Impact of a Dialectic Behavior Therapy—Corrections Modified (DBT-CM) Upon Behaviorally Challenged...

Impact of a Dialectic Behavior Therapy—CorrectionsModified (DBT-CM) Upon Behaviorally ChallengedIncarcerated Male Adolescentsjcap_275 105..113

Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN, Karen Kesten, MS, Wanli Zhang, PhD, andRobert Trestman, MD, PhD

Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN, is Professor, School of Nursing/Department of Medicine; Director, Research &Evaluation—Correctional Managed Health Care, University of Connecticut. Karen Kesten, MS, is Project Coordinator, Department of Medicine,University of Connecticut Health Center. Wanli Zhang, PhD, is Statistician, Department of Psychiatry, University of Connecticut Health Center. RobertTrestman, MD, PhD, is Professor, Department of Medicine, Psychiatry & Nursing, Correctional Managed Health Care, University of Connecticut HealthCenter, Storrs, Connecticut, USA.

Search terms:Male young offenders, cognitive-behaviormanagement, aggression

Author contact:[email protected], with a copy tothe Editor: [email protected]

Funding provided by National Institutes ofMental Health Grant # 2002-IJ-CX-K009.

doi: 10.1111/j.1744-6171.2011.00275.x

PURPOSE: This article reports the findings of a Dialectical Behavioral Therapy—Corrections Modified (DBT-CM) intervention upon difficult-to-manage, impul-sive, and/or aggressive incarcerated male adolescents.METHODS: A secondary analysis of a subsample of 38 male adolescents who par-ticipated in the study was conducted. A one-group pretest–posttest design was used;descriptive statistics and t-tests were conducted.RESULTS: Significant changes were found in physical aggression, distancing copingmethods, and number of disciplinary tickets for behavior.CONCLUSION: The study supports the value of DBT-CM for the management ofincarcerated male adolescents with difficult-to-manage aggressive behaviors.

Introduction

According to a December 2009 Bureau of Justice Statisticsreport, there were 92,854 youth held in juvenile facilities as ofthe 2006 Census of Juveniles in Residential Placement, con-ducted by the Office of Juvenile Justice and DelinquencyPrevention (Sabol, West, & Cooper, 2009; Sickmund, Sladky,Kang, & Puzzanchera, 2008). Of these, approximately 40% areheld for violent crimes (criminal homicide, violent sexualassault, robbery, and aggravated assault) and 51% reportsymptoms of depression and anxiety (Sedlak & McPherson,2010).

Increasingly, over the past 20 years, youth exhibiting sig-nificant mental health and behavioral problems have comeinto contact with juvenile justice systems. Studies have shownthat at least 20% of youth entering the justice system have amental health problem, with a majority also experiencinga co-occurring substance abuse disorder (Shelton, 2001;Skowyra & Cocozza, 2007; Trupin, Stewart, Beach, & Boesky,2002). These youth pose particular management challenges,as these offenders have particular difficulty adjusting to therules and routines and are more likely to incur violations andaccumulate disciplinary consequences while incarcerated.These youth frequently receive behavioral tickets for how theyact, including verbal threats, self-harm, refusing to follow

directions, disorderly conduct, destruction of property, attimes assault; and when placed in segregation cells, will oftenregress to smearing feces or throwing urine (Quinn & Shera,2009). Such reported violations are indicative of their emo-tional, behavioral, and cognitive difficulties. Authors andclinicians agree that without appropriate treatment, thesebehaviors are likely to persist, causing distress to the adoles-cent and adding stress to the correctional environment(Berzins & Trestman, 2004; Fazel, Doll, & Langsrom, 2008).

This article presents adolescent data from a larger study ofadults and youth designed to test the implementation of adialectic behavior therapy (DBT) modified for a state correc-tional system. It was important to examine the data on theyouth separately, based upon the belief that the youth aredifferent from the adult population and they have uniquedevelopmental needs. Presented here is the limited literatureregarding the use of dialectic approaches with incarceratedyouth; a description of the intervention, methods, and thefindings of this secondary data study.

Background

The use of cognitive–behavioral approaches with youth whohave challenging behaviors and who have become involved

Journal of Child and Adolescent Psychiatric Nursing ISSN 1073-6077

105Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 105–113 © 2011 Wiley Periodicals, Inc.

with juvenile justice systems is well supported (Quinn &Shera, 2009; Skowyra & Cocozza, 2007; Trupin et al., 2002).Among the cognitive–behavioral approaches, DBT, designedby Linehan (1993a), has shown particular promise for appli-cation to corrections populations.

While similar to cognitive–behavioral therapy (CBT) withits use of core therapeutic procedures such as problemsolving, exposure, skill training, contingency management,and behavior therapy, DBT departs from standard CBT ina number of ways. It begins by emphasizing a “dialectical”approach to behavior change, encouraging an individual toaccept his or herself as he or she is in the present, within thecontext of reshaping his/her cognitions, and changing theindividual’s future behavior (Linehan, 1993a). As a generaltherapeutic framework, DBT attempts to address maladap-tive behaviors by teaching emotional regulation, inter-personal effectiveness, distress tolerance, core mindfulness,and self-management skills. The application of these skills iscoached, encouraged, and reinforced. DBT also attempts toengage the individual in therapy, providing motivation andsupport for change by emphasizing the management oftherapy-interfering behaviors and the relationship betweenthe therapist and the client. DBT has been shown to signifi-cantly reshape maladaptive cognitions and reduce the inci-dence of self-destructive behaviors (i.e., self-mutilation,suicide, and parasuicidal behaviors), and has become the firstempirically supported treatment for borderline personalitydisorder (Linehan, Armstrong, Suarez, Allmon, & Heard,1991; Linehan, Tutek, Heard, & Armstrong, 1994; Rathus &Miller, 2000).

With its clear hierarchy of treatment targets and behaviormodification (through functional analysis), DBT is wellsuited for the treatment of many problems characterized bybehavior dyscontrol. Individuals with borderline personalitydisorder have characteristics similar to other difficult-to-treatpopulations, such as emotional instability, anger manage-ment problems, aversive affect, interpersonal dysregulation,self-damaging behavior, cognitive disturbances and rigidity,and self-dysfunction (Linehan, 1993a). Because this particu-lar treatment modality uses a specialized behavioral skillspackage to target the cognitions behind these behaviors, DBTcan and has been successfully modified and adapted to othertreatment areas, such as suicidality in adolescents (Rathus& Miller, 2000), substance abuse (Dimeff, Rizvi, Brown, &Linehan, 2000), and forensic inpatients (McCann, Ball, &Ivanoff, 2000).

Berzins and Trestman (2004) describe the application ofDBT in the correctional environment which is frequentlycited. As with DBT, the aim is to teach a form of dialecticalthinking that enables incarcerated persons to solve problemswhen in conflict. This protocol typically includes four coremodules: mindfulness, interpersonal effectiveness, distresstolerance, and emotion regulation. The protocol addresses

the underlying impaired executive cognitive functioningknown to play an important role in the etiology of violent andaggressive behaviors (Morgan & Lilienfeld, 2000).

Yet there are limited studies in the literature demonstratingthe use of DBT with incarcerated adolescents. In a report byDrake and Barnoski (2006), they have shown a 14% reductionin recidivism for their 70% white and 79% female sample (63youth with 65 youth in the comparison group). In a secondstudy of the effectiveness of DBT upon the behaviors of 22female (50% white) offenders, Trupin et al. (2002) found asignificant decrease in serious behavior problems duringtheir 10-month intervention; but suicidal acts, aggressivebehavior, and class disruptions were not significantly reducedthroughout the year when compared with the year prior tothe intervention.

Despite the limitations of the published data regarding theapplication of DBT to the adolescent offender population,and the uneven findings that, at present, are in part because ofsmall sample sizes and the challenges of implementingresearch within secure environments, there is support fromstudies of use of DBT outside of corrections, with the adoles-cent population that offers impetus to continue replicatingthese efforts (Quinn & Shera, 2009). As an example, Nelson-Gray et al. (2006) report that 71% of their sample of 32outpatient adolescent program completers demonstratedclinically significant improvement following the use of Line-han’s (1993b) skills training manual for treating borderlinepersonality disorder modules.

In a review of the literature conducted by Paschall andFishbein (2002), these authors clearly demonstrate the rela-tionships between impaired executive cognitive functioningand violent and aggressive behaviors. Because executive cog-nitive functioning is involved in the planning, initiation, andregulation of goal-directed behavior (Luria, 1980; Milner,1995), deficits in its function often contribute to poor behav-ioral self-regulation, social skills, and judgment. Such a deficitor “clinical impairment” may be the result of an injury inthe frontal lobes of the brain (Paschall & Fishbein, 2002).However, there are more problematic deficits, those referredto as “subclinical impairments” which are not readily observ-able or easily diagnosable. These less apparent deficits can beaffected by a variety of hereditary, behavioral, and environ-mental factors such as poor nutrition, alcohol abuse, andexposure to violence, which can impact the physical andpsychological development of the youth.

The Development Perspective

Several theories have emphasized a developmental trajectoryof delinquency (Huizinga, Loeber, & Thornberry, 1993;Loeber et al., 1993; Elliott, Huizinga, & Ageton, 1985).Moffitt(1993) summarized two prototypes for the development ofdelinquency. The first, the life-course-persistent prototype,

Impact of a Dialectic Behavior Therapy—Corrections Modified (DBT-CM) Upon Behaviorally Challenged Incarcerated Male Adolescents

106 Journal of Child and Adolescent Psychiatric Nursing 24 (2011) 105–113 © 2011 Wiley Periodicals, Inc.

which originates in childhood, has neurodevelopmentalvariation manifested in cognitive deficits (difficult tempera-ment and hyperactivity) and interacts with inadequateparenting, poor family relations, and poverty. As the adoles-cent transitions to adulthood, the relationship between theindividual and the environment gradually becomes charac-terized by aggression and antisocial behavior that continuesthrough midlife. The second type, adolescence-limited-offending, originates in the social process, begins later in ado-lescence, and disappears in young adulthood (Moffitt, 2003).The main difference lies in the fact that the preadolescentdevelopment for this group was normal, reflecting psycho-logical difficulties that arise from the gap between biologicalchange and the lack of access to mature behavioral options.

The Risk and Protective Factors Perspective

One of the more influential approaches in understandingthe reasons for delinquency focuses on identifying whichrisk factors are associated with elevated levels of delinquentand antisocial behaviors (Herrenkohl et al., 2000). Simplydefined, risk factors are those factors that increase the likeli-hood of a negative outcome, and protective factors reducenegative outcome by means of interacting with risk factorsand moderating their effects or by means of direct influenceprotective factors decreased likelihood of negative outcome(DeMatteo & Marczyk, 2005). The ratio of protective and riskfactors changes with age. For example, growing up with a lowsocioeconomic status or in a dangerous or violent neighbor-hood is associated with higher rates of offenses and convic-tions (Farrington, 1998; Loeber & Farrington, 2000). Further,growing up in large aggressive families, with parents withpoor parenting skills, exposed to maltreatment, and emo-tional deprivation, have all been associated with increasedrisk for antisocial and delinquent behaviors (Kumpfer &Alvarado, 2003; Loeber & Farrington, 1998).

It is particularly important to note that developmentalfactors rarely operate alone and tend to interact with otherenvironmental factors. Individual risk factors include prena-tal and perinatal complications. Psychological and behavioralcharacteristics that have been identified as risk factors includelow IQ, delayed language development, hyperactivity, impul-sivity, restlessness, risk taking, antisocial beliefs, greaternegative emotionality, and substance abuse (DeMatteo &Marczyk, 2005; Hawkins et al., 1998; Kashani et al., 1999;Loeber & Farrington, 1998). Despite the importance of therisk and protective factors’ approach to identifying indicatorsof delinquency, Rutter (2006) maintains that risk factorsand threats alone do not lead to dysfunction and negativeoutcomes. As an example, growing up with a low socioeco-nomic status can be related to increased risk for delinquencybecause of a lack of opportunities for a solid education;because it is associated with parental psychopathology and

substance abuse; because of increased risk to exposure tocriminal activities; or through its association with negativepsychological factors such as low self-esteem and depression.But, for some youth, they seem to beat the odds in the face ofadversity.

Social, environmental, and biological risk factors havebeen identified, which help to explain the demographic andgeographic variations in the prevalence of violent and aggres-sive behaviors among adolescent youth. Kann et al. (2000)found the highest prevalence rates for fighting and weaponsamong Hispanic and African American high school studentsand among urban students in a national study. Snyder andSickmund (1999) report higher rates of violence amongmales and ethnic minority groups, as well as similar urbangeographic variations for weapon carrying, with juvenilemurders concentrated in urban areas.

Importance of Coping

There is consensus that adolescence is a significant and dis-tinct period of human development marked by the transitionfrom childhood to adulthood. Between the ages of 11 and 18,a rapid sequence of physical, cognitive, social, and behavioraltransformations occurs (Friedman, 2000). Coping behaviorsare particularly important, given the variety of stressors thatmay be experienced with achieving these developmentaltasks. In addition to the normative changes with which alladolescents need to cope, a large proportion of adolescentscope with serious stressors such as parental divorce, life inpoverty, serious medical conditions, abuse and neglect, andparental substance abuse (Sandler, Wolchik, MacKinnon,Ayers, & Roosa, 1997). Understanding how adolescents copewith serious stressors in their immediate environment is par-ticularly important because adolescents are at an increasedrisk for negative psychological outcomes such as depression,anxiety, suicide, and other health problems (Boekaerts, 1996),including increased violent and aggressive behaviors.

Like other psychological qualities, coping strategies followa developmental trajectory (Eisenberg, Fabes, & Guthrie,1997). Some indicators of coping, such as reactivity andinhibition control, are present at birth (Davis & Emory,1995) and shaped by learning. Learning strategies in adoles-cence include previous personal experience, peer modeling,perception of personal vulnerability, and social persuasionby others (Ireland, Boustead, & Ireland, 2005). Aldridge andRoesch (2008) developed a typology of minority adolescentcoping and found that three types of coping existed. The firstgroup (44.6%) was those who minimally employed copingstrategies and were referred to as low generic copers. Overall,these minority adolescents were psychologically healthy, andalthough they used their coping strategies sparingly, theywere effective at reducing their stress. The second group(48.3%) was those who use active strategies such as planning



and were labeled as active copers. Considered the most adap-tive of the three groups, these adolescents primarily usedacceptance, religion, and humor as strategies which wouldlead to adaptive outcomes. The third group (7.3%) was thosewho were avoidant or used passive strategies most frequentlyand are labeled avoidant copers. Interestingly, adolescentswithin the avoidant coping typology were maladjusted incomparison with the other two groups, characteristicallypreferring to focus on and vent their emotions and engage insubstance use. Although this could be considered adaptivein some circumstances, it is generally considered to result inworse adjustment outcomes and, when combined with sub-stance use, likely to lead to negative health outcomes andrisky consequences (Hofstein, 2009). These authors foundadolescent avoidant copers engaged in more denial andbehavioral disengagement, strategies that have been linkedto maladjustment. Aldridge and Roesch (2008) found thatthe poor conditions of their communities and limitationswithin their families further supported the use of moreavoidant/disengaging strategies relative to the other copingstrategies.

Development of interventions for delinquent youth, then,shares the underlying assumption that because at-risk adoles-cents demonstrate certain less adaptive coping skills, theyrevert to aggressive or delinquent behaviors and exhibit otheremotional and behavioral problems. Traditionally, copingis considered a mediator in the relationship between stressorsand physiological and psychological outcomes (Carver,Scheier, & Weintraub, 1989). How stressors in the environ-ment influence psychological functioning may depend onthe interpretations and reactions of the individual to thestressors, environment, or situation. DBT, then, focuses onchanging the thoughts and emotions that precede problembehaviors, as well as solving the problems that contribute toproblematic thoughts, feelings, and behaviors.

Longitudinal studies examining the developmental path-ways of youthful offenders have demonstrated that the behav-ioral manifestations of these exposures are unfortunatelyseen particularly among males (Hawkins et al., 2000), yet theliterature found on use of DBT with incarcerated youth focusprimarily upon female incarcerated offenders. This second-ary data analysis examines the application of a correctionsmodified-dialectic behavior therapy among incarceratedadolescent males of mixed races and ethnicities. The need formental health treatment in corrections for this populationis very well documented (Fazel et al., 2008; Rosenblatt,Rosenblatt, & Biggs, 2000).

Methods

A secondary data analysis was conducted on a subsample of38 adolescent males to test the hypothesis that participantswill show reduced aggression, impulsivity, and improved

coping after completing the DBT-corrections modified(DBT-CM) groups. A pretest–posttest one-group design wasused. Descriptive analyses were conducted using SPSS version15.0 (SPSS Inc. Chicago, IL, USA). A paired sample t-test wasutilized to test for mean differences before and after the16-week intervention, with alpha set at p = .05. A chi-squareanalysis was conducted to assess whether there were anydifferences between those who completed the intervention(n = 26) and those who did not (n = 12) based on demo-graphic variables. Institutional Review Board (IRB) approvalwas obtained through the University of Connecticut (IRB #04-156-2).

Sample

Participants with impulsive behavior problems wererecruited for participation from the one facility in the statethat holds male adolescent youth committed to the stateDepartment of Correction. Youth were referred as potentialparticipants by correctional facility unit majors and correc-tional mental health personnel. Those youth referred werethose youth perceived by corrections staff to be unpredict-able and were those inmates who were difficult to manageas indicated by the high number of behavioral tickets theyreceived. Once voluntary participants were identified, ascreening visit was conducted to discuss eligibility for par-ticipation in the study protocol. Individuals were excludedfrom participation if any of the following factors were evi-denced: presence of any unstable medical or neurologicaldisorder that would interfere with participation in the proto-col or cause additional risk; non-English speaking; less than1 year from end of sentence; appearing not to understandthe procedures and aims of the study as described on theinformed consent form; screening positive for psychopathy,as evidenced by a score of more than 30 on the Hare Psych-opathy Checklist-Screening Version (Hare, 1991). An indi-vidual had the choice to drop out of DBT-CM and/or theinterview sessions at any point without penalty or effect ontheir current status within the state Department of Correc-tion or the care received in that facility. Prior to participationin the DBT-CM intervention, a psychological assessmentof the participant’s current mental, physical, and emotionalstate was conducted.

The adolescent sample enrolled during the study period(2004–2006) included 38 adolescent males. Twelve partici-pants were lost to the study. Reasons for attrition were: fourwithdrew from the group on their own; one was transferredto a different facility, and seven youth were released. Achi-square analysis was conducted to assess whether therewere any differences between those who remained in thestudy. There were no significant differences based on race(c2 = 5.336, d.f. = 4, p = .255), age (c2 = 3.057, d.f. = 4, p = .548),or education level (c2 = 4.752, d.f. = 4, p = .314).



DBT-CM Intervention

Extensive adaptations to the vocabulary and examplesincluded in the DBT-CM treatment manual were required toincrease the likelihood that participants would benefit fromDBT (Trestman, Gonillo, & Davis, 2004). Given the higherincidence of reading and learning problems among incarcer-ated individuals (Samuelsson, Herkner, & Lundberg, 2003;Slaughter, Fann, & Ehde, 2003), the DBT vocabulary wasadapted to make it easier to understand, and many pictureswere added to increase iconic learning. Numerous exampleswere changed and added, to reflect the types of situationsincarcerated individuals face. In addition to modifying the“content” of clinical materials to make them appropriate forforensic settings, it was also necessary to tailor the “form” ofclinical materials. For example, participant workbooks werethermal bound, rather than being bound with any metalmaterials that participants could use to injure themselvesor others. Additionally, whenever the research cliniciansrequired use of some type of object (such as pencils), thatobject had to be acceptable (approved) according to thatcorrectional facility’s safety and security protocol.

The skills training group includes four core modules:mindfulness, interpersonal effectiveness, distress tolerance,and emotion regulation. The mindfulness module focuses ongiving attention to the present moment and targets self-dysregulation and identity confusion by emphasizing self-awareness. The interpersonal effectiveness module teachesassertiveness, interpersonal skills, and conflict resolution. Thedistress tolerance module focuses on using strategies to toler-ate distress, without making it worse, by engaging in oldimpulsive and self-destructive behaviors and by teaching dis-traction and self-soothing techniques. Lastly, the emotionregulation module assists participants in identifying anddescribing their emotions, accepting their trauma experi-ences, and focusing on being less reactive to them, and thenhow to increase positive emotions. These four skills modulesare designed to increase adaptive behaviors and cognitiveabilities while decreasing maladaptive behaviors and cogni-tions (Berzins & Trestman, 2004).

In teaching each of the DBT-CM skills to incarcerated par-ticipants, examples relevant to participants’ daily experiencesin their correctional facility are used. The DBT-CM skills areprojected with plans for release to anticipate applications ofthe skills in their outside lives. The teaching of almost everyskill was modified, with examples and subtle adjustments tocorrespond to the correctional setting.

Highly structured DBT-CM groups (16 weeks) were co-ledby a team of two research clinicians. If an individual discon-tinued participation in the DBT-CM protocol for any reason,he could still choose to continue with the research interviewsessions (posttest). Prior to participation in the 16-weekDBT-CM intervention, a study research assistant met with the

participant to conduct an interview using a battery of psycho-logical assessment tools that assessed the participant’s currentmental, physical, and emotional state.

Instruments

The primary outcome was to measure a reduction in aggres-sive and impulsive behavior and improve coping as measuredby pretest–posttest rating collected through semi-structuredinterview assessments (to eliminate literacy issues and secu-rity with pencils) to measure impulsive aggression:

1. The Buss–Perry Aggression Questionnaire (BPAQ), a29-item, five-point Likert scale designed to assess four dimen-sions, including physical aggression, verbal aggression, anger,and hostility (Buss & Perry, 1992). Internal consistency forthe four subscales and total score range from .72 for VerbalAggression to .89 for the Total score. Retest reliability over 9weeks ranged from .72 for the Anger subscale to .80 for thePhysical Aggression subscale and Total score.

2. Overt Aggression Scale-Modified (OAS-M), a 25-item toassess the severity, type, and frequency of aggressive behaviorweighted by severity and frequency. Subtypes include: verbalaggression, physical aggression against objects, and physicalaggression against self and physical aggression against others(Coccaro, Harvey, Kupsaw-Lawrence, Herbert, & Bernstein,1991). Inter-rater reliability has been demonstrated to be .91for ratings by two clinical raters for OAS-M Aggression andIrritability. Test–retest reliability within a 1 to 2-week periodhas been shown to have an intraclass correlation for aggres-sion on Time 1 and Time 2 of .46 and .54, respectively (Suriset al., 2005).

3. Brief Psychiatric Rating Scale, the Total Score, and item 5(Hostility) were used from this 18-item rating scale designedto assess the severity of psychopathology. Items addresssomatic concern, anxiety, emotional withdrawal, conceptualdisorganization, guilt, tension, mannerisms and posturing,grandiosity, depressive mood, hostility, suspiciousness, hallu-cinatory behaviors, motor retardation, uncooperativeness,unusual thought content, blunted affect, excitement, and dis-orientation (Overall & Gorham, 1962). Inter-rater reliabilitiesranged from .82 to .93, with the highest agreement on somaticconcern and unusual thought content subscales (Ligon &Thyer, 2000).

4. Disciplinary ticket information collected from recordson participants 12 months prior to starting groups and 6months after completing groups (disciplinary tickets aregiven to inmates when a behavioral offense has been madewithin the prison facility).

Additionally, a self-report basic demographic question-naire designed for this study containing questions aboutage, ethnicity, and socioeconomic status was collected. TheWays of Coping Checklist (WCCL), a 33-item Likertscale self-report checklist measures eight different coping



styles—confrontational coping, seeking social support,planful problem solving, self-control, distancing, positivereappraisal, accepting responsibility, and escape/avoidance(Folkman & Lazarus, 1988). The typical reliability acrosssubscale scores ranges from .60 to .75 (Rexrode, Petersen, &O’Toole, 2008). Lastly, the Positive and Negative Affect Scales(PANAS) were used to measure general positive and negativeaffect states (Watson, Clark, & Tellegen, 1988). This 20-itemscale requires a self-report across five criterion measures:calmness, temperance, two scales of tolerance, and emotion-ality on a Likert scale. Watson et al. (1988) report internalconsistency reliability for scales from .86 to .90 for positiveaffect and from .84 to .87 for negative affect. Correlationsbetween the two scales range from -.12 to -.23, indicatingindependence of the two factors (Huebner & Dew, 1995).

Results

Thirty-eight participants agreed to volunteer and were con-sented; 12 were lost to the study. Of the 26 participants whoremained in the study, all were male with their ages between16 and 19 years (M = 17.92, SD = .796). Participants’ self-reported races included African American (38.5%), Hispanic(34.6%), Caucasian (23.10%), and other (3.8%); and theireducation level ranged from grade 8 to 12 (M = 10.36, SD =1.254). Eighty-five percent of these youth reported that theywere not married and the remaining 15% reported that theywere cohabitating. The youth reported their family and socialnetworks as having up to seven relatives living in their homes(M = 3.23, SD = 1.728) and two friends (M = .23, SD = .587),and had up to 40 relatives within a 20-mile radius of wherethey lived. Sixty-one percent of youth were unemployed,30.8% were employed part-time, and the remaining worked35 hr a week or more. Eighty-eight percent of the youthclaimed some religious connection.

Overall health, education, and rehabilitation needs as mea-sured by the state Department of Correction risk scores foundalmost all youth to have some need: 20% of youth withserious treatment need and highest level of supervision; 44%with moderate treatment needs; 32% with mild treatment

need; and the remaining 4% with minimal or no needs. Sixyouth (23.1%) were referred for sex offense treatment. Thebreakout across needs categories is included in Table 1.

The primary types of crime (offense classification) withwhich participants were charged were violent (60%) (e.g.,use of weapon, physical or sexual assault, manslaughter,or murder), with the remaining charged with nonviolentoffenses (e.g., drug possession, larceny, probation violation,or breach of peace). Twenty-three youth (88.5%) were sen-tenced to less than 5 years, and the others were sentencedbetween 5 and 10 years. None of the participants had a historyof escape.

To test the hypothesis that participants will show reducedaggression, impulsivity, and improved coping after complet-ing the DBT-CM groups, physical aggression as measured byBPAQ (t = 7.576, d.f. = 21, p = .000) and using distancing(WCCL subscale) as a coping strategy (t = 2.529, d.f. = 9,p = .032) showed statistical differences at posttest. There was asignificant change in disciplinary tickets from pre- to posttest(t = 2.753, d.f. = 24, p = .011), indicating that correctionalofficers observed an improvement in aggressive and impul-sive behaviors following the intervention. Improved scores,although not significant, were found on PANAS NegativeAffect, and the Self- Control subscale on the WCCL.Althoughnot significant, these are worth exploring with a larger sampleand more rigorous design.

Discussion

As a result of the DBT-CM intervention, a reduction inaggression and a reduction in the number of disciplinarytickets received indicated improved adolescent behavior. Thecorrections-modified modules were designed to be relevantto the participants’ daily experiences in their correctionalfacility. The teaching of almost every skill was modified withexamples and subtle adjustments to correspond to the correc-tional setting. At the same time, youth were helped with pro-jected plans for release to anticipate applications of DBT-CMskills in their outside lives. This finding is similar to otherstudies of DBT in correctional environments with adolescent

Table 1. Risk Scores for Treatment Planning Needs

Risk score Medical Mental health Substance abuse Safety/violence Education Vocational

Minimal/none 42.3% 3.8% 11.5%n = 11 n = 4 n = 3

Mild 53.8% 3.8% 23.1% 84.6 38.5% 23.1%n = 14 n = 4 n = 6 n = 22 n = 10 n = 6

Moderate 80.8% 34.6% 15.3% 53.8% 65.3%n = 21 n = 9 n = 4 n = 14 n = 17

Serious 11.5% 30.8% 7.6% 11.5%n = 3 n = 8 n = 2 n = 3

n = 26.



populations (Drake & Barnoski, 2006; Trupin et al., 2002).Aggressive and impulsive behaviors were the primary targetbehaviors for the intervention, and their reduction improvesthe safety of both the youth and staff and ultimately reducescost to the system.

The use of distancing as a coping strategy was an interest-ing finding, particularly as coping strategies had beendescribed in the literature as consisting of behaviors such asdistraction, self-criticism, substance abuse, blaming others,denial, and wishful thinking (Aldridge & Roesch, 2008). Inthinking about the relationship between the high stress envi-ronments of the prison, however, the need to distance oneselffrom the pressure of a stressful situation may take on an adap-tive function and may be effective in dealing with short-termstressors. Similarly, within the context of an extremely violentneighborhood, mental and behavioral disengagement copingmay be particularly important in maintaining psychologicaland physical health (Grant et al., 2000). While the complexityof the relationship between the high stress environment,coping, and outcome for youth at high risk is debated, the useof substances is not; nor are the effects of chronic exposureto violent environments toward the development of negativecoping strategies such as blaming others or self, doingnothing, or avoiding others, which act as a conduit to poorpsychological outcomes such as post-traumatic stress disor-der, anxiety, depression, and conduct disorder (Dempsey,2002). Further, Kliewer, Lepore, Oskin, and Johnson (1998)suggested that the use of avoidant coping behaviors at a youngage may influence and prevent the youth from engaging inpositive coping behaviors.

The lack of significant finding for self-control and accept-ing as ways of coping, and negative symptoms, are of interest,as it would be expected that youth would feel better as a resultof the intervention. Adolescence under the best of circum-stances is a stressful life event, as adolescents’ biologic andpsychological selves attempt to integrate into the whole adultperson they are to become. Added to the cumulative effects ofthe stressors leading to adolescent incarceration, the mea-sures and secondary analytic design may not have been suffi-cient to detect change in all the variables of interest in thisstudy.

Conclusion

The preliminary results of this study provide support for thecontinued study of DBT-CM skills training for aggressive andimpulsive male adolescent offenders. The improvement seenin physical aggression, distancing coping style, and disciplin-ary tickets are a positive indication that the 16-week skillstraining groups continue to be implemented as the evidencebase is developed to support the intervention.

Given the limitations of this study, the small sample sizeand the lack of control group, there is a need to consider the

use of instruments designed specifically for adolescent popu-lations. Such modifications are likely to increase sensitivityand yield stronger results. Despite these limitations, thesefindings were encouraging and suggest that program imple-mentation would contribute to a decrease in problematicbehavior and improvement in quality of life for participants.Decreasing impulsive and aggressive behavior clearly hasindications for youth behavior management within theprison and reduced injury to the workforce. Further, implica-tions for postincarceration self-management of behavior arelong-term outcomes of interest.

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