Volume 4, Issue 1 • Winter 2015

Table of Contents

Foreword

Modifying Dialectical Behavior Therapy for Incarcerated Female Youth: A Pilot Study

The Impact of Child Protective Service History on Reoffending in a New Mexico Juvenile Justice Population

Social Distance Between Minority Youth and the Police:
An Exploratory Analysis of the TAPS Academy

Rural Youth Crime: A Reexamination of Social Disorganization Theory’s Applicability to Rural Areas

How to Help Me Get Out of a Gang: Youth Recommendations to Family, School, Community, and Law Enforcement Systems

Exploratory Research Commentary:
How Do Parents and Guardians of Adolescents in the Juvenile Justice System Handle Adolescent Sexual Health?

Modifying Dialectical Behavior Therapy for Incarcerated Female Youth: A Pilot Study

Breanna Banks, Department of Educational Psychology and Counseling, University of Tennessee, Knoxville; Tarah Kuhn, Department of Psychiatry, Vanderbilt University; Jennifer Urbano Blackford, Department of Psychiatry, Vanderbilt University.

Correspondence concerning this article should be addressed to Breanna Banks, Department of Educational Psychology and Counseling, 413 Student Services Building, University of Tennessee, Knoxville, TN 37996. E-mail: bbanks@vols.utk.edu

Keywords: evidence-based programs, incarcerated juveniles, mental health disorders

Abstract

The prevalence of mental and emotional disturbance is a persistent problem for youth detained in correctional facilities. Females within this population, while often considered by the social science and juvenile justice communities to be a subset of their male counterparts, present with unique biological, cultural, social, and psychological stressors, including extensive trauma histories and internalizing behaviors. In addition, organizational barriers to the implementation of many treatment models exist for females in juvenile justice settings; hence, little evidence-based mental health treatment designed specifically for this population currently exists. There is evidence that Dialectical Behavior Therapy (DBT) successfully addresses many of the types of problems presented by this population. In this study, we examined the implementation process and treatment outcomes of a modified DBT group in a correctional facility for adolescent females with a variety of mental and emotional problems. Mental health program implementation was the main focus of this study. Modifications were made to group leaders’ training requirements, duration of the group, and group session format to fit the needs of this population. A brief description of preliminary treatment outcomes is included.

Introduction

The prevalence of mental and emotional disturbance in the juvenile justice population is a persistent problem in the United States. Over the past decade, research has consistently indicated a significantly higher level of mental and emotional disturbance among youth involved in the juvenile justice system than among youth in the general population (Otto, Greenstein, Johnson, & Friedman, 1992; Cauffman, Feldman, Waterman, & Steiner, 1998; Loeber, Farrington, & Washburn, 1998; Teplin, Abram, McClelland, Dulcan, & Mericle, 2002; National Mental Health Association, 2004; Skowyra & Cocozza, 2006; and Sedlak & McPherson, 2010). Approximately 65 to 70% of youth in the juvenile justice system meet criteria for at least one mental health diagnosis, compared to 20 to 30% of adolescents in the general population. In addition, females in the juvenile justice system have even higher levels of psychological and emotional problems than their male counterparts. For example, Sedlak and McPherson (2010) found that females in custody reported 8 to 20% more problems with attention, hallucinations, anger, anxiety, depression/isolation, trauma, and suicidal thoughts or feelings than their male counterparts. The number of adolescent females being arrested and placed in secure correctional facilities in the United States is increasing despite the fact that the overall number of juveniles arrested for criminal offenses is declining (Cooney, Small, & O’Connor, 2008).

Unique biological, cultural, social, and psychological stressors combined with negative general life experiences have made females in the juvenile justice system especially vulnerable to specific crises once incarcerated. Females in the juvenile justice population often have a negative self-image, a history of poor and even violent relations with peers and family, and unhealthy or destructive interpersonal and romantic relationships (Chesney-Lind & Okamoto, 2001). Trauma and abuse are especially prevalent in this population, with 50 to 75% of delinquent females having a history of physical, sexual, and/or emotional abuse (Zahn, Day, Mihalic, & Tichavsky, 2009). With such high rates of trauma and abuse, girls entering the juvenile justice system are more likely than boys to experience Post-Traumatic Stress Disorder (PTSD) and other internalizing emotional problems—such as depression, anxiety, negative self-image, affective dysregulation, personality disorders, and parasuicidal behavior (McReynolds, Schwalbe, & Wasserman, 2010; Cooney et al., 2008; National Mental Health Association, 2004).

Historically, delinquent females have been treated by the juvenile justice and social science communities as a subset of their male counterparts (Chesney-Lind, Morash, & Stevens, 2008). The standard treatments—developed specifically for delinquent males—tend to focus on the acting-out and externalizing behavior that is typical of male juvenile offenders (i.e., assault, gun-related offenses, etc.; Hoyt & Scherer, 1998). In their qualitative study of adolescents and staff in juvenile corrections facilities, Belknap, Holsinger, and Dunn (1997) found that incarcerated girls believed corrections facilities were systemically sexist, racist, and often made their problems worse. In addition, these researchers found staff attitudes ranged from being deeply passionate about addressing the needs of girls in the system to hatred of working with girls. Though adolescent females are being arrested and incarcerated at higher rates than ever before and have a higher prevalence of mental and emotional problems, only one evidence-based program has been developed specifically to treat the mental and emotional needs of this population (Zahn et al., 2009). While there is increasing evidence of the effectiveness of gender-specific programming at lower levels of the juvenile justice system, such interventions have not been widely applied in the correctional setting. In an expansive review of programs established for girls in the juvenile justice system, Acoca and Dedel (1998) describe 11 prevention and intervention programs that include mother-daughter services, advocacy, residential care, academics, teen pregnancy, aftercare, and community-based supervision. However, only one of these programs is offered in a secure residential center.

Cooney et al. (2008) suggest that female-specific treatments have not been developed because adolescent females’ delinquent behavior (i.e., status offenses, internalizing symptoms, relational aggression, etc.) often does not result in the same degree of socio-environmental costs and consequences as adolescent males’ delinquent behavior. Evaluation research on the implementation of male-oriented treatment programs among females has shown mixed results. Some studies suggest no difference in effectiveness while others show these programs are less effective (Gorman-Smith, 2003) or even harmful for females (Hipwell & Loeber, 2006). Furthermore, in their 2006 study Hipwell and Loeber suggest that the detention environment (i.e., seclusion, staff insensitivity, loss of privacy, etc.) can exacerbate delinquent adolescent females’ internalizing symptoms. Hubbard and Matthews (2008) support the utilization of traditional juvenile justice treatment approaches among females, especially those involving cognitive behavioral therapy, but suggest that these treatments be modified to address the specific types of cognitive and behavioral processes that are more common among girls (i.e., self-debasing distortions and internalizing behaviors). In addition, since many types of cognitive behavioral therapy (CBT) are delivered in a group format, Hubbard and Matthews (2008) also recommend that groups be structured in a way that is strengths-focused and designed to help empower females.

Despite the lack of evidence-based treatments for adolescent females in correctional settings, effective treatments have been developed for females with similar problems in other settings. One of the most effective of these treatments is DBT.

DBT (Linehan, 1993a; Linehan, Heard, & Armstrong, 1993) is a derivative of CBT and was originally developed for the treatment of chronically suicidal and self-harming adult females with Borderline Personality Disorder (BPD). DBT incorporates behavioral therapy, dialectical philosophy, and Zen Buddhist practice and philosophy (Linehan, 1993a). The complete DBT protocol consists of five treatment components: individual therapy, group skills training, telephone coaching, case management, and a therapist consultation team. While DBT was originally developed to treat females with Borderline Personality Disorder (BPD), DBT has demonstrated effectiveness in the treatment of adults and adolescents with a variety of mental disorders, including depression (Wineman, 2009; Blackford & Love, 2011), PTSD (Spoont, Sayer, Thuras, Erbes, & Winston, 2003), and deliberate self-harm (Katz, Cox, Gunasekara, & Miller, 2004; Wineman, 2009). In addition, females in juvenile corrections facilities have been found to exhibit behavioral and affective symptoms similar to those of women with Borderline Personality Disorder, including emotional dysregulation (i.e., mood disturbance, affective lability, and uncontrolled anger), behavioral disturbance (i.e., violent aggression, self-harm, and poor impulse control), self-destructive behavior (i.e., substance abuse and sexual and criminal behaviors in adolescence), and severe relational problems, i.e., childhood sexual/physical abuse, poor/inconsistent self-image, and violent/abusive relationships (Teplin et al., 2002; Trupin, Stewart, Beach, & Boesky, 2002). It is important to note that the use of DBT with this population does not imply an increased potential for personality disorders. While the behavioral and affective symptoms prevalent among incarcerated female youth often overlap with the symptoms of BPD, no existing research suggests that juvenile justice–involved girls are more likely to be diagnosed with BPD than females in the general population.

Dialectical Behavior Therapy in Incarcerated Female Youth

Although the majority of literature published on DBT is based on work done in mental health or research settings, DBT has also been implemented in juvenile correctional settings to treat adolescent females diagnosed with a variety of mental health problems (Trupin et al., 2002). Trupin et al. (2002) adapted and implemented a DBT program in a juvenile rehabilitation facility housing incarcerated females. Researchers adapted DBT for this population by changing behavioral targets to better fit an adolescent forensic population and by training all staff in administering DBT. Youth in the study were separated into three groups: 1) a mental health treatment group (e.g., youth receiving mental health treatment) who received DBT; 2) a mental health treatment group that did not receive DBT; and 3) a non-mental health treatment group that received DBT. The mental health group that did not receive DBT received treatment as was usually offered. Youth in the DBT mental health group exhibited a significant reduction in behavior problems, while youth in the non-mental health treatment group who received DBT did not. Risk assessment scores showed no significant differences between DBT and non-DBT treatment groups, but these scores did show a significant decrease within groups. Researchers suggested these mixed results could partially be attributed to regular transfer of youth into and out of the mental health group due to suicidal or other aggressive behavior. Such transfer maintained the high rates of behavioral problems throughout the study period. In addition, researchers emphasized the importance of comprehensive staff training in DBT in effectively reducing problematic behavior.

However, we suggest extensive staff training and several other factors may actually serve as barriers to the implementation of DBT in juvenile correctional settings.

Barriers to Implementation

Historically, skeptics of evidence-based treatment implementation have posed the question, “Is it realistic to attempt to organize, deliver, and evaluate mental health treatments in correctional settings?” (Cullen & Gendreau, 2000). In the process of treatment implementation, researchers and therapists may experience a variety of problems due to systemic barriers such as: making initial contact and maintaining a working relationship with those who work in the correctional setting; lacking an understanding of the setting’s feasibility to host evidence-based treatments; lacking confidence in the institution’s stability; sensing incongruence between the values or interests of the setting’s stakeholders and treatment providers/evaluators; and having difficulty maintaining funding streams (Gendreau, Goggin, & Smith, 1999). Researchers agree that the implementation of evidence-based treatments in “real world” correctional settings can be an arduous process, but maintain that it is a worthy and possible pursuit (Bourgon & Armstrong, 2005; Gendreau, et al., 1999).

DBT is no exception. While there is evidence of the effectiveness of DBT in a correctional setting, there are potential barriers to the application of the full DBT protocol due to high costs, clinician training requirements, and organizational barriers. First, treatment costs for adolescents in juvenile justice facilities rest with state governments. Shrinking budgets and resources make covering costs for intensive, long-term treatment challenging (Stephani, 2004). Second, fidelity to the DBT model requires extensive clinical training and consultation provided by approved DBT specialists. Access to this level of training and consultation can be difficult in juvenile justice correctional facilities due to the significant amount of time required and financial demands, as well as high turnover rates. Third, some DBT components—such as the 24-hour phone consultation—are not suitable or practical in juvenile correctional settings. Fourth, the frequent movement of youth into and out of correctional facilities makes it difficult to complete the full DBT protocol, which can require between 1 and 4 years of treatment (Linehan, 1993b).

DBT Skills Training Group: A Potential Solution

Despite the many barriers to using the standard DBT protocol in a juvenile corrections setting, there may be significant value in identifying and applying a set of core DBT skills aimed at affect regulation, internalizing symptoms, and interpersonal effectiveness, which would specifically target the identified needs of this population. Part of the larger DBT protocol, the DBT skills-training group is potentially a practical and more cost effective means of implementing DBT within the juvenile correctional setting. This group setting allows for multiple youth to be treated simultaneously over a shorter period of time than is possible with the standard DBT protocol. Also, therapists participating in DBT skills-training may require less intensive training than those using the standard protocol, since the skills training group utilizes a highly manualized protocol (Linehan, 1993b). Researchers have implemented modified DBT skills-training groups only with similar populations and have had positive outcomes (Nelson-Gray et al., 2006; Salerno, 2005).

DBT skills training takes place weekly in a psychoeducational group in which the leader teaches skills in four main modules: core mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. Homework is assigned weekly to provide skills practice. Clients also use daily diary cards to document emotions, behaviors, and skills used each week. Completion of all four skill modules typically requires a total of 6 months in weekly group skills training.

The DBT skills-training group may be appropriate for females in juvenile justice correctional settings because it is a short-term, cost-effective, evidence-based treatment. DBT includes a broad set of skills that have been shown to benefit female adolescents who have difficulty with emotion regulation, interpersonal relationships, behavioral control, and coping with extensive trauma. Although similar treatments have been implemented in correctional settings for adult and adolescent females, there is no evidence as to whether the DBT skills-training component only can be modified and implemented in a juvenile justice correctional facility for females, in a way that maximizes cost effectiveness, attention to systemic barriers, and treatment outcomes.

Framework for Implementation

Based on years of clinical experience in correctional settings, Gendreau, Goggin, & Smith (1999) created a taxonomical framework that outlines four core areas of successful treatment program implementation in correctional settings: organizational factors, program factors, change agent(s), and staff factors. Organizational factors pertain to the host setting where the program will be implemented. These include the managerial, structural, and cultural characteristics of the setting. Program factors refer to the clinical and fiscal components of the treatment program that will be implemented. The program should be scientifically validated and should cause as few resource and financial strains on the setting as possible. The change agent(s) is described as the person(s) who is primarily responsible for initiating and leading the treatment implementation process. The change agent should be knowledgeable about the setting and the treatment, appropriately credentialed, and aligned with the setting’s mission and goals. Staff factors include characteristics of the persons who will directly deliver the treatment, as well as treatment supervisors. Staff should be in consistent contact with the change agent, be trained in the implemented treatment, and play an active role in the design of the treatment program. In this study, we utilized this framework to assess the process and effectiveness of the group implementation of DBT skills-training.

Purpose of Study

In this pilot study, we examined the implementation process of a modified DBT skills-training group for females with emotional and behavioral problems at a juvenile correctional facility. Our primary goal in this study was to determine the feasibility of successfully implementing a modified version of a DBT skills-training group in a correctional juvenile justice facility. A secondary goal of this study was to use existing clinical outcomes measures to assess participant progress.

Method

Participants

Twelve female adolescents participated in a DBT skills-training group in a secure correctional facility for adolescent females. The facility houses approximately 20 to 25 females between the ages of 13 and 18 years who meet at least one of the following criteria: (a) she has been adjudicated for a violent or attempted violent offense; (b) she has a history of adjudication offenses resulting in determinate placement; (c) she has been adjudicated for a sexual offense for which she has not received treatment; (d) she has been adjudicated for or has a history of three or more felony offenses; or (e) she has absconded from community placement and has been charged with a subsequent offense (State of Tennessee Department of Children’s Services, 2011).

We collected data before and after treatment for 9 of the 12 participants. Demographic data were collected at intake to the facility. Participants ranged in age from 14 to 18 years (M = 16, SD = 1.33) and were predominantly Caucasian (70%), with 19% African American and 11% Hispanic. Education levels varied: 33% had less than an 8th grade education; 33% had completed some high school; and 33% had a high school diploma or GED. The participants’ age of onset for emotional or behavioral problems was 7.8 years (SD = 3.65) and the average age for first treatment or counseling session was 10.5 years (SD = 3.24). The majority of group members reported that someone else recommended they participate in the DBT skills-training group (67%) and 22% reported participating in the group against their will. As this was a pilot group, it was not part of the individual programming mandated as part of the youth’s stay in the facility. Participation in the DBT skills-training group was recommended by the facility’s treatment team, but the youth’s release was not contingent upon participation or completion (as was the case with mandated treatment components, such as individual therapy and family therapy). We did not obtain diagnostic information for the purpose of this study; however, mental health symptoms data were collected before and after treatment.

Treatment Modification and Implementation

The primary goal of this pilot study was to examine whether a DBT skills-training group could be successfully modified and implemented in a correctional facility for adolescent females.

Treatment in this facility was provided as part of a contract with the State of Tennessee, thus clinicians were vendors working within the structure of the state juvenile correctional setting. Clinicians and interns were present in the facility full-time during the work week. They were integrated into the facility’s treatment team structure and collaborated with administrators in evidence-based program planning and implementation of treatment and milieu interventions. Being in the role of a contract vendor in a state facility added another level of coordination and engagement with the hosting agency around program development. Collaboration included suggestions and consultation around evidence-based practice and protocol; however, final decisions regarding what type of program and services were implemented were made by the state agency. While the training clinicians implemented the modified DBT skills-group as a treatment pilot, the purpose of this study was to assess feasibility from a program development perspective.

The full DBT protocol (e.g., individual therapy and skills group provided by fully trained DBT therapists, 24-hour telephone coaching) was not implemented due to systematic barriers unique to this environment (e.g., budget constraints, short duration of participants’ residence in the facility, and lack of clinicians’ formal DBT training). It was especially important to utilize a treatment that simultaneously met the therapeutic needs of the participants while accommodating the unique constraints of the setting. This group was modified and implemented to meet these needs.

Linehan (1993b) stated that the “mixing and matching to suit particular needs and treatment philosophies” (p. 11) is permissible and often required. Our DBT skills-training group was pared down from the 6 months typically provided for DBT skills training to 12 weeks. As release and transfer to different facilities was common, the 12-week treatment duration allowed all participants to complete skills training without interruption or attrition.

We followed standard pre/post measures used by the Vanderbilt University Community Mental Health Center in administering assessments, which required no additional training or cost. Furthermore, due to the highly manualized nature of the DBT skills-training group, group leaders were able to consolidate and follow the DBT skills-training manuals (Linehan, 1993b; Spradlin, 2003) with no formal training in DBT. Group leaders received weekly supervision from an on-site licensed professional counselor with formal DBT training. Leaders discussed and planned the content for each week’s group during supervision. The clinical supervisor participated in the group as an observer but did not actively engage in treatment delivery.

The DBT skills-training group received for 12 weeks one 90-minute weekly session led by two psychiatric nursing interns. The sessions were occasionally observed by a DBT-trained licensed professional counselor (LPC) on-site. Referrals were made by facility staff and clinicians based on symptoms related to cutting or other self-harm, affective dysregulation, poor interpersonal skills, and/or internalizing or self-destructive behaviors. The group was conducted in the afternoons to avoid conflict with school hours. Group sessions followed the standardized DBT skills group schedule, which consists of five main subjects: introduction, mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance (Linehan, 1993b). Group leaders used the Linehan (1993b) skills training manual in conjunction with Don’t Let Your Emotions Run Your Life, a self-help manual that consists of additional explanations and activities based on DBT skills designed for non-DBT trained persons (Spradlin, 2003).

Two weeks were allotted for each of the five major content areas of DBT skills group, with the final 2 weeks reserved for review and graduation. Homework was assigned weekly to promote skills practice. Participants monitored and recorded feelings, behaviors, and skills use with daily diary cards. No other components of the standard DBT protocol were provided as part of this treatment program. Participants received other treatments as usual throughout the duration of the group, which included non-DBT individual and family therapy for all participants and pharmacotherapy for a portion of the participants. Individual therapy included informal check-in regarding the use and perceived effectiveness of DBT skills learned in the group. Some participants received individual and/or family therapy from the DBT skills-training group leaders, while others were assigned to clinicians not involved with the skills training group.

Group leaders ran the group using a highly structured psychoeducational format. The DBT skills-training group room was set up with tables in a semi-circle, with the group leaders sitting on the open side of the circle in front of a white board and poster pad. Participants were provided with writing and drawing supplies, and candy was provided sporadically for use in group activities.

Measures and Analyses

The primary goal of this pilot study was to determine the effectiveness of using a modified version of a DBT skills-training group to overcome systemic barriers to DBT, and to implement the DBT skills-training group in a way that adequately met the unique needs of adolescent females in a juvenile correctional facility. Implementation measures assessed organizational factors, program factors, change agent(s), and staff factors (Gendreau et al., 1999). We collected qualitative information on these dimensions from group leaders via face-to-face interviews and e-mail. Treatment providers were asked to describe the following: (a) design of the group; (b) rationale for design of the group; (c) logistical information regarding the group (e.g., time frame, group size, scheduling, supplies, etc.); (d) training and supervision; (e) barriers to implementing the group; and (f) successes of implementing group. In addition, the second author (Tarah Kuhn) served as the clinical lead for the contract agency and was thoroughly familiar with the structural and programmatic components of the agency.

The secondary goal of this pilot study was to use existing, routine clinical assessment tools to measure participant progress. We used the Ohio Youth Scales for Problems, Functioning, and Satisfaction (Turchik, Karpenkov, & Ogles, 2007). The Ohio Youth Scales is a self-report assessment often used in state-funded mental health systems, and was the clinical assessment tool used most commonly by the contracted treatment vendor in the facility. Researchers used this instrument in a similar study of adult women receiving DBT skills training in a community mental health setting (Blackford & Love, 2011).

In an attempt to understand the collected data in a way that reflects target behaviors of DBT, we grouped items on the Ohio Youth Scales Problems Subscale into internalizing and externalizing subscales. We also used the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) to assess depression as an additional measure of internalizing behavior. We selected the BDI-II because of its common use in therapy efficacy studies and its exceptional psychometric properties. Both measurement instruments have demonstrated reliability and validity (Turchik, Karpenkov, & Ogles, 2007; Beck, Steer, & Carbin, 1988). We used Cronbach’s alpha to measure reliability on the internalizing and externalizing scales. Internalizing behavior scale had acceptable to excellent internal reliability at pre- (α = .84) and post-test (α = .94). The externalizing behavior scale had similar alpha scores at pre- (α = .78) and post-test (α = .90).

Of the Ohio Youth Scales, the Problems Subscale measures a variety of problems such as arguing with others, hurting self, and feeling sad on a 05 scale, with 0 = none of the time and 5 = all of the time. The Hope Subscale consists of four questions on a 16 scale, with higher scores indicating greater hope. The Satisfaction with Treatment Subscale consists of four questions on a 16 scale, with higher scores indicating greater satisfaction. The Functioning subscale has 20 items, including “getting along with family,” “controlling emotions and staying out of trouble,” “attending school and getting passing grades in school,” and “feeling good about yourself.” Each was rated on a 04 scale, with “0 = extreme troubles” and “4 = doing very well.”

We selected internalizing and externalizing items from the Problems Subscale and grouped them accordingly with good to excellent internal reliability. We measured internalizing behavior before and after treatment with seven items (α = .84; α = .78), including “hurting yourself (cutting, scratching self, taking pills),” “talking or thinking about death,” and “feeling worthless or useless.” We measured externalizing behavior before and after treatment with nine items (α = .94; α = .90), including “getting into fights,” “causing trouble for no reason,” and “yelling, swearing, or screaming at others.”

We measured depression with the BDI-II and included scores as another measure of internalizing behavior. Scores higher than 14 on the BDI-II indicated depression. Scores in the 1419 range were considered mild depression, 2028 indicated moderate depression, and 2963 indicated severe depression (Beck et al., 1996). We assessed participant progress by comparing pre- and post-treatment measures by participant using paired t-tests using an alpha of .05 to test for statistical significance. To control for possible Type I error inflation due to multiple comparisons, we also performed multivariate permutation paired t-tests (Blackford, Salomon, & Waller, 2009; Blackford, 2007) to obtain a corrected p-value. We measured effect size by computing a Cohen’s d (Cohen, 1992) corrected for dependent groups (Dunlap, Cortina, Vaslow, & Burke, 1996).

Results

A DBT skills-training group was successfully modified and implemented in a correctional facility for female adolescents. Implementation was measured using qualitative data provided by group leaders on organizational factors, program factors, change agent(s), and staff factors (Gendreau et al., 1999). A full description of the DBT skills group implementation process per framework of Gendreau, et al. (1999) is provided in Table 1. Rather than coding data, we used qualitative data gathered from treatment providers to assess components of the Gendreau, et al. (1999) framework (see Table 1).

Table 1. DBT Skills Group Implementation

Organizational Factors

The agency has a history of adopting new initiatives.

Vanderbilt Department of Psychiatry and the State of Tennessee Youth Development Centers (YDCs) have a longstanding history of collaboration. This partnership has aimed to serve the needs of female youth in the juvenile correctional setting since the opening of New Visions YDC in 2005. This includes consistent endeavors to seek out and provide evidence-based gender specific treatment, structure, and milieu interventions.

The agency efficiently puts its new initiatives into place.

The DBT skills group was the only initiative assessed in this study. The group was proposed and completed within the year that the group leaders were at the agency.

The bureaucratic structure is moderately decentralized, thus allowing for a flexible response to problematic issues.

The direct administrative staff in the agency was easily accessible and committed to making changes to support the needs of the population. Regular weekly meetings were held between facility administration and treatment providers, which addressed programming needs, as well as issues with individual youth.

Issues are resolved in a timely fashion.

Not assessed in this study.

Issues are resolved in a non-confrontational manner.

No significant issues reported, therefore not assessed in this study.

There is little task/emotional-personal conflict within the organization at the interdepartmental, staff, management, and/or management-staff levels.

Generally contract treatment providers working within this female adolescent juvenile correctional setting expressed feeling supported by the administration at the institution, with little conflict.

Staff turnover at all levels has been less than 25% during the previous 2 years.

Not assessed in this study.

The organization offers a formal program of instruction in the assessment and treatment of offenders on a biannual basis.

Formal instruction occurred for both state and Vanderbilt clinical staff upon orientation to the facility. There was no formal biannual process in place. Additional formal instruction in the assessment and treatment of offenders occurred as part of the ongoing clinical supervision process which was conducted weekly for all Vanderbilt staff. Additionally, state and Vanderbilt clinical staff participated as needed in trainings that impact milieu-based interventions.

Program Factors

The need for the program has been empirically documented (e.g., surveys, focus groups).

The need for the program was identified by treatment providers and administrators based on the presenting problems of youth in the facility. DBT skills training was chosen due to the existing empirical evidence of DBT with similar populations and the low demand on agency resources.

The program is based on credible scientific evidence.

Researchers have modified and implemented DBT skills training group only with similar populations with positive outcomes (Nelson-Gray et al., 2006; Salerno, 2005).

The program does not overstate the gains to be realized (e.g., recidivism reduction).

DBT skills group aimed to improve incarcerated adolescent females’ skills related to emotion regulation, interpersonal relationships, behavioral control, and coping with extensive trauma in a cost-effective way. While a long-term goal is to reduce recidivism, this group was not designed to do so directly.

Stakeholders (i.e., community sources, management, and staff) agree that the program is timely, addresses an important matter, and is congruent with existing institutional and/or community values and practices.

Not assessed in this study.

Stakeholders agree the program matches the needs of the clientele to be served.

Not assessed in this study.

Funding originates from the host agency.

This group did not require any additional funding as it utilized unpaid interns and available site resources (i.e. supplies used in other groups, regular group meeting space/time, etc.). Clinical supervision provided was an existing expectation of staff involved with practicum students.

The fiscal aspects of the program (a) are cost-effective, (b) do not jeopardize the continued funding of existing agency programs, and (c) are sustainable for the near future.

The implementation of this group resulted in no extra costs to the facility or significant demands on resources (i.e. materials, space, time, etc.). Security officers were made aware of each group meeting, with one security officer on stand-by in the event of behavioral disruption, consistent with standard procedure for all clinical groups in this setting.

The program is being initiated during a period when the agency is free of other major problems and/or conflicts.

The facility was not experiencing any major problems or conflicts at the time of planning or implementation of the DBT skills group.

The program is designed to (a) maintain current staffing levels, (b) support professional autonomy, (c) enhance professional credentials, and (d) save staff time and/or effort.

DBT skills group did not introduce additional staffing demands. Group leaders were unpaid psychiatric nurse practitioner interns who were trained and supervised by an existing site therapist. Site therapists run groups as part of their standard clinical practice.

Program initiation proceeds (a) incrementally, (b) has a pilot/transitional phase, and (c) initially focuses on achieving intermediate goals.

The purpose of this study was to evaluate the DBT skills group in its pilot phase. The group was planned and implemented over an approximate 6-month period.

Change Agent

The change agent has an intimate knowledge of the agency and its staff.

The contract agency providing treatment and implementing the DBT skills group has an extensive history of collaboration with the setting.

The change agent has the support of senior agency officials, as well as that of line staff.

The supervising therapist received approval from the setting’s superintendent before implementing the DBT skills group. The interns who led the group reported that they were supportive of the group and excited to gain experience in delivering DBT.

The change agent is compatible with the agency’s mandate and goals.

The implementation and delivery of gender-appropriate, evidence-based treatment is part of the treatment agency’s contract mandate.

The change agent has professional credibility.

The supervising therapist was a licensed professional counselor who had received formal training in DBT. Group leaders were psychiatric nurse practitioner students from Vanderbilt University.

The change agent has a history of successful program implementation in the agency’s program area.

The contract agency providing treatment is involved in program development and implementation across multiple domains within the juvenile justice setting and has served as a consultant to the state around evidence-based practice.

In bringing about change, the change agent employs (a) central routes of persuasion, (b) motivational interviewing techniques (e.g., empathy, discrepancy, non-confrontational, self-efficacy support), (c) reciprocity, (d) authority (but does not use threats), (e) reinforcement (e.g., praise), (f) modeling, (g) systemic problem-solving, and (h) advocacy/brokerage.

Not assessed in this study.

The change agent continues until there are clear performance indications that management and staff are able to maintain the delivery of the program with a reasonable degree of competence.

The supervising therapist observed groups and provided weekly supervision to group leaders throughout group leaders’ tenure at the agency. Supervision consisted of discussion of the DBT skills group as well as general supervision concerns.

Staff Factors

The staff have frequent and immediate access to the change agent.

Group leaders received weekly supervision from the supervising therapist. The supervising therapist was on-site at all times when group leaders were present at the agency.

The staff understand the theoretical basis of the program.

Group leaders received academic training on DBT and cognitive behavioral therapy through Vanderbilt University. Group leaders utilized two DBT treatment manuals (Linehan, 1993b; Spradlin, 2003) for the duration of the group. Ongoing clinical supervision was also provided.

The staff have the technical/professional skill to implement the program. They have taken applied courses on the assessment and treatment of offenders.

Group leaders were nurse practitioner interns who were provided with applied coursework regarding treatment of adolescents. Practical experience with the offender population was gained through the internship experience, exposure to literature specific to this population, and supervision. Ongoing clinical supervision was also provided to help further development of skills.

The staff think (i.e., self-efficacy) they can run the program effectively.

Group leaders reported feeling confident about teaching DBT skills and managing the group due to the weekly supervision component and the structured nature of the DBT skills group manuals.

To run the program efficiently, the staff are (a) given the necessary time, (b) given adequate resources, and (c) provided with feedback mechanisms (e.g., focus groups and workshops).

Group leaders reported having no difficulty in acquiring resources, space, security, or supervision when implementing the group. Set time during clinical supervision was utilized for planning of weekly group activities.

The staff participate directly in designing the new program.

The group leaders initially proposed the idea to design and lead the DBT skills group in consultation with their clinical supervisor. Both expressed an interest in DBT but had no formal training. They worked closely with the supervising therapist to adapt the DBT skills group as described in the Linehan (1993b) and Spradlin (2003) manuals to a delivery system that was fitting for the correctional setting.

Treatment providers stated they were able to prepare and establish goals for the group by relying on the high level of structure and guidance in the DBT skills training manuals and supervision from a trained DBT therapist (Linehan, 1993b, Spradlin, 2003). One treatment provider stated, “I had taken a class on cognitive behavior therapy and had read quite a bit, but had never been officially trained in DBT. Having the manuals and supervision from a trained therapist made it much easier to explain and practice DBT skills with the girls. I would practice the skills by myself, too.”

The DBT skills-training group was completed in 12 weeks, with no breaks or interruption in treatment. All of the participants completed the group and graduated successfully. Successful graduation was defined as attendance at all group sessions. We did not collect data on the attrition rates in other groups held at this facility. However, based on the qualitative data collected from clinicians, this group’s attrition rate was slightly lower than that of the other groups, possibly because the DBT skills-training group lasted for 12 weeks rather than 16 weeks, which was the timeframe for the other groups. “Having the group after school hours kept the teachers and administrators happy. We had group between the hours of school and dinner; a time when the girls tended to act out,” said one of the group leaders.

Participants were removed from the group by group leaders using a “three strikes” system, with a missed group or severe behavioral disruption resulting in one strike. Upon receiving three strikes, participants would be removed from the group. During this study, no participants were removed from the group. One treatment provider recalled participant behavior in the group this way: “Sometimes it took us some time to get the girls settled and ready for group. We practiced mindfulness every group, but would sometimes have to move it to the beginning or the end depending on where the girls were that day. Staying flexible while sticking to the manual was tricky, but [the supervisor] helped us with maintaining structure.” Regarding barriers, treatment providers stated that the content might have been too advanced for some of the participants. One group leader stated, “DBT uses some fairly large words and complicated concepts, like dialectics! I think that if other terms could be incorporated to make things like ‘emotional dysregulation’ and ‘interpersonal effectiveness’ more accessible to the girls, they might have understood the concepts a bit more easily. For example, they all really took to the concept of ‘wise mind.’ It is much simpler than some of the other components of DBT.”

In addition to investigating DBT skills group implementation, we analyzed clinical assessment data to assess participant progress. The Ohio Youth Scales provided a global assessment of functioning pre- and post-treatment. As predicted, the DBT group reported significant reductions in scores on the Problems Subscale (see Table 2 for this and all Ohio Youth Scales outcomes). Treatment satisfaction scores increased significantly from “moderately satisfied with treatment” at pre-test to “quite a bit satisfied with treatment” at post-test. At pre-test, Functioning scale scores averaged as participants having “some troubles.” This improved as participants reported functioning “ok” at post-test, which approached significance (p = .06). On the Hope subscale, initial scores were slightly low and indicated that the “future looks both good and bad.” Although there was an increase in the scores at post-test, the increase was modest and did not reach statistical significance (p = .17).

As a post-hoc analysis, the Problems scale was separated into internalizing and externalizing behaviors (see Table 2). When internalizing behaviors were analyzed, initial scores indicated problems several times during the past month. Following treatment, participants reported problems as occurring once or twice per month, which shows a significant decrease (p = .003). The scores of another measure of internalizing behavior, depression, dropped by 50% after treatment. Before treatment, participants rated their depression as severe, on average. After treatment, scores were significantly lower and in the mild depression range (see Table 2). However, when we analyzed externalizing behaviors separately, there were no significant changes (t(9) = .11, p = .91); participants experienced externalizing behaviors both before and after participation in the DBT skills-training group.

Subscale

N

Pretest

X

Pretest

sd

Posttest

X

Posttest

sd

t

p

d

Problems

9

1.11

0.93

2.70

1.11

-2.91

.02*

-.66

Hope

9

2.64

0.91

2.27

0.76

0.77

.46

.26

Functioning

9

1.56

0.53

1.22

0.44

2.00

.08

.69

Satisfaction

9

2.90

1.03

1.78

0.44

3.07

.02*

1.09

Depression

9

38.67

12.46

19.11

21.44

4.29

.003*

1.83

Problems Subscales

Internalizing

9

2.00

1.44

4.25

0.87

-4.29

.003*

-1.49

Externalizing

9

3.61

1.35

3.67

1.31

-.11

.91

-.04

Note. * = significant following correction for multiple testing.

Discussion

While previous literature suggests that DBT can be implemented in a juvenile correctional setting, the costs are high. The only study in which DBT was fully implemented included special state funding and required extensive DBT training for six staff members. The cost of training staff members whose turnover rates are often high, makes the cost of training one of the most challenging barriers to implementing DBT (Trupin et al., 2002). Other studies (Nelson-Gray et al., 2006; Salerno, 2005) have attempted to address this barrier by implementing one component of DBT—group skills training.

One goal of this study was to determine whether the DBT skills-training group could be feasibly implemented in a correctional facility for female adolescents with low demand on systemic resources, including funding, time, staff, and administration. The major finding of this study was that the DBT skills-training group was successfully modified and implemented with preliminarily promising outcomes in this setting, without substantial demand on the facility’s resources. This study demonstrated that DBT, a treatment proven effective in reducing the behavioral and emotional problems commonly experienced by incarcerated adolescent females, can be efficiently modified and executed without imposing significant financial or occupational burdens on a highly structured juvenile correctional system.

We found that after participating in a modified version of DBT skills-training group, participants experienced a decrease in internalizing symptoms commonly associated with depression, anxiety, and PTSD. Feelings of worthlessness, sadness, and parasuicidal behavior are especially high in this population; all significantly decreased in our pilot sample of youth who participated in this modified DBT skills-training group.

Limitations and Directions for Future Research

While this pilot study generated positive preliminary findings, it has several limitations. We observed statistical significance for many of the outcome measures, but the sample size was quite small. Further, this study utilized a within-subjects pre-test/post-test design with no control group. Future studies should utilize larger samples in a treatment-as-usual group design to determine whether DBT skills training improves symptoms relative to existing treatments. Also, we found that the Functioning scale of the Ohio Youth Scales may not have been best suited for this population because of the lack of participants’ access to many of the items (“participating in hobbies/recreational activities,” “completing household chores,” “earning money”). Another limitation in this study is the lack of formal fidelity monitoring. Group plan and structure were incorporated into supervision, but quality assurance was not directly measured. This could be remedied by including video or audio recording of group sessions and the creation of fidelity checklists to be completed by group leaders. Furthermore, future studies should attempt to identify whether there are specific components of DBT skills training that are more effective for addressing the unique behavioral and emotional problems experienced by this population. This information could be used to design and evaluate a modified DBT skills-based treatment specifically for adolescent females in correctional facilities. Finally, while we collected data from clinical staff only, future researchers would be wise to collect data from all staff (e.g., front line, administrative, education, etc.) to gain a more thorough understanding of the impact of the implementation and effectiveness of these treatments.

As with most pilot studies, the results of this study raise more questions than they provide answers. While behavioral healthcare in juvenile corrections has improved dramatically over the past 10 years, broad gaps exist in the literature regarding effective and systematic implementation of these treatments. Several studies have identified DBT as an effective treatment approach for the problems of incarcerated youth, but further study of systematic implementation of DBT in its many forms is needed. Given the financial and systemic barriers to providing evidence-based treatment in juvenile correctional settings, simplifying DBT by providing only a modified skills training group was our attempt to deliver this treatment efficiently and effectively in the juvenile corrections environment.

Although we focused heavily on implementation in this study, we did not adequately consider the dimension of sustainability. Since completion of this study, the correctional facility has closed. This prevents the possibility of continuing the follow-up, full-scale study originally planned. However, the contracted treatment vendor is currently in the process of partnering with the agencies to which participants were sent, with the intention of continuing this study—with the caveat of a change from correctional to other forms of residential setting. Therefore, to avoid similar complications in future studies, researchers and clinicians should complete thorough checks to ensure the stability of their settings. Important aspects to consider include staff turnover, administrative changes, political climate, and funding streams.

Implications and Conclusions

The increasing evidence for the effectiveness of DBT skills-training groups in similar settings and populations makes it an attractive treatment to meet the unique needs of incarcerated adolescent females. Overall, we identified two major themes that may be pertinent for similar settings. These themes relate to the appropriateness of this and other evidence-based treatments for (a) the persons being served, and (b) the setting itself. Bourgon and Armstrong (2005) suggest that the level and type of service that a setting implements should be based on an assessment of the clients’ risks and needs. This assessment should include a comprehensive battery of evidence-based measures that assess clients’ physical health status, emotional/mental health status, family history, socioeconomic history, educational history, and offending history (Bourgon & Armstrong, 2005). Based on the needs of the population within a particular setting, treatment providers and administrators should collaborate to identify goals and possible evidence-based treatments that could be effectively implemented and evaluated in the setting. The framework of Gendreau et al. (1999) could serve as a tool to guide this process.

In the present pilot study, we utilized an emotion-focused cognitive behavioral treatment that was well matched with the symptoms exhibited by girls in the juvenile justice system (i.e., feelings of worthlessness, sadness, emotional reactivity, and parasuicidal behavior). Furthermore, since previous research suggests that these symptoms may be linked to offending behavior in this population, it is possible that DBT skills training could inhibit recidivism (Wasserman & McReynolds, 2011; McReynolds et al., 2010). A unique finding of this study suggests DBT should be amended to not only address the clinical needs, but also the developmental needs of this population. The modified skills training group met the facility’s needs by placing low demands on staff, funding, and resources while fostering a high level of collaboration between treatment providers and administrators. Although we were unable to draw causational conclusions about treatment effectiveness due to the naturalistic design of this study, we urge other researchers to expand on this study by further investigating the generalizability of these preliminary findings in other female juvenile justice correctional facilities.

About the Authors

Breanna Banks, MA, is a doctoral student at the University of Tennessee, Knoxville.

Tarah Kuhn, PhD, is an assistant professor and clinical psychologist at Vanderbilt University Medical Center, Nashville, Tennessee.

Jennifer Urbano Blackford, PhD, is an associate professor in psychiatry and psychology at Vanderbilt University Medical Center, Nashville, Tennessee.

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