New York City Barry Rosenfeld, Ph.D., A.B.P.P. Fordham University, Bronx, NY USA Overview Riker’s Island � Background � Introduction to DBT � Rationale and theoretical overview � Elements of treatment � Adaptation to offender treatment � Challenges in adapting DBT � A case vignettes or three � Summary/Future directions What Should Offender What is DBT? Treatment Look Like? � Integrative treatment incorporating cognitive, behavioral techniques with mindfulness ‐ based � Core issues include: strategies � RNR principles � Originally developed by Linehan (1993) for � Addressing motivation to change treatment of self ‐ injury in Borderline PD � Acceptance and non ‐ confrontational approach � Subsequently applied to wide range of problem � Development of pro ‐ social skills behaviors (substance abuse, eating disorders, � Measurable outcomes juvenile offenders)
Theoretical Background & Treatment Frame Biological Dysfunction in the Emotion Regulation System Ac c e ptanc e Change Invalidating Environment Bio so c ial Bio so c ial T T he o ry he o ry Diale c tic s Pervasive Emotion Dysregulation (BPD) The General Approach � Principle, not protocol driven Biological Dysfunction in the Emotion Regulation System � Allows for considerable flexibility but creates challenges for therapists � Treatment engagement is CRUCIAL first step � Validation is integral to developing engagement Invalidating Environment � Focus is development of skills, not insight � Functional assessment of individual behavior key � Individual and group elements support each other Pervasive Emotion Dysregulation (BPD) Under ‐ experience of Emotion (Psychopathy) What Is Validation? � Validation is: Vulne rability F ac to rs � Treating the client as worthy of attention and respect � Finding kernels of truth or wisdom in client’s behavior Pro ble m Be havio r � Seeing the the client’s point of view – and saying so � What validation can do is: � De ‐ escalate a dysregulated individual Pro mpting E ve nt � Reduce isolation, stress and opposition � Strengthen ability to find own wisdom, confidence � Strengthen the relationship L inks � Increase desire to solve problems, change behavior Co nse que nc e s
Elements of DBT Adapting the Approach � Emphasizing commitment � Four “modes” of treatment � Explicit validation of mandated tx/power differential � Group skills training – 4 modules: mindfulness, emotion � Problem Orientation: MUST find shared genuine goal regulation, distress tolerance, interpersonal effectiveness � Treatment targets � Individual therapy sessions – focuses heavily on behavioral � Instant offense is starting point, but often minimized analysis, reviewing problem behaviors, applying skills � Other illegal behaviors � Coaching – enables application of skills to everyday � Treatment interfering behaviors problems and situations � Lying, threats, being unavailable for tx (rearrest) � Consultation team – provides support and feedback for � Structuring the environment (SAFETY) therapists � Observing limits around self-disclosure � Ancillary treatments often recommended – e.g., � Multiple staff available at all times � Regular violence risk assessments substance abuse, psychopharmacology Commitment Strategies Treatment Target Hierarchy � Issue of mandated treatment prominent 1. Life-threatening behaviors � Explicit validation of experience of mandated treatment � Violent behaviors, thoughts, and urges � Explicit validation of bias, racism, injustice in their lives � Suicidal behaviors, thoughts and urges and the criminal justice system, as appropriate � Serious criminal behaviors and urges � Freedom to choose with absence of alternatives 2. Therapy-interfering behaviors � Agreement on goals is essential � Absenteeism, lying, no homework � Is life worth living? � What changes would YOU like to see? 3. Quality-of-life interfering behaviors • “Minor” or non ‐ violent criminal behaviors • Interpersonal, employment, housing, school ‐ related • Mental health/substance abuse needs Adapting the Skills Summary of DBT Approach � Most skills were originally developed for women � DBT principles appear to have excellent utility � Adaptations for antisocial males include: � Need to focus on all emotions, not just distress � Finding balance between demands of probation, work, � Concept of dialectics avoids power struggles other obligations, AND impulse to refuse treatment � Treatment engagement and extensive validation � Weighing pros/cons of impulsive actions in response to allows treatment to occur frustrating situations (e.g., impulse to fight, no ‐ show) � Behavioral contingencies frequently create problems � Using mindfulness exercises to address reactivity in real world … crime and aggression pay! � Teaching validation and dialectical thinking � Challenging cognitions that support antisocial behaviors w/ dialectical strategies, not confrontation � Teaching problem ‐ solving skills
Project SHARP Preliminary Observations � 6 ‐ month program comparing DBT, anger mgmt � Began expanding treatment population from � Participants referred from NYC Dept of Probation, stalking to DV to general offender sample court (direct), lawyers (most mandated to tx) � Incorporated CAPP to permit more comprehensive � Initial intake assessment focused on diagnosis, assessment of psychopathy, assessing change understanding offense, violence risk assessment � Varying levels of success � Collateral info available varied from none to extensive � No apparent connection to psychopathy severity � Formal assessment before participation included � Trainee therapists seemed to disarm offenders � Structured clinical interview (SCID I & II, PCL ‐ SV) � Helps minimize power struggles � Battery of self ‐ report questionnaires � Exclusion criteria: acute or unmanaged psychosis, high risk of violence, adults, English speaking Case Vignette: VL Case Vignette: RH � 23 y.o. mixed race M, arrested for grand larceny but � 31 y.o. BM referred after domestic violence arrest w/ extensive psych hx, multiple past violent offenses � Multiple prior arrests for domestic violence � Raised in foster care 2 o mo’s substance abuse; ran away � Also had hx of gun possession & distribution charges (first arrested at age 15, multiple felony charges) frequently, involved in ETOH/SA since 10 y.o. � Raised by mo, in/out of group homes as child; extensive � > 20 prior arrests; hx of physical abuse – family and in group homes � Multiple prior hosps, suicide attempts/gestures � PCL ‐ SV=19; dx’d w/ APD, cannabis abuse � High level of psychopathy (PCL ‐ SV=21); met dx criteria � Initially manipulative and superficial; some attendance for APD, BPD, Paranoid and Depressive PD’s probs (late, occasional missed sessions) � Easily engaged but VERY needy; attendance probs due � By month 4, had become more engaged; actively to childcare responsibilities (gf’s child) participating in group, calling between sessions � Completed tx, w/ no evidence of reoffense @ 2 yr f/u � At 2 ‐ year f/u had no re ‐ arrests Case Vignette: LR Case Vignette: AW � 29 y.o. HM referred for stalking and DV; had multiple � 27 y.o. WM self ‐ referred at gf’s suggestion open cases against two different women � Acknowledged long hx of criminal behavior, infidelity in relationships, but no prior arrests � Attributed charges to anger when both women discovered he was cheating on them � Upper middle class background (both parents MDs), college grad, but minimal work hx, aimless lifestyle � Lived in multiple homes as child; on own since 14 y.o. � Hx of psych tx, dx’d w/ APD, bipolar (Rx: Depakote) � Had moderate level of psychopathy (PCL ‐ SV=16) and significant ETOH/SA hx, but no prior psych tx � Motivation seemed questionable; presented as very manipulative, but more engaged as tx progressed � Attended 3 sessions, but rearrested on new charge � Resumed tx 3 mos later, but rearrested after another 3 � Therapist left mid ‐ tx; requested continued tx outside of study (offered $, meet at Starbucks); became angry sessions; never able to engage in tx when request not met and refused new therapist
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