Practice-based outcomes of dialectical behaviour therapy (DBT) targeting anger and violence, with male forensic patients: a pragmatic and non-contemporaneous comparison

Pilot Randomized Controlled Trial of a Yoga-Based Intervention Targeting Anger Management for People Who Are Incarcerated

Introduction: Incarceration represents an opportune moment to improve self-management of anger and aggression. A hatha yoga-based intervention (YBI) could serve as a useful adjunctive intervention for anger within prisons. Methods: We enrolled 40 people with elevated levels of anger who were incarcerated (20 in a women's facility, and 20 in a men's facility) in a 10-week pilot randomized controlled trial of a YBI versus. a health education (HE) control group. Participants attended their respective groups once per week. We examined indices of feasibility and acceptability, including intervention credibility, expectancy the intervention would be helpful, intervention satisfaction, class attendance, engagement in personal practice, instructor fidelity, intervention safety, and study recruitment and retention rates. We also examined changes in clinical outcomes including anger, depression, anxiety, and behavioral infractions over time. Results: We met targets for several outcomes: credibility of the YBI and HE interventions, expectancy that they would be helpful, and satisfaction with the programs. Instructors demonstrated fidelity to both manuals. There were no serious adverse events related to study participation. Class attendance did not meet our target outcome in either facility and rates of personal practice met our target outcome in the men's but not the women's facility. For people enrolled in the YBI, anger, depression, and anxiety tended to decrease over time. Qualitative interviews with participants pointed to overall high satisfaction with the YBI and provided information on facility-related barriers to class attendance. Conclusion: Although we did not meet all our feasibility targets in this study, we note high participant enthusiasm. Thus, we believe this line of research is worth pursuing, with further attention to ways to decrease facility-related barriers to class attendance and personal practice. Clinical trials registration: NCT05336123.

Sexual fulfilment, wellbeing and risk considerations for people with sexual attractions to children

Research focused on understanding the experiences of individuals with sexual attractions to children and their pursuit of sexual fulfilment faces notable limitations, primarily stemming from ethical and legal challenges, and pervasive social stigma. This review paper explores these challenges and outlines the connections between sexual fulfilment, treatment goals and overall wellbeing. We consider the importance of sexual satisfaction in promoting mental and physical health, and its potential role in reducing the risk of sexually abusive behaviors. Recognizing that promoting healthier and more fulfilling lives extends beyond risk mitigation, the paper highlights future research avenues such as exploring the conceptualization and achievement of sexual satisfaction. In examining alternative perspectives, including the potential risk enhancement associated with achieving sexual fulfilment, we also argue the need for an evidence-based approach and robust research agenda to inform and guide interventions. Through these considerations, the paper aims to encourage a more informed and compassionate understanding of sexual fulfilment for people with sexual attractions to children.

[What is effective in forensic addiction treatment? A non-systematic look into the evidence base for treatment approaches and interventions in the context of Sect. 64 of the German Criminal Code]

Forensic addiction treatment according to Section 64 of the German Criminal Code is playing an increasingly important role in the German system of correctional institutions. In recent years, the question of the effectiveness of treatment as a whole has been the focus of numerous studies. Less frequently, however, research has addressed the evidence base of therapeutic interventions and efficacy factors. Since this article takes a non-systematic look into the current state of knowledge on specific interventions and factors that play a role in the effective treatment of addicted offenders, the question of what exactly works can only be answered in a rudimentary way. The concept of Therapeutic Community appears to be largely empirically supported. Based on such evidence as is currently available, motivational interviewing and dialectical-behavioral therapy can be considered the most promising forms of therapy. The effectiveness of forensic addiction treatment lies possibly less in the application of individual approaches than in questions of the setting and the attitude of those providing treatment.

Behavioral Self-Blame in PTSD-Etiology, Risk Factors, and Proposed Interventions

BACKGROUND

Feeling out of control during a traumatic event may evoke behavioral self-blame (BSB) to avoid feeling helpless following trauma by restoring one's sense of control. BSB is a common, persistent, and treatment-resistant post-traumatic stress symptom. The present study investigates the etiology and risk factors of BSB following a traumatic event and the reasons for its persistence over time.

METHOD

Subjects were a group of 546 Israeli ex-combat soldiers (M age = 24.93 ± 5.657) registered in an Israel Defense Forces (IDF) combat reaction clinic. All completed the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), the Brief Symptom Inventory (BSI), and the PTSD Checklist for the DSM-5 (PCL-5). Item 10 of the PCL-5 served to measure BSB. The PDEQ and BSI measured distress and feeling out of control during the event. We used descriptive analyses of the data, t-test, and linear regression analysis to reveal the relationship between the research variables.

RESULTS

Feeling out of control during a traumatic event often increases BSB and post-traumatic stress symptoms. A significant correlation emerged between continuing distress characterizing individuals who experience a persistent lack of control and BSB. Female combat soldiers were at a higher risk of BSB than their male counterparts.

CONCLUSION

Loss of control experienced during a traumatic event may result in persistent long-term feelings of lack of control over one's behavior.

Treatment outcomes of Veteran men in a comprehensive dialectical behavior therapy program: Characterizing sex differences in symptom trajectories

Dialectical Behavior Therapy (DBT) is one of the primary psychosocial treatments for reducing suicidal behaviors and improving psychosocial outcomes among patients with borderline personality disorder (BPD) and has been shown to reduce BPD symptoms when delivered in a Veteran Affairs medical center setting. Despite evidence of similar rates of BPD in both men and women, the vast majority of treatment outcome research in BPD has focused on women. We sought to characterize sex differences in symptom trajectories among Veterans participating in a comprehensive DBT program. We found that Veteran men and women who entered the DBT program were diagnostically and demographically similar. Participants exhibited reductions in BPD symptoms and improvements in emotion regulation over the course of treatment. Moreover, Veteran men reported BPD symptom reductions that were not statistically inferior to those of Veteran women and exhibited a sharper reduction in these symptoms. This research provides support for the use of DBT as a psychosocial treatment for Veteran men with BPD symptoms.

Relationships between dynamic risk factors for externalising problem behaviour and group climate in adults with mild intellectual disability in forensic treatment

BACKGROUND

Relationships between dynamic risk factors for externalising problem behaviour and group climate were investigated in 151 adult in-patients with mild intellectual disability or borderline intellectual functioning in a Dutch secure residential facility.

METHOD

Regression analysis was used to predict total group climate score and Support, Growth, Repression, and Atmosphere subscales of the 'Group Climate Inventory'. Predictor variables were Coping Skills, Attitude towards current treatment, Hostility, and Criminogenic attitudes subscales of the 'Dynamic Risk Outcome Scales'.

RESULTS

Less hostility predicted a better overall group climate, better support and atmosphere, and less repression. A positive attitude towards current treatment predicted better growth.

CONCLUSION

Results indicate relationships of hostility and attitude towards current treatment with group climate. A focus on both dynamic risk factors and group climate may provide a basis for improving treatment for this target group.

Gratitude, Forgiveness, and Anger: Resources and Risk Factors for Italian Prison Inmates

The adjustment of prison inmates is recently becoming a social concern. In the current study we focused on the role of gratitude, interpersonal forgiveness, and anger, which have been widely addressed as likely to influence people's health and adaptive behaviors, in shaping prison inmates' psychological wellbeing and criminal attitudes. Participants were 104 male prison inmates aged between 24 and 75 (M_age = 46.63, SD = 11.38) imprisoned in Northern Italy who were asked to fill in an anonymous self-report questionnaire. Results highlighted that all dimensions considered play an important, albeit different and highly specific, role; Gratitude is a promotional factor that enhances psychological wellbeing, whereas interpersonal forgiveness appears to be a protective factor against the adoption of a criminal attitude as violence or antisocial intent. Finally, anger is a risk factor toward both psychological wellbeing and violent behaviors. Implications of these results and further developments of the study are discussed.

A systematic review of the efficacy of psychological treatments for people detained under the Mental Health Act

WHAT IS KNOWN ON THE SUBJECT?: International reviews have looked at therapy outcomes for patients on mental health wards, showing it is associated with reduced emotional distress and readmission. Reviews have not looked at which specific treatments are most effective. No review has been done in England and Wales for patients detained specifically under the Mental Health Act.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

The paper gives an overview of the limited evidence in England and Wales. The paper shows which therapies have been measured. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Larger studies are needed across all types of patient wards in England and Wales with random allocation to types of therapy and longer-term follow-up. More studies are needed where researchers are not aware of the therapy being delivered. More studies need to use a mixture of patient and clinician outcome measures. Outcomes should also measure incident, readmission and reoffending rates. More evidence is needed from patients who are female, non-white and who are diagnosed with depression and anxiety.

ABSTRACT

INTRODUCTION: The efficacy of psychological interventions delivered under the Mental Health Act (1983) (MHA) in England and Wales is unclear. While meta-analyses have reviewed acute and forensic psychological interventions in wider geographical areas, there has been no review specifically in the unique MHA context.

AIM

A systematic review was conducted of psychological outcomes for inpatients detained under the MHA in England and Wales.

METHOD

Diagnoses and type of psychological intervention were not restricted, provided a psychological outcome measure was used. Studies were identified through APA PsychInfo, MEDLINE, CINAHL and Academic Search using a combination of key terms. Data extraction included effect direction, statistical significance, intervention type, format and duration, study size, inpatient setting, control group and study quality.

RESULTS

High-quality evidence was sparse. Some improvements were found in overall well-being, self-esteem, social functioning, problem-solving, substance use, anger, offending attitudes, fire-setting, violence, anxiety, depression, personality disorder and psychosis. However, the overall evidence base is lacking.

DISCUSSION

Larger-scale randomized controlled trials are needed across secure, acute and learning disability inpatient settings in England and Wales with longer term follow-up, blind assessors and both self-report and clinician-rated measures, as well as incident, readmission and reoffending rates. Greater representation is needed of females, non-white groups and affective disorders.

CLINICAL IMPLICATIONS

The efficacy of psychological interventions for inpatients detained under the MHA in England and Wales remains unclear. Clinicians are encouraged to use relevant outcome measures in relation to treatment goals, to monitor the efficacy of interventions being offered to this client group.

RELEVANCE TO MENTAL HEALTH NURSING

This paper highlights the current body of evidence for psychological interventions in inpatient settings within England and Wales, which is an environment in which mental health nursing plays an important role in patients' recovery. This evidence is also particularly important as there is a shift in clinical practice to training nursing staff to deliver some of the low-intensity psychological interventions, such as behavioural activation, solution-focussed therapy and motivational interviewing.

Do Changes in Emotional States Predict Therapy Alliance in Dutch Male Offenders in Mandated Clinical Care?

Therapy alliance has been studied largely in voluntary psychotherapy but less is known about its predictive factors for positive alliance and treatment outcome in forensic populations. The aim of this study was to examine the relationship between offenders' emotional states and therapy alliance. Moreover, we were interested in the predictive impact of emotional states early in treatment on alliance at 18 months into treatment. Self-ratings of emotional states and alliance by 103 male offenders, and therapist-ratings for therapy alliance were examined using hierarchical multiple regression analyses. Participants were primarily convicted for violent of sexual offenses, and were diagnosed with antisocial, borderline or narcissistic personality disorders. Healthy emotional states were predictive of mid-treatment agreement on therapy goals and therapist ratings on tasks within the therapy. Unhealthy emotional states were predictive of patient-rated agreement on tasks. Emotional states were not predictive for the reported therapist/patient bond or global alliance ratings. This study emphasizes the importance of healthy emotional states in treatment of offenders with personality disorders.

Contextualist Perspectives in the Treatment of Antisocial Behaviors and Offending: A Comparative Review of FAP, ACT, DBT, and MDT

This article presents a comparative review of the application of four contextualist therapies in the treatment of antisocial behavior and offending. The therapies reviewed are functional analytic psychotherapy (FAP), acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), and mode deactivation therapy (MDT). A descriptive and comparative review was conducted through a search carried out in both general and specific databases related to each therapy. We included a total of 44 studies treating any type of antisocial behavior or offending. Results show that these interventions have been used to treat challenging behavioral patterns, inmates' institutional behaviors, exhibitionism, at-risk adolescents' aggressive conducts, and offending behaviors performed by juveniles who committed robbery and/or serious sexual offenses. The main conclusions are that the four therapies show very positive outcomes: Although FAP and ACT have been used more sparsely, DBT and MDT have been employed in a larger number of interventions and using more controlled comparative designs. The therapeutic components that seem to be relevant to understanding in a transversal way how changes in behavior are achieved are acceptance/validation of clients' histories of neglect and abuse and clients' commitment to behaving toward their valued directions in life.

Changes in Emotions Over the Course of Dialectical Behavior Therapy and the Moderating Role of Depression, Anxiety, and Posttraumatic Stress Disorder

Evidence-based borderline personality disorder (BPD) treatments such as dialectical behavior therapy (DBT) emphasize the acquisition and use of strategies to down regulate negative emotion. However, little research examines whether specific emotions change during DBT. Further, it is unclear if BPD-relevant comorbidities that involve heightened emotion-namely, depression, anxiety disorders, and posttraumatic stress disorder (PTSD)-moderate these outcomes. This study investigated which specific emotions (hostility/anger, fear, shame/guilt, and sadness) decrease during DBT, and whether comorbid depression, anxiety disorders, and PTSD moderate these outcomes. Individuals with BPD (N = 101) completed 6 months of standard DBT and provided measurements of specific emotions at every session and at pre-, mid-, and posttreatment. Generalized estimating equations revealed moderate effect-sized reductions in anger at major assessment time points. Anxiety disorders and PTSD moderated the effect of time on fear, shame, and guilt. PTSD also moderated the effect of time on sadness. For all moderating effects, individuals with the comorbidity exhibited greater reductions than those without. These findings corroborate that DBT reduces several specific emotions, and comorbid PTSD and anxiety disorders may facilitate this effect for fear, shame/guilt, and sadness (clinical trial registration number = NCT03123198).

A preliminary evaluation of the effectiveness of dialectical behaviour therapy in a forensic psychiatric setting

Dialectical behaviour therapy (DBT) is a therapy model incorporating elements of Eastern philosophies and cognitive behavioural principles. Originally designed for people struggling with chronic suicidality and borderline personality disorder (BPD), it has been adapted to treat complex, multi-diagnostic presentations, such as those in forensic mental health settings. To date, there has been little evaluation when the primary diagnosis is of psychosis. To explore the effectiveness of DBT, with patients, with multiple comorbidities, including psychosis, in a forensic psychiatric inpatient setting. A descriptive outcome study with a cohort of offender-patients in one specialist forensic mental health unit. Before and after treatment change scores were compared on anger, aggression, hopefulness, coping abilities, emotional intelligence, insight and subjective symptom severity scales, as well as staff-rated risk, and length of stay. Nine men and five women residents in one Canadian secure hospital completed a standard DBT programme, and self-ratings, over about 1 year. Scale scores indicated significantly increased insight and acknowledgment of problems. Apparently increased anger and vengeance scores were clinically associated. Independent staff ratings indicated reductions in risk and most patients achieved early release. This study provides support for extension of the use of DBT to offender-patients with psychosis among the complex mix in their presentation. It suggests that a randomised controlled trial with cost-benefit analysis is warranted, as well as further work, to promote understanding of mechanisms of effectiveness.

Strategies for Assessing and Preventing Inpatient Violence in Forensic Hospitals: A Call for Specificity

Abstract. Violence within inpatient forensic hospitals is a significant and enduring problem that leads to harm to staff and patients and causes significant expenditures. This paper provides comprehensive recommendations for developing and implementing violence reduction strategies within forensic settings that are predicated on appropriate evaluation for violence risk. This paper posits that proper strategies must take into account subtypes of violence and classifying risk with systematic and continuous evaluations. Treatment interventions should be geared to patients most at-risk for violence. By recognizing the dynamic nature of violence, hospital administrators can work closely with institution staff to provide support for improving the environment of forensic hospitals. By employing empirically based treatment interventions on both acute and long-term units, forensic hospitals can provide a safer environment.

Dialectical Behavior Therapy for Men With Borderline Personality Disorder and Antisocial Behavior: A Clinical Trial

In addition to suicidal behaviors, men with borderline personality disorder (BPD) often display antisocial behavior that could impair contacts with mental health services. While research has established effective treatments for women with BPD, this is not yet the case for men. The authors evaluated 12 months of dialectical behavior therapy (DBT) for 30 men with BPD and antisocial behavior, using a within-group design with repeated measurements. The authors found moderate to strong, statistically significant pre-to posttreatment reductions of several dysfunctional behaviors, including self-harm, verbal and physical aggression, and criminal offending (rate ratios 0.17-0.39). Symptoms of BPD and depression were also substantially decreased. The dropout rate was 30%, and completing participants reported high satisfaction with treatment and maintained their improvements at 1-year follow-up. The authors conclude that DBT could be an effective treatment alternative for men with BPD and antisocial behavior, and it merits future studies with more rigorous design.

Dialectical behaviour therapy (DBT) for forensic psychiatric patients: An Italian pilot study

BACKGROUND

Several previous randomised controlled trials of dialectical behaviour therapy (DBT) since Linehan's original have shown that it has an advantage over standard care or other psychological treatments, but focus is usually on suicide-related behaviours, and little is known about its effect with offender-patients.

AIMS

To evaluate DBT with a group of offender-patients in the Italian high intensity therapeutic facilities-the Residenze per l'Esecuzione delle Misure di Sicurezza (REMS), established under the Italian Law 81/2014.

METHODS

Twenty-one male forensic psychiatric in-patients with borderline personality disorder were enrolled and randomly assigned to 12 months of standard DBT together with all the usual REMS treatments (n = 10) or usual REMS treatments alone (n = 11). All participants completed the same pretreatment and posttreatment assessments, including the Barratt Impulsiveness Scale (BIS-11), Difficulties in Emotion Regulation Scale (DERS), and Toronto Alexithymia Scale 20 (TAS-20).

RESULTS

Men receiving DBT showed a significantly greater reduction in motor impulsiveness, as measured by the BIS-11, and emotional regulation, as reflected by the DERS total score, than the controls. There were no significant differences between groups in alexithymia scores.

CONCLUSIONS

Italy has innovative forensic psychiatric facilities with a new recovery-rehabilitation approach, but the ambitious goals behind these cannot be achieved by pharmacology alone. For the first time in clinical forensic settings in Italy, there has been limited access to DBT. This small pilot study suggests this is likely to help ameliorate traits associated with violent and antisocial behaviours, so a full-scale randomised controlled trial should follow.

Psychological and psychosocial interventions offered to forensic mental health inpatients: a systematic review

OBJECTIVE

To examine the evidence for the use of psychological and psychosocial interventions offered to forensic mental health inpatients.

DESIGN

CINAHL, MEDLINE, PsycINFO, ScienceDirect and Web of Science databases were searched for research published in English between 1 January 1990 and 31 May 2018.

OUTCOME MEASURES

Disturbance, mental well-being, quality of life, recovery, violence/risk, satisfaction, seclusion, symptoms, therapeutic relationship and ward environment. There were no limits on the length of follow-up.

ELIGIBILITY CRITERIA

We included randomised controlled trial (RCT) studies of any psychological or psychosocial intervention in an inpatient forensic setting. Pilot or feasibility studies were included if an RCT design was used.We restricted our search criteria to inpatients in low, medium and high secure units aged over 18. We focused on interventions considered applicable to most patients residing in forensic mental health settings.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias.

RESULTS

17 232 citations were identified with 195 full manuscripts examined in detail. Nine papers were included in the review. The heterogeneity of the identified studies meant that meta-analysis was inappropriate. The results were presented in table form together with a narrative synthesis. Only 7 out of 91 comparisons revealed statistically significant results with no consistent significant findings. The most frequently reported outcomes were violence/risk and symptoms. 61% of the violence/risk comparisons and 79% of the symptom comparisons reported improvements in the intervention groups compared with the control groups.

CONCLUSIONS

Current practice is based on limited evidence with no consistent significant findings. This review suggests psychoeducational and psychosocial interventions did not reduce violence/risk, but there is tentative support they may improve symptoms. More RCTs are required with: larger sample sizes, representative populations, standardised outcomes and control group interventions similar in treatment intensity to the intervention.

PROSPERO REGISTRATION NUMBER

CRD42017067099.

Changes in Problematic Anger, Shame, and Disgust in Anxious and Depressed Adults Undergoing Treatment for Emotion Dysregulation

Emotion dysregulation, the pervasive difficulty managing negative emotions, is a core problem across mood and anxiety disorders. Anger, shame, and disgust are particularly problematic emotions, impacting both disorder severity and treatment outcome. We previously found that a 16-week dialectical behavior therapy skills training group (DBT-ST) was superior to an activities-based support group (ASG) in decreasing emotion dysregulation in 44 adults with high emotion dysregulation who met diagnostic criteria for an anxiety or depressive disorder. We presently examine these participants' changes in anger, shame, disgust, and distress using self-reports collected over 6 months during and after treatment. Hierarchical linear modeling analyses show that DBT-ST was superior to ASG in decreasing anger suppression (d = 0.93) and distress (d = 1.04). Both conditions significantly reduced shame, disgust propensity, and disgust sensitivity, but neither was superior for these outcomes. The treatments did not significantly reduce anger expression. Mediation analyses suggest that condition indirectly influenced 4-month anger suppression, shame, and distress through its effect on 2-month emotion dysregulation. These findings suggest that DBT-ST is efficacious for certain problematic emotions and distress in depressed and anxious adults and that common factors may account for some, but not all, of its benefits.

Treatment of personality disorder: skills-based therapies

A variety of therapies have been developed or adapted to treat personality disorder over recent years. This article will review skills-based treatments (as opposed to insight-based treatments). Two approaches are outlined: cognitive-behavioural therapy and dialectical behaviour therapy. The article details the underpinning theory and the model of personality disorder utilised by the two approaches, and describes how the therapy is applied. Evidence of therapeutic efficacy is presented along with information about accessing training and therapy materials.

[Standards for treatment in forensic committment according to § 63 and § 64 of the German criminal code : Interdisciplinary task force of the DGPPN]

People who have been convicted of a crime due to a severe mental disorder and continue to be dangerous as a result of this disorder may be placed in a forensic psychiatric facility for improvement and safeguarding according to § 63 and § 64 of the German Criminal Code (StGB). In Germany, approximately 9000 patients are treated in clinics for forensic psychiatry and psychotherapy on the basis of § 63 of the StGB and in withdrawal centers on the basis of § 64 StGB. The laws for treatment of patients in forensic commitment are passed by the individual States, with the result that even the basic conditions differ in the individual States. While minimum requirements have already been published for the preparation of expert opinions on liability and legal prognosis, consensus standards for the treatment in forensic psychiatry have not yet been published. Against this background, in 2014 the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) commissioned an interdisciplinary task force to develop professional standards for treatment in forensic psychiatry. Legal, ethical, structural, therapeutic and prognostic standards for forensic psychiatric treatment should be described according to the current state of science. After 3 years of work the results of the interdisciplinary working group were presented in early 2017 and approved by the board of the DGPPN. The standards for the treatment in the forensic psychiatric commitment aim to initiate a discussion in order to standardize the treatment conditions and to establish evidence-based recommendations.

Psychodynamic Treatment of the Criminal Offender: Making the Case for Longer-Term Treatment in a Longer-Term Setting

In recent years, prisons and jails have become de facto psychiatric hospitals, responsible for the care and treatment of individuals with serious mental illness. Historically, cognitive-behaviorally informed therapeutic approaches have been the treatment of choice among mental health practitioners in correctional settings. However, inmate-clients often present with complex diagnostic issues that are arguably better served by long-term treatment options, such as psychodynamic psychotherapy. We first review the nature of psychotherapy in the correctional setting, as well as treatment barriers and challenges faced by both mental health providers and inmate-clients. We then review treatment studies that examine the efficacy of various therapeutic techniques in correctional/forensic contexts. Finally, we argue that, due to the complex nature of psychopathology, average length of time incarcerated, and treatment issues that arise in this multifaceted and challenging setting, mental health treatment providers should consider providing psychodynamic treatment modalities when working with incarcerated individuals. We also argue that more research is needed to examine the efficacy of these treatment approaches with inmate-clients.

[Dialectical behavior therapy approaches with disruptive behavior disorders]

Disruptive behaviour disorders comprise the diagnosis conduct disorder (CD) and in adults the diagnosis antisocial personality disorder (APD). CD is seen as a difficult-to-treat disorder with a high risk for persistent behavioral problems. In addition, CD is seen as the precursor to antisocial personality disorder (Kretschmer et al., 2014). Dialectical behavior therapy (DBT) was originally developed by Marsha Linehan (1991) for the treatment of borderline personality disorder, but because of the core deficits in emotion regulation in disruptive behavior disorders, DBT is also increasingly being recommended for the treatment of CD and APD. This review presents DBT adaptions for the forensic setting and for the treatment of CD/APD. Clinical implications are discussed.

Pilot study of a brief dialectical behavior therapy skills group for jail inmates

Regulating emotions, refraining from impulsive, maladaptive behavior, and communicating effectively are considered primary treatment needs among jail inmates. Dialectical behavior therapy (DBT; Linehan, 1993a) skills address these deficits and have been implemented in long-term correctional settings, but have yet to be adapted for general population inmates in short-term jail settings. This study assessed the feasibility and acceptability of a DBT skills group in a jail setting, as well as its utility in improving coping skills and emotional/behavioral dysregulation. Male jail inmates participated in an 8-week DBT skills group and completed pre- and posttest assessments of coping skills, emotional/behavioral dysregulation, and measures of treatment acceptability. Out of 27 who started therapy, 16 completed it, primarily due to involuntary attrition such as transfer to another correctional facility. Although several logistical issues arose during this pilot study, preliminary results suggest that a brief DBT skills group is feasible and acceptable in a jail setting, and may improve coping skills and reduce externalization of blame among general population jail inmates. This study lays the groundwork for larger, controlled trials of abbreviated DBT skills groups for general population inmates in short-term jail settings. (PsycINFO Database Record

Dialectical Behaviour Therapy [DBT] with People with Intellectual Disabilities: A Systematic Review and Narrative Analysis

BACKGROUND

There is mixed evidence regarding the effectiveness of psychological therapies for people with intellectual and developmental disorders. Although systematic reviews have supported the use of dialectical behaviour therapy with people with borderline personality disorder, there are no comparable reviews regarding DBT with people with intellectual and development disabilities.

METHODS

Studies were identified using a systematic approach and were selected if they reported an intervention that included a DBT skills group and then assessed using the Evaluative Method for Determining Evidence Based Practice.

RESULTS

Seven studies reported adaptations and outcomes of DBT for people with intellectual and development disabilities, four of which delivered full DBT programmes with three describing DBT skills groups. All studies were appraised with regard to methodological quality and the adaptations and results examined.

CONCLUSIONS

The findings indicate that DBT and DBT skills groups can be adapted for people with intellectual and development disabilities, but further high-quality research is needed to make conclusions about efficacy and effectiveness.

Non-pharmacological interventions for reducing aggression and violence in serious mental illness: A systematic review and narrative synthesis

BACKGROUND

For people with mental illness that are violent, a range of interventions have been adopted with the aim of reducing violence outcomes. Many of these interventions have been borrowed from other (offender) populations and their evidence base in a Serious Mental Illness (SMI) population is uncertain.

AIMS

To aggregate the evidence base for non-pharmacological interventions in reducing violence amongst adults with SMI and PD (Personality Disorder), and to assess the efficacy of these interventions. We chose to focus on distinct interventions rather than on holistic service models where any element responsible for therapeutic change would be difficult to isolate.

METHODS

We performed a systematic review and narrative synthesis of non-pharmacological interventions intended to reduce violence in a SMI population and in patients with a primary diagnosis of PD. Five online databases were searched alongside a manual search of seven relevant journals, and expert opinion was sourced. Eligibility of all returned articles was independently assessed by two authors, and quality of studies was appraised via the Cochrane Collaboration Tool for Assessing Risk of Bias.

RESULTS

We included 23 studies of diverse psychological and practical interventions, with a range of experimental and quasi-experimental study designs that included 7 Randomised Controlled Trials (RCTs). The majority were studies of Mentally Disordered Offenders. The stronger evidence existed for patients with a SMI diagnosis receiving Cognitive Behavioural Therapy or modified Reasoning & Rehabilitation (R&R). For patients with a primary diagnosis of PD, a modified version of R&R appeared tolerable and Enhanced Thinking Skills showed some promise in improving attitudes over the short-term, but studies of Dialectical Behaviour Therapy in this population were compromised by high risk of experimental bias. Little evidence could be found for non-pharmacological, non-psychological interventions.

CONCLUSIONS

The evidence for non-pharmacological interventions for reducing violence in this population is not conclusive. Long-term outcomes are lacking and good quality RCTs are required to develop a stronger evidence base.

Does Suicidal Ideation Influence Memory? A Study of the Role of Violent Daydreaming in the Relationship Between Suicidal Ideation and Everyday Memory

Individuals at risk for suicide experience periods of emotional, enduring, and vivid thoughts about their death by suicide and frequently report violent daydreams about death. Daydreaming is associated with forgetfulness and memory impairments. However, no studies have examined whether suicidal ideation is associated with deficits in everyday memory capabilities and whether violent daydreaming may influence these relationships. This study tested these hypotheses in a sample of 512 young adults. Self-report measures of subjective everyday memory capabilities, violent daydreaming, and suicidal ideation were administered. Results indicated that suicidal ideation and violent daydreaming were each significantly associated with greater impairments in everyday memory retrieval and everyday memory encoding (i.e., attentional tracking). Furthermore, violent daydreaming accounted for the relationship between suicidal ideation and impairments in everyday memory retrieval and memory encoding. Notably, findings remained after controlling for gender and depressive symptoms, a robust predictor of memory impairments. Implications and limitations are discussed.

Crime, violence, and behavioral health: collaborative community strategies for risk mitigation

Criminal conduct is not always violent, and violence does not always lead to criminal charges. Moreover, crime and violence have multifaceted etiologies. Most violence in society is not attributable to mental illness. Where there is a small relationship between violence and mental illness, the risk of violence increases for individuals with substance use histories. Underlying trauma can also play a role. Antisocial attitudes, behaviors, and peer groups further increase the risk that individuals, including those with mental illness, will find themselves at risk of criminal recidivism. Criminal histories among public mental health populations, and mental health and substance use disorders among criminal populations are each higher than general population comparisons. Care within behavioral health settings should therefore target decreased criminal recidivism and decreased violence as part of recovery for those individuals at risk, using trauma-informed approaches and peer supports. Interventions that show promise bring criminal justice and behavioral health systems together, and include police-based diversion, specialty courts, court-based alternatives to incarceration, and coordinated re-entry programs. This article reviews these options along with specific risk management strategies, such as using risk, needs, and responsivity factors as a means of improving overall outcomes for persons with mental illness, while minimizing their risk of further criminalization and victimization.

California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines

Here we provide comprehensive guidelines for the assessment and treatment of violence and aggression of various etiologies, including psychotic aggression and impulsive aggression due to schizophrenia, mood disorders, ADHD, or trauma, and predatory aggression due to psychopathy and other personality disorders. These guidelines have been developed from a collection of prescribing recommendations, clinical trial results, and years of clinical experience in treating patients who are persistently violent or aggressive in the California Department of State Hospital System. Many of the recommendations provided in these guidelines employ off-label prescribing practices; thus, sound clinical judgment based on individual patient needs and according to institution formularies must be considered when applying these guidelines in clinical practice.

Impact of dialectical behavior therapy versus community treatment by experts on emotional experience, expression, and acceptance in borderline personality disorder

Evidence suggests that heightened negative affectivity is a prominent feature of Borderline Personality Disorder (BPD) that often leads to maladaptive behaviors. Nevertheless, there is little research examining treatment effects on the experience and expression of specific negative emotions. Dialectical Behavior Therapy (DBT) is an effective treatment for BPD, hypothesized to reduce negative affectivity (Linehan, 1993a). The present study analyzes secondary data from a randomized controlled trial with the aim to assess the unique effectiveness of DBT when compared to Community Treatment by Experts (CTBE) in changing the experience, expression, and acceptance of negative emotions. Suicidal and/or self-injuring women with BPD (n = 101) were randomly assigned to DBT or CTBE for one year of treatment and one year of follow-up. Several indices of emotional experience and expression were assessed. Results indicate that DBT decreased experiential avoidance and expressed anger significantly more than CTBE. No differences between DBT and CTBE were found in improving guilt, shame, anxiety, or anger suppression, trait, and control. These results suggest that DBT has unique effects on improving the expression of anger and experiential avoidance, whereas changes in the experience of specific negative emotions may be accounted for by general factors associated with expert therapy. Implications of the findings are discussed.

Using Mindfulness- and Acceptance-Based Treatments With Clients From Nondominant Cultural and/or Marginalized Backgrounds: Clinical Considerations, Meta-Analysis Findings, and Introduction to the Special Series

A growing body of research suggests that mindfulness- and acceptance-based principles can increase efforts aimed at reducing human suffering and increasing quality of life. A critical step in the development and evaluation of these new approaches to treatment is to determine the acceptability and efficacy of these treatments for clients from nondominant cultural and/or marginalized backgrounds. This special series brings together the wisdom of clinicians and researchers who are currently engaged in clinical practice and treatment research with populations who are historically underrepresented in the treatment literature. As an introduction to the series, this paper presents a theoretical background and research context for the papers in the series, highlights the elements of mindfulness- and acceptance-based treatments that may be congruent with culturally responsive treatment, and briefly outlines the general principles of cultural competence and responsive treatment. Additionally, the results of a meta-analysis of mindfulness- and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds are presented. Our search yielded 32 studies totaling 2,198 clients. Results suggest small (Hedges' g=.38, 95% CI=.11 - .64) to large (Hedges' g=1.32, 95% CI=.61 - 2.02) effect sizes for mindfulness- and acceptance-based treatments, which varied by study design.

The physician's unique role in preventing violence: a neglected opportunity?

BACKGROUND

Episodes of explosive rage and violence comprise a symptom complex which can have a devastating effect on a person's life. In the community this behavior is seen as workplace violence, domestic abuse and road rage, while in the clinical setting, this behavior is rarely mentioned by patients, despite evidence that it can signify an important biological disorder that may afflict more than three percent of the population.

DISCUSSION

Patients are often reluctant to seek help for episodic attacks of rage, especially attacks which are accompanied by physical violence. Although, in the past, clinicians have had few treatment options to offer, recent neuroscience advances have created new possibilities to understand and help patients with this neglected problem. No formal medical guidelines for treating violence exist; however, many patients can be helped by diagnosis, referral and treatment. Treatment can include pharmaceuticals and nutrients, as well as referral for anger management or behavioral therapy.

SUMMARY

The astute clinician has an opportunity to positively impact an important problem through the diagnosis and treatment of patients with symptoms of intermittent explosive disorder.

Does maladaptive coping mediate the relationship between borderline personality traits and reactive and proactive aggression?

The aim of this study was to identify associations between borderline personality (BP) traits and reactive and proactive aggression, and to compare the meditational effects of maladaptive coping in samples of older adolescents (n = 133) and young adults (n = 93), which has not hitherto been explored. This was a cross-sectional study that used self-report measures to assess BP traits on a continuum, trait-based reactive and proactive aggression, and coping strategies. In adults, maladaptive emotional coping significantly mediated the relationship between BP and reactive aggression, and maladaptive avoidant coping mediated the relationship between BP and proactive aggression; no significant mediational effects were found for adolescents. These findings highlight potential explanations for associations between BP traits and reactive and proactive aggression in young adults, and indicate that reactive aggression in adult BPs could be decreased by reducing emotional coping, and proactive aggression by reducing avoidant coping.

DBT in an outpatient forensic setting

Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidence-based treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings.

Dialectical behaviour therapy with adolescents

BACKGROUND

  Dialectical behaviour therapy (DBT) is the first empirically validated treatment for chronically suicidal patients diagnosed with borderline personality disorder (BPD). Numerous randomised clinical trials conducted with adults with BPD have demonstrated that DBT is effective in reducing suicidal and non-suicidal self-injurious (NSSI) behaviours. Other research on the use of DBT for adults has shown that the treatment is effective in reducing a variety of problem behaviours in a range of therapeutic settings. In the last decade, a number of studies have evaluated DBT as a promising treatment for adolescents with different psychological disorders and behaviours, including borderline personality disorder (BPD), eating disorders, externalising disorders, and suicidal and NSSI behaviours. This article reviews the literature on the use of DBT with adolescents.

RESULTS

  Overall findings indicate some empirical support for the conclusion that DBT is a promising treatment for adolescents with BPD symptomatology, suicidal ideation and comorbid depression, bipolar disorder, disordered eating behaviours and aggressive and impulsive behaviours. Adolescents in these studies were also hospitalised less frequently when treated with DBT. Moreover, studies conducted with these populations suggest that DBT may be adapted for use in outpatient, inpatient, community, and residential treatment settings.

CONCLUSIONS

  The authors conclude that DBT may be effective in treating adolescents with additional disorders and dysfunctional behaviours not yet examined. Data from soon to be completed randomised controlled trials need to be published.

Emerging Approaches to Counseling Intervention

Dialectical Behavior Therapy (DBT) is a comprehensive, multimodal cognitive behavioral treatment originally developed for individuals who met criteria for borderline personality disorder (BPD) who displayed suicidal tendencies. DBT is based on behavioral theory but also includes principles of acceptance, mindfulness, and validation. Since its development, DBT has been adapted to various populations and has been successfully used in a wide array of settings. This article presents the approaches used in DBT with a particular emphasis on (a) the philosophy and assumptions on which the treatment is based, (b) the major theoretical constructs and the DBT conceptualization of the client, (c) the intervention and specific techniques used, (d) research supporting the theory and treatment, and (e) the integration of diversity, culture, and social justice.

Targeting criminal recidivism in mentally ill offenders: structured clinical approaches

Decreasing criminal recidivism in justice-involved individuals with mental illness, is among the most consistently desired outcomes by programs, policy makers and funding agencies. Evidence-based practices with track records of effectiveness in treating mental illness and co-occurring substance abuse, while important clinically, do not necessarily address criminal recidivism. Addressing recidivism, therefore, may require a more targeted criminal justice focus. In this paper, we describe recent challenges to decriminalization approaches and review factors associated with recurrent criminal behavior. In particular, we focus on structured clinical interventions which were created or adapted to target the thoughts and behaviors associated with criminal justice contact.

Borderline personality disorder as a female phenotypic expression of psychopathy?

Evidence suggests that the combination of the interpersonal-affective (F1) and impulsive-antisocial (F2) features of psychopathy may be associated with borderline personality disorder (BPD), specifically among women (e.g., Coid, 1993; Hicks, Vaidyanathan, & Patrick, 2010). However, empirical research explicitly examining gendered relationships between BPD and psychopathy factors is lacking. To further inform this area of research, we investigated the hypothesis that the interplay between the two psychopathy factors is associated with BPD among women across two studies. Study 1 consisted of a college sample of 318 adults (51% women), and Study 2 consisted of a large sample of 488 female prisoners. The interpersonal-affective (F1) and impulsive-antisocial psychopathy (F2) scores, measured with self-report and clinician-rated indices, respectively, were entered as explanatory variables in regression analyses to investigate their unique contributions to BPD traits. Across two independent samples, results indicated that the interaction of high F1 and F2 psychopathy scores was associated with BPD in women. This association was found to be specific to women in Study 1. These results suggest that BPD and psychopathy, at least as they are measured by current instruments, overlap in women and, accordingly, may reflect gender-differentiated phenotypic expressions of similar dispositional vulnerabilities.

Dialectical behavior therapy for suicidal adolescents with borderline personality disorder

Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and nonsuicidal self-injury. This article introduces dialectical behavior therapy's theoretical underpinnings, describes its adaptation for suicidal adolescents, and provides a brief review of the empirical literature evaluating DBT with adolescents.

A DBT Skills training group for family caregivers of persons with dementia

A Dialectical Behavior Therapy Skills training manual (DBT Skills) was adapted for use with caregivers of individuals with dementia. Implementation occurred in a community clinic with a heterogeneous caregiver group at risk for elder abuse. Sixteen caregivers completed the 9-week group. The results point to improved psychosocial adjustment, particularly increased problem-focused coping, enhanced emotional well-being, and less fatigue. Caregivers tended to utilize individual therapeutic services at a higher rate during the period of group attendance, indicative of appropriate help-seeking behavior in highly demanding situations. Six of the 16 caregivers repeated the training sequence in "booster" groups. Follow-up data from the booster groups suggest that high-risk caregivers may require continuing support to maintain treatment gains. In addition to demonstrating the feasibility of DBT Skills with caregivers, the results warrant a controlled outcome evaluation.