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Promising preliminary results for DBT in a forensic psychiatric setting

Dialectical behavior therapy (DBT) shows promising results in reducing aggressive behavior in a forensic psychiatric sample. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2017, 1-12

The Potential for a Skills-Based Dialectical Behavior Therapy Program to Reduce Aggression, Anger, and Hostility in a Canadian Forensic Psychiatric Sample: A Pilot Study

Authors

Monica F. Tomlinson, The University of Western Ontario
Peter N. S. Hoaken, The University of Western Ontario

Abstract

Dialectical behavior therapy (DBT) is designed to target maladaptive behaviors, such as aggression. The present pilot study assessed whether DBT reduces aggression, anger, and hostility in a forensic psychiatric sample (N D 15). A randomized waitlist control pre-post/follow-up crossover design was employed. Group-level findings indicated a reduction in hostility during and following DBT. Individual- level findings indicated some reductions in aggression during and following DBT. Individual-level findings indicated that participants in DBT improved more on measures of aggression compared to participants in treatment as usual. These results are preliminary. Implications and future directions in research are discussed.

Keywords

Dialectical behavior therapy, forensic psychiatric patients, aggression, anger, hostility

Summary of the Research

“The forensic mental health care system in Canada is responsible for rehabilitating individuals who have engaged in criminal behavior and been found Not Criminally Responsible on Account of a Mental Disorder. Given that these individuals both suffer from severe mental disorders and have histories of criminal behavior, forensic psychiatric hospitals are tasked with the dual responsibility of treating their mental disorders and reducing their risk to society. Treatment in these settings primarily focuses on pharmacotherapy, which is less expensive, resource-intensive, and time consuming than psychotherapy. Pharmacotherapy also has more evidence than psychotherapy for treating primary psychotic disorders, which 70.9% of Canadian forensic psychiatric patients have as their primary diagnosis.” (p. 1)

“While pharmacotherapy is an evidence-based treatment for the primary psychotic diagnoses in these settings, there is little evidence that pharmacotherapy is effective in reducing antisocial behavior either in the hospital or out in the community. There is also little evidence that pharmacotherapy is effective for treating the secondary diagnoses that are equally prevalent among forensic psychiatric populations (e.g., personality disorders, substance use disorders). These secondary diagnoses are highly related to antisocial behavior both in the hospital and the community. The National Trajectory Project in Canada recently reviewed the diagnoses most related to recidivism among 1,800 forensic psychiatric patients and found that a primary psychiatric diagnosis had no influence on risk of recidivism, a substance use disorder increased risk by 1.41 and a personality disorder diagnosis increases risk by 1.48 (when the index offence was against a person as opposed to property). Therefore, the current pharmacotherapy focused approach to rehabilitation in forensic psychiatric hospitals is neither addressing the safety issues in these settings, nor is it addressing the diagnoses or behaviors most related to ongoing antisocial behaviors.” (p. 1)

“Recent research has suggested that evidence-based psychotherapeutic approaches which explicitly target aggressive behavior be incorporated into general psychiatric care in this population. Dialectical behavior therapy (DBT) has surfaced as among the most promising and theoretically appropriate group therapy programs for developing pro-social skills and decreasing antisocial behaviors.” (p. 2)

“DBT has been widely implemented with forensic psychiatric and correctional populations diagnosed with BPD and has been recently recommended to treat individuals with antisocial personality disorder, substance use disorders, and psychopathy. Importantly, DBT has also been deemed one of the most promising therapies for reducing treatment-interfering behaviors, such as physical aggression among individuals with BPD in forensic psychiatric and correctional settings.” (p. 2)

“The following study aims to provide initial evidence that offering a skills-only (i.e., without the individual therapy component) DBT group to a small, diagnostically diverse, forensic psychiatric sample can have both a statistically and clinically meaningful impact on reducing aggression. In this pilot study, the 1993 manual was closely followed. Typically, it takes approximately eight weeks to complete each of the four modules, and then all four modules are repeated. In this pilot, the DBT leaders covered all modules in 6 months (approximately 24 sessions), rather than the prescribed 32 sessions. The transition of patients into outpatient care happened too frequently to repeat all skills modules twice and still retain group members. Therefore, this pilot study will discuss the potential for a six-month, skills-only DBT group to reduce aggression in this sample.” (p. 3)

“Participants’ ages ranged from 28 to 63 years old. Twelve participants identified as Caucasian (80%), one identified as Aboriginal (7%), one as Asian/Pacific Islander (7%), and one as East Indian (7%). Participants had been under the supervision of the forensic mental health care system for an average of 3.6 years. Seven participants had less than a high school education (47%), five participants had a high school diploma (33%), and three participants (20%) had completed some post-secondary education.” (p. 6)

“While these data are preliminary, they demonstrate several interesting trends. First, among the participants who were improving during TAU, there is some indication that they either continued to improve during DBT or maintained their gains. Second, among the participants who were declining during TAU, many of them either continued to decline or moved into the “improvement” or “no change” groups during DBT. Third, among the individuals who remained stable during TAU, most of these individuals moved into the “improvement” group during DBT or remained stable throughout DBT. For example, the two participants who improved on anger during TAU moved into the “no change” group, and two of the three participants in the “no change” group moved into the “improvement” group and one stayed in the “no change” group during DBT. On the hostility measure, no patients improved in the six months before DBT, four patients remained stable, and three declined. During DBT, two patients moved into the “improvement” group, the majority remained stable, and one person continued to decline. During DBT, between 2 and 4 of the 13 participants clinically reliably improved on at least one measure.” (p. 8)

“Important trends were also noted in the six months following DBT. While the percentage of participants who improved was greater on most measures in DBT compared to TAU, it appears that the most improvements occurred in the months following DBT. For example, on impulsive aggression, no participants improved during TAU. In DBT, two participants improved, and during the six months following DBT, four participants showed clinically reliable improvement. In the six months following DBT, only one person declined on a measure of premediated aggression. No other patients declined on any of the measures in the six months following DBT. On measures of impulsive aggression, four participants from the “no change” group clinically reliably improved following DBT. These results suggest that the effects of DBT are most noticeable in the months following DBT, perhaps because patients are able to consolidate and synthesize their skills.” (p. 9)

Translating Research into Practice

“These preliminary findings offer an important starting point for future research. The paramount goal in forensic psychiatric hospitals is rehabilitation and successful, sustainable, reintegration back into society. This goal cannot be met with pharmacotherapy alone. Individuals in these settings need concrete skills with which to cope with the inevitable challenges of inpatient care and reintegration into society. Further, staff need evidence-based therapies for targeting behaviors that threaten safety within the hospital. Future research with larger sample sizes and a more stringent methodology are needed. With these very preliminary findings, the authors are hopeful that future, more methodologically rigorous studies, can help support the use of DBT for reducing aggression, anger, and hostility among forensic psychiatric patients both in forensic facilities and in society.” (p. 10)

Other Interesting Tidbits for Researchers and Clinicians

“When comparing the TAU and DBT groups during the first six months of the study, there is some indication that participants are improving during DBT, or are maintaining their pre-DBT scores. Given that several participants declined during TAU and no participants declined during DBT in the first six months, these results provide no suggestion that DBT is harmful for patients who are declining during TAU. These are important trends that, with a larger sample size, may be detected using more traditional statistical analyses.” (p. 9)

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Authored by Kenny Gonzalez

Kenny Gonzalez is currently a master’s student in the Forensic Psychology program at John Jay College. His main research interest include forensic assessment, specifically violence risk. In the future, Kenny hopes to obtain a Phd in clinical forensic psychology and pursue a career in academia and practice.

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Juvenile Offenders with Subclinical Depression Display Similar Delinquent Behaviors as those Diagnosed with Major Depression

Forensic Training AcademyStructured clinical interviews show an increased level of aggression, substance use, and suicidal behavior among juvenile offenders with subclinical depression. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Law and Human BehaviorFeatured Article | Law and Human Behavior| 2015, Vol. 39, No. 6, 593-601

Aggression, Substance Use Disorder, and Presence of a Prior Suicide Attempt among Juvenile Offenders with Subclinical Depression

Authors

Tamara Kang, The University of Texas at El Paso
Jennifer Eno Louden, The University of Texas at El Paso
Elijah P. Ricks, The University of Texas at El Paso
Rachel L. Jones, The University of Texas at El Paso

Abstract

Juvenile justice agencies often use the presence of a Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis as a criterion for offenders’ eligibility for mental health treatment. However, relying on diagnoses to sort offenders into discrete categories ignores subclinical disorders—impairment that falls below the threshold of DSM criteria. The current study used structured clinical interviews with 489 juvenile offenders to examine aggression, presence of a prior suicide attempt, and substance use disorders among juvenile offenders with subclinical depression compared with juvenile offenders with major depression or no mood disorder. Analyses demonstrated that juvenile offenders with subclinical depression reported significantly more aggression, abuse of substances, and the presence of a prior suicide attempt compared to juvenile offenders with no mood disorder, but did not differ significantly on aggression and substance abuse compared with juvenile offenders with major depression. These results have implications for correctional agencies’ policies through which offenders are offered mental health treatment, and provide a first step in identifying early signs of problematic behavior before it worsens. Specifically, the results support the notion that depressive disorders should be viewed along a continuum when determining how to allocate services.

Keywords

aggression, juvenile offenders, subclinical depression, substance abuse, suicide

Summary of the Research

“In response to growing awareness of the high rates of serious mental disorders (e.g., major depression and bipolar disorder) in criminal justice settings when compared with the general population, many juvenile justice agencies have developed, are considering, or are planning to use specialty services to reduce reoffending among juvenile offenders with severe mental illnesses. Specialty services include mental health courts and specialized probation caseloads, which have demonstrated efficacy at preventing recidivism. However, because access to community treatment providers is often limited, specialized mental health courts for juveniles often have eligibility requirements based on whether the offender has a diagnosable serious mental disorder” (p. 593).

The current diagnostic system overlooks individuals with subclinical depression—those who experience some symptoms of major depression and have impairment in their daily lives, but the duration, severity, or number of symptoms does not meet the threshold to warrant a formal diagnosis. For example, a juvenile who does not present with five symptoms for most of day nearly everyday for at least two weeks, however severe, would not be diagnosed with major depression according to the DSM–IV–TR or DSM–5” (p. 594).

“Delinquency, a general term for minor crime, misbehavior, disruptive behavior problems, and wrongdoing, appears to interact with major depression among adolescents because of a shared diathesis. The irritability from major depression seems to exacerbate the already high levels of aggression found in many delinquent adolescents in the community, which increases the likelihood of continued delinquency, and violence… Juvenile offenders with subclinical depression likely have many of the same problematic behaviors as juvenile offenders with major depression, but lack the minimum number of symptoms needed for a diagnosis, and are typically ineligible for specialized services. The lack of treatment for subclinical depression may increase the likelihood that the juvenile offender’s delinquency, suicidal ideation, and substance use progress to clinical levels and result in future rearrest” (p.594).

To examine the distinction between delinquent behaviors associated with major clinical depression versus subclinical depression, the present study compared juvenile offenders with a diagnosis of major depression and juvenile offenders with no mood disorder diagnosis.

“Data were derived from routine intake procedures at a juvenile probation agency, where juvenile offenders received a comprehensive semistructured mental health assessment. The semistructured interview yielded diagnoses based on DSM–IV–TR criteria. As  described later, the information from these interviews was used to sort juvenile offenders into three categories based on the absence or presence of symptoms and/or the duration and severity of the symptoms of major depression the juveniles endorsed” (p.595). The three groups were: no symptom present, presence of a symptom that did not meet full criteria, and presence of a symptom that met full criteria. Both past and present symptoms were placed into a single category of “lifetime occurrence” (p.595). A total of 489 juvenile offenders from a juvenile probation agency in the Southwestern U.S. were interviewed by master or doctoral students using the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) over a 20-month period.

Results

“Juvenile offenders with subclinical depression tended to report behaviors that were similar to juvenile offenders with major depression, and reported higher rates of prior suicide attempts, greater amounts of aggression, and greater rates of substance use disorder than did juvenile offenders with no mood disorder. It appears that juvenile offenders with subclinical depression experience considerable impairment that is similar to that experienced by juvenile offenders with major depression, even without meeting diagnostic criteria for a mental disorder.” (p.597).

“Recidivism risk is complicated to predict, and prior research suggests that the combination of disruptive disorders (e.g., symptoms include initiating physical fights, bullying, aggressively stealing, etc.) and substance use is even more predictive of rearrest than either component alone. Affective disorders on their own do not predict recidivism, but when combined with both disruptive behavior and substance use, the odds of recidivism are more than 2 times more likely than the odds of reoffending for juvenile offenders with no disorder. The present study supports the notion that juvenile offenders with subclinical depression are a special subgroup that may be at a higher risk of reoffending and substance use issues even though they do not have enough symptoms of depression to warrant a diagnosis” (p. 598).

“Juvenile offenders with mental health symptomology, even without meeting criteria for a DSM diagnosis, may be at a disproportionate risk of recidivism and become more deeply embedded in the criminal justice system” (p.598).

Translating Research into Practice

The authors argued against the categorical use of a DSM diagnosis of major depression as the primary determinant for mental health treatment among juvenile offenders. Instead, juvenile offenders should be diverted from the juvenile justice system and assessed for mental health needs.

The use of the Risk-Need-Responsivity (RNR) model for offender populations addresses mental illness under the responsivity model during treatment planning. “When mental illness is addressed during treatment planning, it appears that the offender has a higher likelihood of successfully abstaining from crime, as mental illness is a barrier to effective rehabilitation for criminal behavior” (p.598). If juveniles with subclinical depression are diverted away from the juvenile justice system and receive adequate mental health treatment via the RNR model, they may have a better chance of desisting from future criminal behavior.

“The present study highlights the need for juvenile justice agencies to screen all juveniles for suicidal risk and mental health symptoms…In addition, correctional staff should be educated on the symptoms that overlap and co-occur so that they can better identify the youth who are in need of services, in need of more intensive interventions, or are at a high risk for future delinquency” (p.599).

Juvenile offenders with subclinical depression are a potential high-risk group for delinquent behavior and thus warrant the necessary mental health care, whether or not they have a diagnosis of major depression.

Other Interesting Tidbits for Researchers and Clinicians

Although these findings suggest juveniles with subclinical depression are similar with those diagnosed with major depression in terms of treatment need, “only a small proportion of juveniles with major depression were represented in the sample (8.0% had major depression), whereas juvenile offenders with no mood disorder were overrepresented in the sample” (p.598). Additionally, the study consisted of mainly Latino participants and collapsed past and present symptoms of major depression, aggression, substance use, and suicidality into one single category. Future research may want to address these limitations to both replicate the findings and note any differences in outcomes for other, non-Hispanic ethnicities or when symptom presentation is coded differently.

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As always, please join the discussion below if you have thoughts or comments to add!

Authored by Sara Hartigan

6Sara Hartigan is a second year Forensic Psychology Master’s student at John Jay and hope to obtain a Ph.D. in Clinical Forensic Psychology in the future. My main areas of interest include clinical evaluations and developing treatment interventions within the forensic population.