move individuals to a less restrictive setting once they are approved to transfer.  In this situation, clients may de-escalate or revert to previous negative patterns.

Milieu forensic programs provide structure for inpatients that can help them maintain behavioral control and regain stability in the short term.  At the same time, the inpatient setting does not mimic their lives in the community, and treatment targets on the diary card may not reflect the challenges they will encounter when discharged.  It is therefore important for DBT clinicians to find ways in which experiences in the inpatient setting parallel the environment they will encounter once discharged.  In addition to life threatening behaviors, therapy interfering behaviors, and quality of life behaviors, there are several additional primary targets for inpatients:  behaviors that got you hospitalized, behaviors that must be addressed to be discharged, and behaviors that are likely to be a problem after discharge. 

In terms of support and skill building for the treatment providers, forensic settings face some unique challenges.  Many facilities create DBT teams to address a specific concern, and may fund initial training but not anticipate the ongoing support and training needed to create a sustainable DBT team.  They may therefore not provide teams with time in their schedules for weekly team consultation meetings.  Without administrative support, the time to participate in a team often comes during personal time so that other duties can be met.  This can contribute to team member burnout and reduce the efficacy and engagement of the team members.  In creating teams initially, it is therefore important to educate and orient administrative staff to the DBT model.  The most successful forensic teams have an administrator who supports DBT and understands the time resources needed to create and sustain a team. 

Another challenge faced by forensic team consultation groups relates to maintaining empathy for clients who may harm coworkers or other patients with whom the clinician is actively involved in providing treatment.   Because of this, consistent team consultation meetings are crucial.  Strategies for addressing challenges in team consultation for forensic teams are the same as those in other DBT settings.  The Observer role can be especially important in helping team members identify when another team member may be experiencing judgments and ensuring that they receive adequate support from their team in regaining a nonjudgmental stance.

Despite all of the challenges, DBT in forensic settings can be highly satisfying. With team commitment to meeting all of the functions of a comprehensive treatment program, DBT forensic teams have an opportunity to meet the needs of another population that is highly in need of effective interventions.

Read here for our series on “Staying Balanced When Treating Patients at Risk for Suicide” to learn more about the role teams play!

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.


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