International Journal of Forensic Mental Health

2004, Vol. 3, No. 1, pages 93-103

The Development and Implementation of Dialectical

Behavior Therapy in Forensic Settings
Lisa G. Berzins and Robert L. Trestman

As a result of deinstitutionalization, currently there are three times as many men and women with mental
illness in U.S. jails and prisons than in mental hospitals. Appropriate treatment of this population is critical
to safety within correctional institutions, successful integration of offenders into the community upon release
and a reduction in recidivism. Dialectical Behavioral Therapy (DBT), originally developed by Linehan for
chronically parasuicidal women diagnosed with Borderline Personality Disorder, has been adapted for
many other populations over the past decade, including male offenders in correctional institutions. This
article presents a rationale for use of DBT in a correctional environment and reviews DBT implementations
in correctional settings in North America. Because all of the initiatives thus far have been driven by clinical
need, there are no published adaptations of DBT modified for and generalizable to correctional settings.

The need for mental health treatment within the
United States criminal justice system has never been
greater. By midyear 1998, an estimated 283,000
mentally ill offenders were housed in the nation’s
prisons and jails (Ditton, 1999). As a result of
deinstitutionalization, currently there are three times
as many men and women with mental illness in U.S.
jails and prisons than in mental hospitals. Moreover,
the severity of mental illness of those incarcerated
is increasing. While inmates suffering from severe
depression may just appear withdrawn and un-
sociable, others suffer from severe behavioral
dyscontrol manifested in assaultive, suicidal or self-
mutilating behavior. (Human Rights Watch, 2003).
The nation’s correctional system has essentially
become its default mental health system. The shifting
of persons with serious mental disorders from
hospitals to criminal justice settings has been termed
the “criminalization of the mentally ill” (Munetz,
Grande, & Chambers, 2001).
According to the U.S. Department of Justice,
only six in 10 offenders with mental illness receive
mental health treatment (Ditton, 1999). There is
evidence that mentally ill offenders in prisons
commit more infractions, serve longer sentences and
are more likely to be victimized than inmates who
are not mentally ill (O’Connor, Lovell & Brown,
2002). Mentally ill inmates assigned to The
Washington State Program, mandated by the state
legislature to provide services for mentally ill
offenders, committed infractions at three times the
rate found among general population inmates
(O’Connor et al., 2002). Fifty-three percent of
mentally ill offenders compared to 46% of all other
offenders have committed a violent offense. Mentally
ill offenders were also more likely than other inmates
to have a prior offense and they tended to have longer
prior criminal histories (Ditton, 1999).
The high incidence of personality disorders in
prisons and forensic psychiatric settings is well
documented. In the Colorado Mental Health Institute
at Pueblo (CMHIP) DBT unit, 50% of the patients
carried diagnoses of BPD or Antisocial Personality
Disorder (ASPD) as measured by the Structured
Clinical Interview for DSM-III-R (SCID), and 40%
had both diagnoses (McCann, Ball, & Ivanoff, 2000).

The authors are grateful to the National Institute of Justice (2002-IJ-CX-K009) for their support in making our current research
project possible. The ongoing support of Dr. Dan Bannish (CT Department of Correction) is sincerely appreciated. Many thanks to
Robin McCann (Colorado Mental Health Institute at Pueblo), Chuck Giles (Mondford Psychiatric Unit, TX), Georgina Ashlock (US
Medical Center for Federal Prisoners), Eric Trupin and Brad Beach (Echo Glen Children’s Center, WA), Donna McDonaugh
(Correctional Services of Canada) and Gerald Hover (Twin Rivers Corrections Center, WA) for information regarding their involvement
in the development and evaluation of forensic DBT programs. Thanks also to Catherine Gonillo for her assistance in reviewing the
literature.
Please address correspondence to Robert L. Trestman, Ph.D., M.D., Department of Psychiatry, MC-1410, University of
Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030-1410 (E-mail: trestman@psychiatry.uchc.edu).

©2004 International Association of Forensic Mental Health Services

94 Berzins & Trestman
In a sample of 243 male and female violent offenders,
Coid (1992) found that borderline, antisocial and
narcissistic disorders were the most prevalent.
Blackburn and Coid (1999) also found high rates of
overlap in diagnostic patterns of personality disorders
among violent male offenders. In a sample of 164
adult males who had committed offenses involving
serious violence, frequencies of categorical
diagnoses representing greater that 25% of the
sample were antisocial 62%, borderline 57%
narcissistic 55% paranoid 48% passive-aggressive
34% and histrionic 28%. The authors emphasize the
heterogeneity in personality pathology among
dangerous offenders.
Other studies have found significant comorbidity
between Axis I and Axis II disorders among
offenders. In a study of female inmates, Zlotnick
(1999) reported that 48% of female offenders who
met criteria for ASPD (48%) and BPD (40%) also
had concurrent major depression (48%). A review
of New York State prison mental health data (Rotter
et al., 2002) revealed that 61% of inpatient offenders
and 29% of outpatient offenders had comorbid
diagnoses of a personality disorder and schizo-
phrenia, while 17% of inpatients and 37% of
outpatients had concurrent diagnoses of a personality
disorder and mood disorder.
Evidence suggests that mentally ill offenders
tend to have the greatest difficulty adjusting to prison
rules and routines and are more likely to incur
violations and accumulate disciplinary tickets. In a
sample of 3,426 federal prison inmates, Adams
(1983) found disciplinary infraction rates were 21.6
per 100 for mentally ill offenders compared to 14.0
per 100 for other offenders. Following a review of
inmates’ disciplinary records in Indiana’s special
housing unit, Human Rights Watch (1997) reported
that mentally ill offenders were most frequently
charged with self-mutilation, threatening behavior,
refusing orders, insolence and vulgarity, throwing
urine or feces, assault, battery, disorderly conduct,
destruction of state property, and physically
restricting a staff member.
Without appropriate psychiatric treatment within
the correctional institution, behavioral dyscontrol can
lead to a variety of public safety concerns such as
management crises within the prisons, failure to
integrate successfully in the community upon release
and an increase in recidivism (Trestman, 2002). In a
sample of severely mentally disabled individuals
registered with the Ohio Department of Mental
Health who were incarcerated during mid-1995, 89%
had been arrested previously and 56% of these arrests
occurred within the previous 12 months. At follow-
up, 62% of the sample was rearrested within the post
incarceration year, and 13% of those rearrested were
arraigned for violent offenses (Munetz et al., 2001).
The prevalence of crime and recidivism has led to
an increase in prison sentences. Psychiatric
interventions are critical to improve the management
of mentally ill inmates within the correctional
environment, help inmates integrate into society and
decrease recidivism.
RATIONALE FOR USE OF DIALECTICAL
BEHAVIOR THERAPY IN A CORRECTIONAL
ENVIRONMENT
Background of DBT
Dialectical Behavior Therapy (DBT) was
originally developed to address the needs of
chronically suicidal/parasuicidal females diagnosed
with Borderline Personality Disorder (BPD).
Parasuicide is defined as any intentional, self-
injurious behavior resulting in actual tissue damage,
illness, or risk of death (Linehan, 1993a). It was the
first empirically supported treatment for this
complex, difficult-to-treat population characterized
by affective lability, cognitive disturbances, self-
harming behavior, chronic feelings of emptiness,
interpersonal dysfunction and anger management
difficulties. In a controlled trial comparing DBT to
treatment-as-usual (TAU), DBT significantly
reduced anger, suicide attempts and parasuicidal
behavior, as well as the number of inpatient
psychiatric days. It also improved social adjustment,
treatment compliance and dropout rate (Linehan,
Armstrong, Suarez, Allmon, & Heard, 1991).
DBT is a comprehensive cognitive behavioral
treatment that combines the basic strategies of
behavior therapy with Eastern mindfulness practices.
The fundamental dialectic involves a balance
between validation and acceptance of individuals as
they are, within the context of simultaneously helping
 Development of DBT in Forensic Settings
them to change (Dimeff & Linehan, 2001). Linehan
(1993b) identifies four problem areas that tend to be
found in BPD-confusion about self, impulsivity,
emotional instability and interpersonal problems.
DBT is predicated on Linehan’s biosocial theory that
addresses the etiology of BPD and its associated
behavioral patterns. The ongoing transaction between
the individual’s biological vulnerabilities with his
or her invalidating environment results in pervasive
emotional dysregulation, which is the underpinning
of the individual’s problems.
In “standard” DBT, all modes of treatment
revolve around the individual therapy relationship
(Linehan, 1993a). The DBT primary therapist is
responsible for treatment planning, ensuring progress
toward all DBT targets, helping to integrate other
modes of therapy, consulting to the patient with
regard to effective behaviors with other providers
and management of crises and life threatening
behavior. Before therapy even begins, the therapist
and patient must agree on the goals of treatment and
establish treatment targets in accordance with levels
of disorder. (For the purposes of this paper, only
Level 1 disorders and primary targets will be
discussed. Please refer to Linehan (1993a) for a
complete discussion of treatment for level 2-4
disorders). The goal of treatment with Level 1
disorders is to move the patient from severe
behavioral dyscontrol to behavioral control. This is
accomplished by decreasing life-threatening
behaviors, therapy-interfering behaviors and quality-
of-life interfering behaviors. Life-threatening
behavioral targets include suicide and life-threat-
ening crises behaviors such as risk of imminent
suicide, suicide attempt, homicide, serious aggres-
sion, and severe parasuicidal (self-harm) behaviors.
Therapy-interfering behaviors include behaviors that
interfere with receiving therapy (noncompliance,
failure to attend sessions or to collaborate with the
therapist), behaviors that are disruptive to other
patients, and behaviors that “burn out” the therapist.
Therapists may also engage in therapy-interfering
behaviors such as disrespect for the patient or
behaviors that unbalance therapy (e.g., extreme
acceptance or change; extreme nurturing or
withholding). Examples of quality of life-interfering
behaviors include incapacitating DSM Axis I, II &
IV disorders, extreme financial difficulties, criminal
95
behavior that may lead to jail and homelessness or
severe housing difficulties.
A central component of DBT involves targeting
the four problem areas of BPD by teaching
corresponding behavioral skills modules designed
to increase adaptive behaviors and cognitions while
simultaneously decreasing maladaptive behaviors
and cognitions. The four skills modules include: (1)
mindfulness skills, (2) distress tolerance skills, (3)
emotion regulation skills and (4) interpersonal
effectiveness skills. Mindfulness involves attention
to the present moment and targets self-dysregulation
and identity confusion by emphasizing self-
awareness. Distress Tolerance focuses on using
strategies to tolerate distress, without making it worse
by engaging in impulsive, self-destructive behavior.
It emphasizes distraction and self-soothing tech-
niques, as well as strategies that help individuals
“radically” accept traumatic events in their lives.
Emotion Regulation teaches how to identify and
describe emotions, how to reduce vulnerability to
negative emotions and how to increase positive
emotions. Interpersonal Effectiveness teaches
assertiveness and other interpersonal skills, to help
deal with conflict situations and to get what one
wants and needs in a manner that maintains self-
respect as well as others’ liking and/or respect.
Community Adaptations of DBT
Over the past decade, there has been a prolifera-
tion of adaptations of DBT to other populations and
disorders in a variety of treatment settings. Some of
these adaptations include DBT for suicidal adoles-
cents (Rathus & Miller, 2000), elderly depression
(Lynch, 2000), spouse abuse (Fruzzetti & Levensky,
2000), eating disorders (Telch, Agras, & Linehan,
2001), substance abuse (Dimeff, Shireen, Brown, &
Linehan, 2000) and forensic inpatients (McCann,
Ball, & Ivanoff, 2000). DBT is especially well suited
for the treatment of problems characterized by
behavioral dyscontrol such as self-harm, violent
aggression and poor impulse control. It is highly
structured, particularly during the initial stage of
treatment when the individual is lacking in
behavioral control and consequently engaging in
dysfunctional and life-threatening behaviors.
96 Berzins & Trestman
Forensic Applications of DBT
McCann et al., (2000) contend that several
factors argue for the use of DBT in a forensic
inpatient setting.
(1) The first factor is the high incidence of
personality disorder diagnoses within this population
as discussed earlier in this paper.
(2) The second factor is that DBT is a compre-
hensive cognitive-behavioral treatment that is highly
structured with a clear behavioral hierarchy.
Cognitive behavioral therapy (CBT), which
addresses faulty cognitions, has been used success-
fully with incarcerated offenders. In a meta-analysis
of outcomes from 26 research articles addressing the
effectiveness of group therapy with adult offenders
(Morgan & Flora, 2002), positive effects of CBT
included improved interpersonal functioning, self-
esteem, anger management and a decrease in feelings
of anxiety as well as in disciplinary actions. Allen,
Mackenzie & Hickman (2001) reviewed another set
of studies using two different types of CBT in
correctional environments: one which focused on
increasing moral reasoning and one designed to
change criminogenic thoughts and attitudes. Their
results showed that both approaches appeared to be
successful approaches to reducing recidivism.
(3) Another factor is that managing life-
threatening and aggressive behaviors is critical to
the safe operation of a correctional environment.
Effective treatment of inmates can alleviate stress
for custody staff as well as for the inmates
themselves.
(4) A related factor is that DBT addresses staff
burnout (McCann et al., 2000). Correctional officers
identify the threat of violence by inmates as their
most frequent source of stress. This stress is often
exacerbated by the challenges of dealing with
inmates who exhibit severe behavioral dyscontrol
(Appelbaum, Hickey, & Packer, 2001). Often the
stresses of incarceration tax the limited coping skills
of mentally ill inmates, resulting in increased
dysfunctional behavior. Correctional staff may label
the symptoms of mental illness as “bad behavior”
and therefore retaliate with punitive measures
(Cohen, 2003).
Biosocial Models of BPD and ASPD
Linehan (1993a) postulates a biosocial theory
of BPD that is a result of the transaction between
biological dysfunction in the emotion regulation
system (high sensitivity to emotional stimuli coupled
with a low return to emotional baseline) with
pervasive invalidation over time. This results in an
inability to modulate emotions (pervasive emotional
dysregulation). The invalidating environment is one
in which the individual’s expressions of private
experiences are not validated, but rather are often
punished, trivialized or rejected as inaccurate. One
of the most salient examples of the invalidating
environment is childhood sexual abuse which is
highly associated with both BPD and suicidal/
parasuicidal behaviors. Whereas the risk for sexual
abuse is approximately two to three times greater
for females than for males (Finkelhor, 1979),
epidemiological data suggests that girls and boys are
at equal risk for physical abuse. One study found
that sexual abuse predicted the diagnosis of BPD,
while the combination of physical and sexual abuse
did not (Bryer et al., 1987).
Although to date there has not been direct
empirical validation of this theory, Linehan proposes
that biological causes could conceivably range from
genetic influences to problematic intrauterine events
to early childhood environmental effects on
development of the brain and nervous system.
(Please refer to Linehan 1993a, pp. 42-65, for a
complete discussion of biosocial theory).
McCann et al. (2000) propose a biosocial theory
in which offenders with ASPD, like their counterparts
with BPD, also experience an invalidating environ-
ment, but one which is characterized by harsh and
inconsistent discipline, little positive parental
involvement and inadequate supervision. Conse-
quently, individuals with ASPD appear emotionally
insensitive, in sharp contrast to those with BPD who
are remarkably sensitive emotionally. Neurophysio-
logical support for this view for at least a subset of
the antisocial population is cited (Hare, 1998). The
authors also cite evidence from twin and adoption
studies suggesting that antisocial traits such as
aggression are moderately inheritable (McGuffin &
Thapar, 1998),
 Development of DBT in Forensic Settings
In the biosocial theory of ASPD, the transaction
is between biological emotional insensitivity and two
factors:
1) Disturbed caring: In their histories, individuals
with ASPD report that caring behaviors were
either invalidated or punished. Modeling of
caring behaviors by family and peers was also
notably insufficient. It may be that whereas high
incidences of sexual abuse occur within
individuals with BPD, physical abuse may be a
more predominant factor in the development of
ASPD. Clearly, more research is needed to
support this hypothesis.
2) Models of positive reinforcement for antisocial
behavior: Family members may directly
reinforce the antisocial individual for using
aversive behaviors to terminate aversive
interactions (Patterson, DeBaryshe, & Ramsey,
1989).
THE USE OF DBT IN FORENSIC SETTINGS
Review Section
DBT is being conducted currently or has been
conducted recently in approximately 12 forensic
institutions and at least 8 criminal justice settings in
North America, the United Kingdom and Australia
(McCann et al, 2000). Contact was made with
clinicians at seven forensic/correctional sites within
North America to glean specific information about
the utilization of DBT within each setting. Published
articles describing the programs/research conducted
in three of the settings were also reviewed. (Table 1)
The CMHIP Forensic Model
A striking adaptation of DBT has occurred at
the Colorado Mental Health Institute in Pueblo
(CMHIP), a 300 bed forensic inpatient division (90%
male), housed within a 600 bed state hospital
(McCann et al., 2000). Seventy-five percent of
forensic patients have been assaultive or charged with
a violent crime. Approximately two-thirds have
primary Axis I diagnoses and the remaining one-third
have primary Axis II diagnoses. The most significant
97
adaptation involved an addition to the Emotion
Regulation module to address the emotional
insensitivity of patients diagnosed with (ASPD). The
primary changes included the addition of the goal to
increase emotional attachment, to increase mind-
fulness of empathy and consequences to others; and
the addition of a skill, “Random Acts of Kindness.”
The “Myths about Interpersonal Effectiveness”
Handout was also revised so as to target antisocial
characteristics and a fifth module; Crime Review
(described below) was added. The remainder of the
manual and skills modules remained intact.
Skills training groups are conducted twice a
week, for 75 minutes each. Mindfulness is conducted
for two to three sessions prior to other modules and
at the end of the last module. On average, Inter-
personal Effectiveness is covered over 14 group
sessions, while Emotion Regulation and Distress
Tolerance are each covered over 10 sessions.
Following completion of two complete cycles of
basic DBT Training and satisfactory completion of
a comprehensive exam covering these skills, patients
are referred to the DBT Graduates’ Crime Group,
another innovative forensic intervention. In Crime
Review, patients learn what led up to their crime(s),
practice taking the place of their victim and develop
a relapse prevention plan that includes specific DBT
skills. Each patient is expected to present a
comprehensive chain analysis of his or her crime,
using copies of police reports. The group meets for
1.5 hours a week.
Unlike standard outpatient DBT in which the
focal point of treatment is between the individual
patient and a highly trained outpatient therapist, on
a forensic inpatient unit, individual therapy is costly
and labor intensive. When it is conducted, individual
therapy is only one of many therapies. Analogous to
Level 1 treatment in standard DBT, the goal of
treatment is to move the patient from severe
behavioral dyscontrol to behavioral control. In
addition to life-threatening and therapy-interfering
behaviors, unit-destructive behaviors are also
monitored. Life-threatening behaviors include
killing, maiming, physical or sexual assault and
obtaining, hiding or making weapons. Unit-
destructive behaviors include rule infractions, lying,
conning, harassment, use of substances and violation
of others’ rights. Therapy-interfering behaviors,
 98

Table 1
Summary of DBT Used in Different Correctional Facilities

Institution Contact Population Screening Assessment Modules Hours Length Additional Treatment Training Other
Treatment Manual Manual

Colorado Robin male forensic patient quizzes, 4, ER-revised 2x/wk,75 M-3 repeat 2- BCA group, yes no case
Mental McCann inpatients agreement exams, to address min, 3-12 3,IE-14;ER- Advanced consultation
Health roleplay ASPD per group 10,DT-10 DBT-Crime
Institute Review

US Med Ctr Georgina male forensic extensive none 4 standard, 1 hr 2x standard skills review, no no many inmates
for Fed Ashlock inpatients, BPD mentioned “modify in wk; 13 assertiveness, thrown out
Prisoners- the moment” per grp team bldg
Axis II
Program

Correctional Donna female forensic behaviors don’t graduate 4+ 2 hrs M-6 plus crime cycle, yes will support
Services of McDonough inmates, MHU consistent until behavior orientation 2x/wk, review IE-12; commitment send coaching,
Canada & max sec with BPD, changes and bridging 8 per group ER-14; to tx consultation
no cognitive DT-10 individual tx team
impairment

Echo Glen Eric Trupin; female juvenile none none 5-added self- 1-2x/wk 4 wks each individual tx, yes ? consultation
Berzins & Trestman

Children’s Brad Beach offenders, MHU mentioned mentioned management 60-90 min, Bmod, ed, team, staff
Center, and general 8 per group voc, & rec coaching
Washington population programs
State

Twin Rivers Gerald Hover, outpatient male therapist Horvath’s 4-standard 3x wk for 8 wks, I mo not no no only low risk
Corrections Richard sex offenders referred Working Alliance 50 min., break, next mentioned offenders
Center- Packard Inventory, 9 per group module improved
Washington Hanson
State Risk

Mondford Chuck Giles male forensic actively none 5-standard 2 hrs standard or individual yes no modified to be
Psychiatric inpatients suicidal mentioned plus anger 2x/wk, “DBT Lite” therapy more “inmate
Unit, management 8 per group friendly”,
Lubbock, consultation
TX team
 Development of DBT in Forensic Settings
which are similar to those in standard DBT, include
derogatory comments to group members and staff
which interfere with other patients and create staff
burnout.
Initially, individual therapy was conducted by
members of the nursing staff, but due to staffing
shortage, a Chain Analysis Group was formed to
review diary cards and Behavioral Chain Analyses
(McCann, personal communication, 2003). The
consultation team meets weekly and often grapples
with the dialectical dilemma between staff concerned
primarily with safety and security and those more
focused on treatment. The goal is to find the “truth”
in both positions. Recently, McCann developed a
two-day workshop for staff training that she conducts
with the assistance of the Director of Nursing
(McCann, personal communication, 2003).
Mondford Psychiatric Unit
At Mondford Psychiatric Unit in Lubbock,
Texas, Giles (McCann, personal communication,
2003) revised the DBT manual and handouts to be
more “inmate friendly” (e.g., DEAR MAN became
REAL MAN) and simplified some of the language.
Mondford is a 550 bed psychiatric inpatient hospital
in which 85% of the population is comprised of male
maximum security felons. Of those, 200 have a
history of self-harm (mostly nonlethal). Among the
35-40 offenders who have made a lethal self-harm
gesture while in prison, 18 are actively suicidal. DBT
is reserved for this most “at risk” group, with skills
training and individual therapy conducted by two
different therapists.
Although they do not have much data due to
“internal politics”, Giles’ opinion is that treatment
with DBT has been effective in decreasing cutting
and other parasuicidal behaviors as well as increasing
self-management. For the most dangerous offenders,
they have retrofitted their dayroom with individual
cages so that the therapists can safely co-facilitate
group while sitting in the middle. Groups are limited
to eight inmates.
Skills Training Groups meet twice a week for
two hours. Although there has been some experimen-
tation with the order and length of the skills modules,
staff has found that adherence to Linehan’s standard
format works best (Giles, 2003). For inmates with
99
shorter stays, there is an abbreviated version of
standard DBT, dubbed “DBT Lite”- in this adapta-
tion, staff has selected the worksheets from each
module that they deem most essential. Rather than
running for the standard 12 weeks, “DBT Lite” is
conducted over an 8-week period. A fifth module,
anger management, has been added which was
adapted from Perkinson (1997).
Within each module, there is a list of “criminal
thinking errors” followed by a “corrective.” For
example, from the Emotion Regulation Module:
“Criminal Thinking Error: FEAR: His fears are
widespread, persistent, and intense, especially fear
of being caught for something, fear of injury or death,
and fear of being put down. CORRECTIVE: Learn
to use fear constructively as a guide for responsible
living. Fear can preempt injurious action and is an
incentive for self-improvement.”
U.S. Medical Center for Federal Prisoners,
Axis II Program
At the U.S. Medical Center for Federal Prisoners
in Springfield, Missouri, a separate DBT unit exists
which is housed within a hospital within a prison.
Participants are adult male federal inmates who must
meet criteria for either BPD or Borderline Personality
Traits. According to Georgina Ashlock, Program
Coordinator, the unit is unique in that they accept
inmates with the most severe impulsive and
aggressive behavioral dyscontrol (Ashlock, personal
communication, 2003).
Participation is voluntary and there is an
extensive screening process for referral to the
program. Among the criteria for inmates’ inclusion
are at least 18 months left on their sentence, the
absence of a psychotic disorder, the absence of
mental retardation, no incidences of predatory
violence within the past 12 months, with recent non-
predatory acts of violence to be reviewed on a
case-by-case basis, and sufficient self-control so that
the use of restraints or prolonged housing in a locked
cell are not required. Conversely, inmates are
expelled from the program due to significant acts of
violence, ongoing disruption of the treatment
program for the other inmates and inability to control
behavior sufficiently without the use of restraints or
prolonged housing on a locked unit.
100 Berzins & Trestman
Skills training groups are conducted twice a
week for an hour with 13 inmates per group. Standard
DBT format is utilized for the skills modules
(Linehan, 1993b), although group leaders may take
liberties to “modify in the moment”. In addition to
standard DBT, inmates are offered voluntary skills
review group, assertiveness group and team building
skills. Many of the inmates also participate in
individual therapy. According to Dr. Ashlock, the
most difficult problem has been that of retention.
Due to antisocial behavior, inmates are often expelled
which is problematic in that it creates a selection
bias. To date, there are no empirical outcome
measures.
Twin Rivers Corrections Center- Sex Offender
Treatment Program
As described in Gordon and Hover (1998), the
Twin Rivers Sex Offender Treatment Program
(SOTP) within Washington State’s Department of
Correction has two phases. During Phase I, 200
convicted rapists and pedophiles were treated for one
year during their final 24 months of incarceration.
The focus of treatment was cognitive behavioral and
it was geared toward relapse prevention, behavior
chain analysis, arousal pattern and interventions.
Inmates participated in eight hours of group therapy
and one hour of individual therapy per week.
Phase II occurred in the community and
consisted of 2 1/2 hours of group therapy per week
and individual therapy as needed. DBT skills training
groups were offered to Phase II inmates referred by
their therapists. Presentation and order of skills
modules were in accordance with standard Linehan
format (Linehan, 1993b). Groups met three times a
week for 50 minutes over an eight week session.
There was a one month break and then the next
module would begin.
The authors hypothesized that by teaching
Interpersonal Effectiveness Skills, the degree of
collaboration between inmate and therapist would
increase. As measured by Horvath’s (1981) Working
Alliance Inventory, the pre-post alliance results
demonstrated significance at the .04 level, suggesting
that inmates were more positively collaborating
against inmate pain and self-defeating behaviors than
when they first began the module.
To test the hypothesis that teaching Emotion
Regulation skills would decrease impulsivity, the
authors used the Irritability Scale (Caprara et al.,
1985) in which irritability was defined as “a readiness
to explode at the slightest provocation, including
quick temper, grouchiness, exasperation and
rudeness” (Buss & Durkee, 1957). Not only was this
confirmed by 2-tailed t-test, t(26) = 3.370, p < .002,
but irritability decreased more for those who were
more irritable to start with, F = 12.2; p < .002. Using
Hanson’s Quick Risk Scale (Hanson, 1996), inmates
were then divided according to risk for recidivism.
Results demonstrated that there was a significant
difference between the amount of irritability
experienced by low and high-risk inmates at the start
of the skills group but no difference at the end. In
fact, high-risk inmates began to resemble their low-
risk counterparts prior to the onset of treatment.
With regard to Distress Tolerance, it was
hypothesized that the knowledge of these skills
would increase inmates’ ability to tolerate distress
and pain as measured by the Emotional Susceptibility
Scale (Caprara et al., 1985). Emotional susceptibility
was defined as “the tendency of the individual to
experience feelings of discomfort, helplessness,
inadequacy and vulnerability.” Both high and low-
risk inmates began at the same level of emotional
susceptibility. At the end of skills training, only the
low-risk inmates had made progress whereas those
at high-risk had made none.
Hover and Packer’s (1998) study supports that
the use of DBT group skills training alone can have
positive effects which contrasts with Linehan’s own
findings that skills groups training alone did not have
a significant effect (Linehan, 2003). The authors
suggest screening out low-risk offenders since
treatment effects were often diluted by their presence.
They also note limitations of the study, which include
small sample size, lack of random sampling and the
fact that there was no control group.
Correctional Services of Canada
Correctional Services of Canada offer DBT in
three different forensic settings for female offenders
(McDonaugh, personal communication, 2003). On
their eight-bed mental health unit, offenders receive
two hours of skills training per week, an hour of
individual therapy per week and considerable
 Development of DBT in Forensic Settings
therapeutic support. On the maximum security unit,
aggressive, assaultive and parasuicidal behaviors are
targeted and skills training is conducted individually
or in dyads.
Within the general population, offenders receive
one hour of individual therapy per week, support
coaching on an arranged schedule and one-two hours
of skills training per week. On average, skills training
takes 50-60 sessions. Inmates do not “graduate” until
they have made changes in their behavior. Prior to
beginning the four primary group skills modules,
inmates receive five orientation sessions, which
center on goal setting and commitment to change.
There is also a session on the crime cycle, which
utilizes behavioral chain analysis to help offenders
understand the links that have led to their criminal
behavior.
Skills training groups are conducted for two
hours per group, twice a week, with eight offenders
per group. An additional two hours per week is set
aside for practice. The Mindfulness module is taught
over six sessions with review sessions prior to the
remaining modules. Interpersonal Effectiveness is
conducted over 12 sessions, Emotion Regulation is
conducted over 14 sessions, and Distress Tolerance
is conducted over 10 sessions. Subsequently a
“Bridging Module” is taught which focuses on
difficulties breaking the crime cycle. (At the time of
this communication, this module was in the process
of being piloted).
Inmates are selected for the program on the basis
of behaviors consistent with BPD (rather that the
diagnosis itself). Primary criteria for exclusion are
unmanageable Axis I disorders or significant
cognitive impairment. All staff is trained in DBT and
meet as a consultation team. Although they did not
have outcome data at the time of this communication,
data was in the process of being collected. A
treatment manual had been developed as well as a
manual for staff training.
DBT Program for Incarcerated Female
Juvenile Offenders-Echo Glen Children’s
Center, Washington State
At Echo Glen Children’s Center, a State of
Washington Juvenile Rehabilitation Administration
facility, DBT was adapted to treat female incar-
cerated juvenile offenders (Trupin, Stewart, Beach,
101
& Boesky, 2002). DBT was implemented in two
different residential cottages, one a mental health
treatment unit (MHC) and one a general population
unit (GPCD). A third cottage was a general
population unit that served as a TAU control group
(GPCC). Female offenders on the MHC had higher
rates of mood disturbance (83%), disruptive behavior
toward others (92%), self-harm behavior and ideation
(58%) and thought disturbance (58%). Those on the
GPCD were more likely to have substance use
disorders (75%).
The four standard DBT modules plus Self-
Management skills were each taught over a period
of four weeks. Skills training groups comprised two
staff and up to eight residents, and lasted 60-90
minutes, once or twice per week. Homework
assignments consisted primarily of filling out a Diary
Card that recorded the frequency at which each skill
was attempted. Residents were reinforced for group
participation, skills practice and asking staff for skills
coaching. Staff were also reinforced for reading and
learning about DBT, volunteering to co-facilitate
DBT skills groups and applying DBT skills with
residents. Although all staff received DBT training,
those on the MHC received significantly more than
those on the GPCD (80 vs. 16 hours).
During the 10 month period of the study, suicidal
acts, aggressive behavior and class disruption
significantly decreased throughout the year in the
MHC, but were not significantly reduced compared
to the prior year on the same unit. The authors
proposed that one explanation for the mixed result
was the frequent transfer of new residents who were
suicidal and/or aggressive to the MHC, keeping the
overall rates of problem behavior high. Within the
GPCD, there was not a significant reduction in
behavior problems during the 10 month time period,
although this group had significantly fewer behavior
problems from the outset. Similarly, female offenders
in the GPCC did not demonstrate any severe problem
behavior that met the operational definition.
The DBT training was also designed to provide
staff with alternatives to the use of restrictive
punishment (e.g., room confinement, suicide
precautions, school removal). On the MHC, the rates
of restrictive interventions remained constant
throughout the 10 month study, primarily due to the
transfer to the unit of a resident who was on suicide
precautions. However, compared to the previous
102 Berzins & Trestman
year, staff’s use of punitive actions was significantly
reduced. On the GPCD, staff’s use of restrictive
punishment increased during the 10 month time
period. A few staff members used room confinement
as a group punishment for infringements, which was
considered to be lack of adherence to the DBT model.
The authors note that, unlike staff on the MHC, this
staff did not receive the full DBT training.
Finally, DBT intervention did not result in a
significant decrease in risk assessment scores. Again,
the authors noted that multiple items comprising the
risk assessment are fixed (number of prior offenses,
points for crime, prior drug and alcohol use and sex
offenses) and therefore limit variance in risk scores.
Although the results of the study overall were
quite mixed, the authors conclude that the effective-
ness of DBT intervention is enhanced when treatment
is matched to appropriate behavior (i.e., suicidal,
parasuicidal, extremely aggressive and non-
compliant) and when staff is provided with intensive
training.
SUMMARY AND FUTURE DIRECTIONS
The adaptation of DBT to correctional settings
is in its infancy. To date, all of the initiatives have
been driven by clinical need. As a result, there has
been no published manualization of DBT modified
for, and generalizable to, correctional settings.
Sponsored by the National Institute of Justice, a
current research initiative involves a collaboration
between the State of Connecticut Department of
Correction (CDOC), the University of Connecticut
Health Center (UCHC), and Correctional Managed
Health Care (CMHC)—a department of UCHC
designed to provide all medical and mental health
services to all inmates incarcerated in the state of
Connecticut. This collaboration presents an
opportunity to expand knowledge regarding mentally
ill offenders and facilitates treatment necessary to
ensure public safety. The current study is designed
to formulate, implement and evaluate a corrections-
modified DBT (DBT-CM) within three difficult to
manage, impulsive and aggressive male correctional
populations: adults in special management facilities,
impulsive and aggressive adolescents and sex
offenders. We are in the process of formally adapting,
developing and pilot testing DBT-CM manuals
within these three correctional settings. If these
treatment interventions are effective, we will
standardize the protocol and develop treatment
manuals for use by other state and federal facilities.
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