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Author Manuscript
J Child Adolesc Psychiatr Nurs. Author manuscript; available in PMC 2012 May 1.
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J Child Adolesc Psychiatr Nurs. 2011 May ; 24(2): 105–113. doi:10.1111/j.1744-6171.2011.00275.x.
Impact of a Dialectic Behavior Therapy - Corrections Modified

(DBT-CM) Upon Behaviorally Challenged Incarcerated Male
Adolescents
Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN[Professor][Director],

School of Nursing/Department of Medicine, Research & Evaluation-Correctional Managed Health
Care, University of Connecticut, 231 Glenbrook Rd., Storrs, CT 06269
Karen Kesten, MS,
University of Connecticut Health Center, Department of Medicine
Wanli Zhang, PhD, and
University of Connecticut Health Center, Department of Psychiatry
Robert Trestman, MD, PhD

University of Connecticut Health Center, Department of Medicine, Psychiatry & Nursing,
Correctional Managed Health Care
Abstract
Purpose—This article reports the findings of a Dialectical Behavioral Therapy- Corrections
Modified (DBT-CM) intervention upon difficult to manage, impulsive and/or aggressive
incarcerated male adolescents.
Methods—A secondary analysis of a sub-sample of 38 male adolescents who participated 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 coping methods and
number of disciplinary tickets for behavior.
Conclusion—The study supports the value of DBT-CM for management of incarcerated male
adolescents with difficult to manage aggressive behaviors.
Introduction
According to a December 2009 Bureau of Justice Statistics report, there were 92,854 youth
held in juvenile facilities as of the 2006 Census of Juveniles in Residential Placement,
conducted by the Office of Juvenile Justice and Delinquency Prevention (Sabol, West &
Cooper, 2009; Sickmund, Sladky, Kang & Puzzanchera, 2008). Of these, approximately
40% are held for violent crimes (criminal homicide, violent sexual assault, robbery, and
aggravated assault) and 51% report symptoms of depression and anxiety (Sedlak &
McPhersen, 2010).
Increasingly, over the past twenty years, youth exhibiting significant mental health and
behavioral problems have come into contact with juvenile justice systems. Studies have
Corresponding Author: Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN, Professor, School of Nursing/Department of Medicine,
Director, Research & Evaluation-Correctional Managed Health Care, University of Connecticut, 231 Glenbrook Rd., Storrs, CT
06269, 860-486-0409, [email protected].
Shelton et al. Page 2
shown that at least 20% of youth entering the justice system have a mental health problem,
with a majority also experiencing a co-occurring substance abuse disorder (Skowyra &
Cocozza, 2007; Trupin, Stewart, Beach & Boesky, 2002; Shelton, 2001). These youth pose
particular management challenges, as these offenders have particular difficulty adjusting to

the rules and routines and are more likely to incur violations and accumulate disciplinary
consequences while incarcerated. These youth frequently receive behavioral tickets for how
they act including verbal threats, self-harm, refusing to follow directions, disorderly
conduct, destruction of property, at times assault; and when placed in segregation cells, will
often regress to smearing feces or throwing urine (Quinn & Shera, 2009). Such reported
violations are indicative of their emotional, behavioral, and cognitive difficulties. Authors
and clinicians agree, that without appropriate treatment, these behaviors are likely to persist,
causing distress to the adolescent and adding stress to the correctional environment (Fazel,
Doll, & Langsrom, 2008; Berzins & Trestman, 2004).
This paper presents adolescent data from a larger study of adults and youth designed to test
the implementation of a dialectic behavior therapy modified for a state correctional system.
It was important to examine the data on the youth separately, based upon the belief that
youth are different than the adult population and has unique developmental needs. Presented
here is the limited literature regarding use of dialectic approaches with incarcerated youth, a
description of the intervention, methods and the findings of this secondary data study.
Background
The use of cognitive-behavioral approaches with youth who have challenging behaviors and
who have become involved with juvenile justice systems is well supported (Quinn & Shera,
2009; Trupin, et.al., 2002; Skowyra & Cocozza, 2007). Among cognitive-behavioral
approaches, dialectic behavior therapy (DBT), designed by Linehan (1993), has shown
particular promise for application to corrections populations.
While similar to Cognitive-behavioral Therapy (CBT) with its use of core therapeutic
procedures such as problem solving, exposure, skill training, contingency management and
behavior therapy, DBT departs from standard CBT in a number of ways. It begins by
emphasizing a “dialectical” approach to behavior change, encouraging an individual to
accept his or herself as they are in the present within the context of reshaping their
cognitions and changing their future behavior (Linehan, 1993). As a general therapeutic
framework, DBT attempts to address maladaptive behaviors by teaching emotional
regulation, interpersonal effectiveness, distress tolerance, core mindfulness and self-
management skills. The application of these skills are coached, encouraged and reinforced.
DBT also attempts to engage the individual in therapy, providing motivation and support for
change by emphasizing the management of therapy-interfering behaviors and the

relationship between the therapist and the client. DBT has been shown to significantly
reshape maladaptive cognitions and reduce the incidence of self-destructive behaviors (i.e.,
self-mutilation, suicide and parasuicidal behaviors), and has become the first empirically
supported treatment for borderline personality disorder (Linehan, Armstrong, Suarez,
Allmon, & Heard,, 1991; Linehan, Tutek, Heard, & Armstrong, 1994; Rathus & Miller,
2000).
With its clear hierarchy of treatment targets and behavior modification (through functional
analysis), DBT is well suited for treatment of many problems characterized by behavior
dyscontrol. Individuals with borderline personality disorder have characteristics similar to
other difficult-to-treat populations, such as emotional instability, anger management
problems, aversive affect, interpersonal dysregulation, self-damaging behavior, cognitive
disturbances and rigidity, and self-dysfunction (Linehan, 1993). Because this particular
treatment modality uses a specialized behavioral skills package to target the cognitions
behind these behaviors, DBT can and has been successfully modified and adapted to other
treatment 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 of DBT in the correctional
environment which is frequently cited. As with DBT, the aim is to teach a form of
dialectical thinking that enables incarcerated persons to problem-solve when in conflict.
This protocol typically includes four core modules: mindfulness, interpersonal effectiveness,
distress tolerance, and emotion regulation. The protocol addresses the underlying impaired
executive cognitive functioning known to play an important role in the etiology of violent
and aggressive behaviors (Morgan, & Lilienfeld, 2000).
Yet, there are limited studies in the literature demonstrating the use of DBT with
incarcerated adolescents. In a report by Drake and Barnoski (2006), they have shown a 14%
reduction in recidivism for their 70% white and 79% female sample (63 youth with 65 youth
in the comparison group). In a second study of the effectiveness of DBT upon the behaviors
of 22 female (50% white) offenders, Trupin, Stewart, Beach & Boesky (2002) found a
significant decrease in serious behavior problems during their 10-month intervention; but
suicidal acts, aggressive behavior and class disruptions were not significantly reduced
throughout the year when compared to the year prior to the intervention.
Despite the limitations of the published data regarding the application of DBT to the
adolescent offender population, and the uneven findings which, at present are in part due to
small sample sizes and the challenges of implementing research within secure environments;
there is support from studies of use of DBT outside of corrections with the adolescent
population that offers impetus to continue in replicating these efforts (Quinn & Shera, 2009).
As an example, Nelson-Gray et al. (2006) report 71% of their sample of 32 outpatient
adolescent program completers demonstrated clinically significant improvement following
use of Linehan’s (1993a) skills training manual for treating borderline personality disorder
modules.
In a review of the literature conducted by Paschall and Fishbein (2002), these authors clearly
demonstrate the relationships between impaired executive cognitive functioning and violent
and aggressive behaviors. Because executive cognitive functioning is involved in the
planning, initiation, and regulation of goal-directed behavior (Luria, 1980; Milner, 1995)
deficits in its function often contribute to poor behavioral self-regulation, social skills, and
judgment. Such a deficit or “clinical impairment” may be the result of an injury in the
frontal lobes of the brain (Paschall & Fishbein, 2002). However, there are more problematic
deficits, those referred to as “subclinical impairments” which are not readily observable or
easily diagnosable. These less apparent deficits can be affected by a variety of hereditary,
behavioral, and environmental factors such as poor nutrition, alcohol abuse, and exposure to
violence which can impact youth physical and psychological development.
The Development Perspective. Several theories have emphasized a developmental trajectory

of delinquency (Huizinga, Loeber, & Thornberry, 1993; Loeber et al., 1993; Elliot,
Huizinga, & Ageton, 1985). Moffitt (1993) summarized two prototypes for the development
of delinquency. The first, the life-course-persistent prototype, originates in childhood with
neurodevelopmental variation manifested in cognitive deficits (difficult temperament and
hyperactivity) and interact with inadequate parenting, poor family relations, and poverty. As
the adolescent transitions to adulthood, the relationship between the individual and the
environment gradually becomes characterized by aggression and antisocial behavior that
continues through midlife. The second type, adolescence-limited-offending originates in the

social process, begins later in adolescence, and disappears in young adulthood (Moffitt,
2003). The main difference lies in the fact that the preadolescent development for this group
was normal, reflecting psychological difficulties that arise from the gap between biological
change and the lack of access to mature behavioral options.
The Risk and Protective Factors Perspective. One of the more influential approaches in
understanding the reasons for delinquency focuses on identifying which risk factors are
associated with elevated levels of delinquent and antisocial behaviors (Herrenkohl, Maguin,
Hill et al., 2000). Simply defined, risk factors are those factors that increase the likelihood of
a negative outcome, and protective factors reduce negative outcome by means of interacting
with risk factors and moderating their effects or by means of direct influence protective
factors decreased likelihood of negative outcome (DeMatteo & Marczyk, 2005). The ratio of
protective and risk factors changes with age. For example, growing up with a low
socioeconomic status or in a dangerous or violent neighborhood is associated with higher
rates of offenses and convictions (Farrington, 1998; Loeber & Farrington, 2000). Further,
growing up in large aggressive families, with parents with poor parenting skills, exposed to
maltreatment and emotional deprivation have all been associated with increased risk for
antisocial and delinquent behavior (Kumpfer & Alvarado, 2003; Loeber & Farrington,
1998).
It is particularly important to note that developmental factors rarely operate alone and tend
to interact with other environmental factors. Individual risk factors include prenatal and
perinatal complications. Psychological and behavioral characteristics that have been
identified as risk factors include low I.Q., delayed language development, hyperactivity,
impulsivity, restlessness, risk taking, antisocial beliefs, greater negative emotionality, and
substance abuse (DeMatteo & Marczyk, 2005; Hawkins et al., 1998; Kashani et al., 1999;
Loeber & Farrington, 1998). Despite the importance of the risk and protective factors
approach to identifying indicators of delinquency, Rutter (2006) maintains that risk factors
and threats alone do not lead to dysfunction and negative outcomes. As an example, growing
up with a low socioeconomic status can be related to increased risk for delinquency because
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 to criminal
activities; or through its association with negative psychological factors such as low self-
esteem and depression. But, for some youth, they seem to beat the odds in the face of
adversity.
Social, environmental, and biological risk factors have been identified that help to explain
demographic and geographic variation in the prevalence of violent and aggressive behaviors
among adolescent youth. Kann et al (2000) found the highest prevalence rates for fighting
and weapons among Hispanic and African American high school students and among urban
students in a national study. Snyder and Sickmund (1999) report higher rates of violence
among males and ethnic minority groups, as well as similar urban geographic variations for
weapon carrying, with juvenile murders concentrated in urban areas.
Importance of Coping. There is consensus that adolescence is a significant and distinct

period of human development marked by the transition from childhood to adulthood.
Between the ages of 11 and 18 a rapid sequence of physical, cognitive, social, and
behavioral transformations occur (Friedman, 2000). Coping behaviors are particularly
important, given the variety of stressors that may be experienced with achieving these
developmental tasks. In addition to the normative changes with which all adolescents need
to cope, a large proportion of adolescents cope with serious stressors such as parental
divorce, life in poverty, serious medical conditions, abuse and neglect, and parental
substance abuse (Sandler, Wolchik, Mackinnon, Ayers, & Rossa, 1997). Understanding how
adolescents cope with serious stressors in their immediate environment is particularly
important because adolescents are at an increased risk 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 follow a developmental trajectory

(Eisenberg, Fabes, & Guthrie, 1997). Some indicators of coping, such as reactivity and
inhibition control are present at birth (Davis & Emory, 1995) and shaped by learning.
Learning strategies in adolescence include previous personal experience, peer modeling,
perception of personal vulnerability, and social persuasion by others (Ireland, Boustead, &
Ireland, 2005). Aldridge and Roesch (2008) developed a typology of minority adolescent
coping, and found that three types of coping existed. The first group (44.6%) was those who
minimally employed coping strategies and were referred to as low generic copers. Overall,
these minority adolescents were psychologically healthy, and although they used their
coping strategies sparingly, they were 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 adaptive of the three groups, these adolescents primarily used
acceptance, religion and humor as strategies which would lead to adaptive outcomes. The
third group (7.3%) was those who were avoidant or used passive strategies most frequently
and are labeled avoidant copers. Interestingly, adolescents within the avoidant coping
typology were maladjusted in comparison to the other two groups, characteristically

preferring to focus on and vent their emotions and engage is substance use. Although this
could be considered adaptive in some circumstances, it is generally considered to result in
worse adjustment outcomes and, when combined with substance use, likely to lead to
negative health outcomes and risky consequences (Hofstein, 2009). These authors found
adolescent avoidant copers engaged in more denial and behavioral disengagement, strategies
that have been linked to maladjustment. Aldridge and Roesch (2008) found that the poor
conditions of their communities and limitations within their families further supported the
use of more avoidant/disengaging strategies relative to the other coping strategies.
Development of interventions for delinquent youth, then, shares the underlying assumption
that because at-risk adolescents demonstrate certain less adaptive coping skills, they revert
to aggressive or delinquent behaviors and exhibit other emotional and behavioral problems.
Traditionally, coping is considered a mediator in the relationship between stressors and
physiological and psychological outcomes (Carver et al., 1989). How stressors in the
environment influence psychological functioning may depend on the interpretations and
reactions of the individual to the stressors, environment or situation. DBT then, focuses
onchanging the thoughts and emotions that precede problem behaviors, as well as solving
the problems that contribute to problematic thoughts, feelings and behaviors.
Longitudinal studies examining the developmental pathways of youthful offenders have

demonstrated that the behavioral manifestations of these exposures are unfortunately seen
particularly among males (Hawkins et al., 2000), yet the literature found on use of DBT with
incarcerated youth focus primarily upon female incarcerated offenders. This secondary data
analysis examines the application of a corrections modified- dialectic behavior therapy
among incarcerated adolescent males of mixed races and ethnicities. The need for mental
health treatment in corrections for this population is very well documented (Fazel, et al.,
2008; Rosenblatt, Rosenblatt, & Biggs, 2000).
Methods
A secondary data analysis was conducted on a subsample of 38 adolescent males to test the
hypothesis that participants will show reduced aggression, impulsivity, and improved coping
after completing the Dialectic Behavior Therapy-Corrections Modified (DBT-CM) groups.
A pretest-posttest one-group design was used. Descriptive analyses were conducted using
SPSS version 15.0. A paired sample t-test was utilized to test for mean differences before
and after the 16 week intervention with alpha set at p=.05. A chi-square analysis was
conducted to assess whether there were any differences between those who completed the
intervention (n=26) and those who did not (n=12) based on demographic variables. IRB
approval was obtained through the University of Connecticut (IRB # 04-156-2).
Sample
Participants with impulsive behavior problems were recruited for participation from the one
facility in the state that holds male adolescent youth committed to the state Department of
Correction. Youth were referred as potential participants by correctional facility unit majors
and correctional mental health personnel. Those youth referred were those youth perceived
by corrections staff to be unpredictable and were those inmates who were difficult to
manage as indicated by the high number of behavioral tickets they received. Once voluntary
participants were identified, a screening visit was conducted to discuss eligibility for
participation in the study protocol. Individuals were excluded from participation if any of
the following factors were evidenced: presence of any unstable medical or neurological
disorder that would interfere with participation in the protocol or cause additional risk; non-
English speaking; less than one year from end of sentence; appearing not to understand the
procedures and aims of the study as described on the informed consent form; screening
positive for psychopathy, as evidenced by a score of more than 30 on the Hare Psychopathy
Checklist-Screening Version (PCL-SV) (Hare, 1991). An individual had the choice to drop
out of DBT-CM and/or the interview sessions at any point without penalty or effect on their
current status within the state Department of Correction or the care received in that facility.
Prior to participation in the DBT-CM intervention, a psychological assessment of the
participant’s current mental, physical, and emotional state was conducted.
The adolescent sample enrolled during the study period (2004–2006) included 38 adolescent
males. Twelve participants were lost to the study. Reasons for attrition were: four withdrew
from the group on their own; one was transferred to a different facility, and seven youth
were released. A chi-square analysis was conducted to assess whether there were any
differences between those who remained in the study. There were no significant differences
based on race (χ 2 =5.336, df =4, p=.255), age (χ 2 =3.057, df=4, p=.548), or education level
(χ 2 = 4.752, df=4, p=.314).
DBT-CM Intervention
Extensive adaptations to the vocabulary and examples included in the DBT-CM treatment
manual were required to increase the likelihood that participants would benefit from DBT
(Trestman, Gonillo, & Davis, 2004). Given the higher incidence of reading and learning
problems among incarcerated individuals (Samuelsson, Herkner, & Lundberg, 2003;
Slaughter, Fann, & Ehde, 2003), the DBT vocabulary was adapted to make it easier to
understand, and many pictures were added to increase iconic learning. Numerous examples
were changed and added, to reflect the types of situations incarcerated individuals face. In
addition to modifying the ‘content’ of clinical materials to make them appropriate for
forensic settings, it was also necessary to tailor the ‘form’ of clinical materials. For example,
participant workbooks were thermal bound, rather than being bound with any metal
materials that participants could use to injure themselves or others. Additionally, whenever
the research clinicians required use of some type of object (such as pencils), that object had
to be acceptable (approved) according to that correctional 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
on giving attention to the present moment and targets self dysregulation and identity
confusion by emphasizing self-awareness. The interpersonal effectiveness module teaches
assertiveness, interpersonal skills and conflict resolution. The distress tolerance module
focuses on using strategies to tolerate distress, without making it worse by engaging in old
impulsive and self-destructive behaviors by teaching distraction and self-soothing
techniques. And, the emotion regulation module assists participants in identifying and
describing their emotions, accepting their trauma experiences and focusing on being less
reactive to them, and then how to increase positive emotions. These four skills modules are
designed to increase adaptive behaviors and cognitive abilities while decreasing maladaptive
behaviors and cognitions (Berzins & Trestman, 2004).
In teaching each of the DBT-CM skills to incarcerated participants, examples relevant to

participants’ daily experiences in their correctional facility are used. DBT-CM skills are
projected with plans for release to anticipate applications of the skills in their outside lives.
The teaching of almost every skill was modified with examples and subtle adjustments to
correspond to the correctional setting.
Highly structured DBT-CM groups (16 weeks) were co-led by a team of two research
clinicians. If an individual discontinued participation in the DBT-CM protocol for any
reason, they could still choose to continue with the research interview sessions (posttest).
Prior to participation in the 16-week DBT-CM intervention, a study research assistant met
with the participant to conduct an interview using a battery of psychological assessment
tools that assessed the participant’s current mental, physical and emotional state.
Instruments
The primary outcome was to measure a reduction in aggressive and impulsive behavior and
improve coping as measured by pretest-posttest rating collected through semi-structured
interview assessments (to eliminate literacy issues and security with pencils) to measure
impulsive aggression: (1) the Buss–Perry Aggression Questionnaire (BPAQ), a 29-item, 5
point Likert scale designed to assess four dimensions including physical aggression, verbal
aggression, anger, and hostility (Buss & Perry, 1992). Internal consistency for the four
subscales and total score range from .72 for Verbal Aggression to .89 for the Total score.
Retest reliability over nine weeks ranged from .72 for the Anger subscale to .80 for the
Physical Aggression subscale and Total score. (2) Overt Aggression Scale-Modified (OAS-
M), a 25-item to assess the severity, type, and frequency of aggressive behavior weighted by
severity and frequency. Subtypes include: verbal aggression, physical aggression against
objects, and physical aggression against self and physical aggression against others
(Coccaro, Harvey, Kupsaw-Lawrence, Herbert, & Bernstein, 1991). Interrater reliability has
been demonstrated to be .91 for ratings by two clinical raters for OAS–M Aggression and
Irritability. Test-retest reliability within a 1 to 2 week period has been shown to have an
intraclass correlation for aggression on Time 1 and Time 2 of .46 and .54, respectively
(Suris, Lind, Kashner, Bernstein, Young & Worchel 2005). (3) Brief Psychiatric Rating
Scale (BPRS), the Total Score and item 5 (Hostility) were used from this 18-item rating
scale designed to assess in severity of psychopathology. Items address somatic concern,
anxiety, emotional withdrawal, conceptual disorganization, guilt, tension, mannerisms and
posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behaviors,
motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement
and disorientation (Overall & Gorham, 1962). Interrater reliabilities ranged from .82 to .93
with the highest agreement on somatic concern and unusual thought content subscales.
(Ligon & Thyer, 2000). (4) Disciplinary ticket information collected from records on
participants 12 months prior to starting groups and six months after completing groups
(disciplinary tickets are given to inmates when a behavioral offense has been made within
the prison facility).
Additionally, a self-report basic demographic questionnaire designed for this study

containing questions about age, ethnicity, and socio-economic status was collected. The
Ways of Coping Checklist (WCCL), a 33 item Likert scale self-report checklist measures
eight different coping styles-confrontational coping, seeking social support, planful problem
solving, self-control, distancing, positive reappraisal, accepting responsibility, and escape/
avoidance (Folkman & Lazarus, 1988). The typical reliability across subscale 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 negative affect states
(Watson, Clark, & Tellegen, 1988). This 20-item scale requires a self-report across five
criterion measures: calmness, temperance, two scales of tolerance, and emotionality on a
Likert scale. Watson, Clark, & Tellegen (1988) report internal consistency reliability for
scales from .86 to .90 for positive affect and .84 to .87 for negative affect. Correlations
between the two scales range from −.12 to −.23 indicating independence of the two factors
(Huebner & Dew, 1995).
Results
Thirty-eight participants agreed to volunteer and were consented, 12 were lost to the study.
Of the 26 participants who remained in the study, all were male with their ages between 16
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 their
education level ranged from grade 8 to 12 (M=10.36, SD=1.254). Eighty-five percent of
these youth reported that they were not married and the remaining 15% reported that they
were cohabitating. The family and social networks of these youth were reported by these
youth as having up to 7 relatives living in their homes (M=3.23, SD=1.728) and 2 friends
(M=.23, SD=.587), and had up to 40 relatives within a 20 mile radius of where they lived.
Sixty-one percent of youth were unemployed, 30.8% employed part-time, and the remaining
worked 35 hours a week or more. Eighty-eight percent of youth claimed some religious
connection.
Overall health, education and rehabilitation needs as measured by the state Department of
Correction risk scores found almost all youth to have some need: 20% of youth with serious
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. Six youth
(23.1%) were referred for sex offense treatment. The breakout across needs categories is
included in Table 1.
The primary types of crime (offense classification) with which participants were charged
were violent, 60% (e.g., use of weapon, physical or sexual assault, manslaughter, or murder)
with the remaining charged with nonviolent offenses (e.g., drug possession, larceny,
probation violation, or breach of peace). Twenty-three youth (88.5%) were sentenced to less
than 5 years, and the others sentenced between 5 to 10 years. None of the participants had a
history of escape.
To test the hypothesis that participants will show reduced aggression, impulsivity, and
improved coping, after completing the DBT-CM groups: physical aggression as measured
by BPAQ (t= 7.576, df=21, p=.000) and using distancing (WCCL subscale) as a coping
strategy (t=2.529, df=9, p=.032) showed statistical differences at post-test. There was a
significant change in disciplinary tickets from pre to posttest (t=2.753, df =24, p =.011),
indicating that correctional officers observed an improvement in aggressive and impulsive

behavior following the intervention. Improved scores, although not significant were found
on PANAS Negative Affect, and the Self-Control subscale on the WCCL. Although not
significant, these are worth exploring with a larger sample and more rigorous design.
Discussion
As a result of the DBT-CM intervention, a reduction in aggression and a reduction in the
number of disciplinary tickets received indicated improved adolescent behavior. The design
of the corrections modified modules were designed to be relevant to the participants’ daily
experiences in their correctional facility. The teaching of almost every skill was modified
with examples and subtle adjustments to correspond to the correctional setting. At the same
time, youth were helped with projected plans for release to anticipate applications of DBT-
CM skills in their outside lives. This finding is similar to other studies of DBT in
correctional environments with adolescent populations (Drake & Barnoski, 2006; Trupin et
al, 2002). Aggressive and impulsive behaviors were the primary target behaviors for the
intervention, and their reduction improves the safety of both the youth and staff and
ultimately reduces cost to the system.
The use of distancing as a coping strategy was an interesting finding, particularly as coping
strategies had been described in the literature as consisting of behaviors such as distraction,
self criticism, substance abuse, blaming others, denial, and wishful thinking (Aldridge &
Roesch, 2008). In thinking about the relationship between the high stress environments of
the prison, however, the need to distance oneself from the pressure of a stressful situation
may take on an adaptive function and may be effective in dealing with short-term stressors.
Similarly, within the context of an extremely violent neighborhood; mental and behavioral
disengagement coping may be particularly important in maintaining psychological and
physical health (Grant et al., 2000). While the complexity of the relationship between the
high stress environment, coping and outcome for youth at high risk is debated, the use of
substances is not; nor are the effects of chronic exposure to violent environments toward
development of negative coping strategies such as blaming others or self, doing nothing, or
avoiding others, which act as a conduit to poor psychological outcomes such PTSD, anxiety,
depression, and conduct disorder (Dempsey, 2002). Further, Kliewer, Lepore, Oskin, and
Johnson (1998) suggested that the use of avoidant coping behaviors at a young age may
influence and prevent youth from engaging in positive coping behaviors.
The lack of significant finding for self-control and accepting as ways of coping, and
negative symptoms are of interest, as it would be expected that youth would feel better as a
result of the intervention. Adolescence under the best of circumstances is a stressful life
event, as their biologic and psychological selves attempt to integrate into the whole adult
person they are to become. Added to the cumulative effects of the stressors leading to
adolescent incarceration, the measures and secondary analytic design may not have been
sufficient to detect change on all the variables of interest in this study.
Conclusion
The preliminary results of this study provide support for the continued study of DBT-CM
skills training for aggressive and impulsive male adolescent offenders. The improvement
seen in physical aggression, distancing coping style and disciplinary tickets are a positive
indication that the 16-week skills training groups continue to be implemented as the
evidence based is developed to support the intervention.
Given the limitations of this study, the small sample size, the lack of control group and there
is a need to consider use of instruments designed specifically for adolescent populations.
Such modifications are likely to increase sensitivity and yield stronger results. Despite these
limitations, these findings were encouraging and suggest that program implementation
would contribute to a decrease in problematic behavior and improvement in quality of life
for participants. Decreasing impulsive and aggressive behavior clearly has indications for
youth behavior management within the prison and reduced injury to the workforce. Further,
implications for post-incarceration self-management of behavior are long-term outcomes of
interest.
Acknowledgments
Funding provided by National Institutes of Mental Health Grant # 2002-IJ-CX-K009.
References
Aldridge AA, Roesch SC. Developing coping typologies of minority adolescents: A latent profile
analysis. Journal of Adolescence. 2008; 31(4):499–517. [PubMed: 17904631]
Berzins LG, Trestman RL. The development and implementation of dialectical behavior therapy in
forensic settings. International Journal of Forensic Mental Health. 2004; 3(1):93–103.
Boekaerts, M. Coping with stress in childhood and adolescence. In: Zeidner, M.; Endler, NS., editors.
Handbook of coping: Theory, research, applications. John Wiley & Sons; Oxford, England: 1996. p.
452-484.
Buss AH, Perry M. The aggression questionnaire. Journal of Personality and Social Psychology. 1992;
63:452–459. [PubMed: 1403624]
Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: A theoretically based approach.
Journal of Personality and Social Psychology. 1989; 56:267–283. [PubMed: 2926629]
Constantine M, Alleyne V, Caldwell L, McRae M, Suzuki L. Coping responses of Asign, Black, and
Latino/Latina New York City residents following the September 11, 2001 terrorist attacks against
the United States. Cultural Diversity and Ethnic Minority Psychology. 2005; 11(4):293–308.
[PubMed: 16478350]
Coccaro EF, Harvey PD, Kupsaw-Lawrence E, Herbert JL, Bernstein DP. Development of
neuropharmacologically based behavioral assessments of impulsive aggressive behavior. Journal of
Neuropsychiatry. 1991; 3(2):S44–S51.
Davis M, Emory E. Sex differences in neonatal stress reactivity. Child Development. 66(1):14–27.
1005. [PubMed: 7497822]
DeMatteo, D.; Marczyk, G. Risk factors, Protective factors, and the prevention of antisocial behavior
among juveniles. In: Heilbrun, K.; Sevin-Golstein, NE.; Redding, RE., editors. Juvenile
Delinquency: Prevention, assessment and intervention. Oxford University Press; NY: 2005. p.
19-44.
Dempsey M. Negative coping as mediator in the relation between violence and outcomes: Inner city
African American youth. American Journal of Orthopsychiatry. 2002; 72:102–109. [PubMed:
14964599]
Dimeff L, Rizvi SL, Brown M, Linehan MM. Dialectical behavior therapy for substance abuse: A pilot
application to methamphetamine-dependent women with borderline personality disorder.
Cognitive and Behavioral Practice. 2000; 7:457–468.
Drake, EK.; Barnoski, R. Recidivism findings for the juvenile rehabilitation administration’s Dialectic
Behavior Therapy program: Final report. Washington State Institute for Public Policy; Olympia,
WA: 2006. (Doc. # 06-07-1201)
Eisenberg, N.; Fabes, RA.; Guthrie, IK. Coping with stress: The roles of regulation and Development.
In: Wolchik, SA.; Sandler, IN., editors. Handbook of children’s coping: Linking theory and
intervention. Plenum Press; NY: 1997. p. 41-70.
Elliott, Delbert S.; Huizinga, David; Ageton, Suzanne. Explaining Delinquency and Drug Use. Sage;
Beverly Hills, CA: 1985.
Farrington, DP. Predictors, causes, and correlates of male youth violence. In: Tonry, M.; Moore, MH.,
editors. Youth Violence, Crime and Justice: A Review of the Research. Vol. 24. University of
Chicago Press; Chicago: 1998. p. 421-475.
Fazel S, Doll H, Langsrom N. Mental disorders among adolescents in juvenile detention and
correctional facilities: A systematic review and meta-regression analysis of 25 surveys. Journal of
the American Academy of Child and Adolescent Psychiatry. 2008; 47(9):1010–1019. [PubMed:
18664994]
Folkman S, Lazarus RS. Coping as a mediator of emotion. Journal of Personality and Social
Psychology. 1988; 54:466–475. [PubMed: 3361419]
Friedman HS. Long-term relations of personality and health: Dynamism, mechanisms, tropisms.
Journal of Personality. 2000; 68(6):1089–1107. [PubMed: 11130733]
Grant KE, O’Koon JH, Davis TH, Roache NA, Poindexter LM, Armstrong ML, Minden JA, McIntosh
JM. Protective factors affecting low-income urban African American youth exposed to stress.
Journal of Early Adolescence. 2000; 20:388–417.
Hare, RD. Manual for the Hare Psychopathy Checklist-Revised. Multi-Health Systems; Toronto: 1991.
Hawkins, DJ.; Herrenkohl, TI.; Farrington, DP.; Brewer, D.; Catalano, RF.; Harachi, TW.; Cothern, L.
Juvenile Justice Bulletin. U.S. Department of Justice, Office of Justice Programs, Office of
Juvenile Justice and Delinquency Prevention; Washington, DC: 2000. Predictors of Youth
Violence. NCJRS 179065
Hawkins, JD.; Herrenkohl, TL.; Farrington, DP.; Brewer, D.; Catalano, RF.; Harachi, TW. A review of
predictors of youth violence. In: Loeber, R.; Farrington, DP., editors. Serious and Violent Juvenile
Offenders: Risk Factors and Successful Interventions. Sage Publications; Thousand Oaks, CA:
1998. p. 106-146.
Herrenkohl TI, Maguin E, Hill KG, Hawkins JD, Abbott RD, Catalano RF. Developmental risk factors
for youth violence. Journal of Adolescent Health. 2000; 26(3):176–86. [PubMed: 10706165]
Hofstein, Y. Coping in court-involved adolescents and the relationship with stressors, delinquency, and
psychopathology. 2009. University of Massachusetts – Amherst: Open Access Dissertations.
Retrieved April 28, 2010 from
http://scholarworks.umass.edu/cgi/viewcontent.cgi?
article=1049&context=open_access_dissertations
Huebner ES, Dew T. Preliminary validation of the Positive and Negative Affect Schedule with
adolescents. Journal of Psychoeducational Assessment. 1995; 13:286–293.
Huizinga D, Loeber R, Thornberry T. Delinquency, Drug Use, Sex, and Pregnancy Among Urban
Youth. Public Health Reports. 1993; 108(suppl.1):90–96. [PubMed: 8210279]
Ireland JL, Boustead R, Ireland CR. Coping style and psychological health among adolescent
prisoners: a study of young and juvenile offenders. Journal of Adolescence. 2005; 28:411–123.
[PubMed: 15925691]
Kann L, Kinchen SA, Williams BI, Ross JG, Lowry R, Grunbaum JA, Kolbe LJ, State and Local
YRBSS Coordinators. Youth risk behavior surveillance—United States, 1999. Morbidity and
Mortality Weekly Report CDC Surveillance Summary. 2000; 49:1–96.
Kashani JH, Husain A, Shekim WO, Hodges KK, Cytryn L, McKnew DH. Current perspectives on
childhood depression: an overview. Clinical Child Psychology and Psychiatry. 1999; 4(4):493–
504.
Kliewer W, Lepore SJ, Oskin D, Johnson PD. The role of social and cognitive processes in children’s
adjustment to community violence. Journal of Consulting and Clinical Psychology. 1998; 66:199–
209. [PubMed: 9489275]
Kumpfer KL, Alvarado R. Family strengthening approaches for the prevention of youth problem
behaviors. American Psychologist. 2003; 58(6/7):457–465. [PubMed: 12971192]
Ligon J, Thyer BA. Interrater reliability of the Brief Psychiatric Rating Scale used at a Community –
based inpatient psychiatric crisis stabilization unit. Journal of Clinical Psychology. 2000; 56(4):
583–587. [PubMed: 10775051]
Linehan MM, Tutek DA, Heard HL, Armstrong HE. Interpersonal outcome of cognitive behavioral
treatment for chronically suicidal borderline patients. American Journal of Psychiatry. 1994;
151:1771. [PubMed: 7977884]
Linehan, MM. Cognitive–behavioral treatment of borderline personality disorder. Guildford Press;
New York: 1993.
Linehan, MM. Skills training manual for treating borderline personality disorder. Guilford Press; New
York: 1993a.
Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of
chronically parasuicidal borderline patients. Archives of General Psychiatry. 1991; 48:1060–1064.
[PubMed: 1845222]
Loeber R, Farrington DP. Young children who commit crime: Epidemiology, developmental origins,
risk factors, early interventions, and policy implications. Development and Psychopathology.
2000; 12:737–762. [PubMed: 11202042]
Loeber R, Farrington DP. Never too early, never too late: Risk factors and successful interventions for
serious and violent juvenile offenders. Studies on Crime and Crime Prevention. 1998; 7:7–30.
Loeber R, Wung P, Keenan K, Giroux B, Stouthamer-Loeber M, Van Kammen WB, Maughan B.
Developmental pathways in disruptive child behavior. Development and Psychopathology. 1993;
5:103–133.
Luria, AR. Higher cortical functions in man. Basic Books; New York: 1980.
McCann RA, Ball EM, Ivanoff A. DBT with an inpatient forensic population: The CMHIP forensic
model. Cognitive and Behavioral Practice. 2000; 7:448–456.
Milner B. Aspects of human frontal lobe function. Advances in Neurology. 1995; 66:67–84. [PubMed:
7771312]
Moffitt TE. Adolescent-limited and life-course-persistent antisocial behavior: A developmental
taxonomy. Psychological Review. 1993; 100:674–701. [PubMed: 8255953]
Morgan AB, Lilienfeld SO. A meta-analytic review of the relation between antisocial behavior and
neuropsychological measures of executive function. Clinical Psychology Review. 2000; 20:113–
136. [PubMed: 10660831]
Myers WC, Scott K, Burgess AW, Burgess AG. Psychopathology, biopsychosocial factors, crime
characteristics, and classification of 25 homicidal youths. Journal of the American Academy of
Child and Adolescent Psychiatry. 1995; 4:1483–1489. [PubMed: 8543516]
Nelson-Gray RO, Keane SP, Hurst RM, Mitchell JT, Warburton JB, Chok JT, Cobb AR. A modified
DBT skills training program for oppositional defiant adolescents: promising preliminary findings.
Behaviour Research and Therapy. 2006; 44:1811–1820. [PubMed: 16579964]
Overall JE, Gorham DR. The brief psychiatric rating scale. Psychological Reports. 1962; 10:799–812.
Pashall MJ, Fishbein DH. Executive cognitive functioning and aggression: a public health perspective.
Aggression and Violent Behavior. 2002; 7:215–235.

Preski S, Shelton D. The role of contextual, child and parental factors in predicting criminal outcomes
in adolescence. Issues in Mental Health. 2001; 2:197–205.
Quinn A, Shera W. Evidence-based practice in group work with incarcerated youth. International
Journal of Law and Psychiatry. 2009; 32:288–293. [PubMed: 19647875]
Rathus JH, Miller AL. DBT for adolescents: Dialectical dilemmas and secondary treatment targets.
Cognitive and Behavioral Practice. 2000; 7:425–434.
Rexrode KR, Petersen S, O’Toole S. The Ways of Coping Scale. Educational and Psychological
Measurement. 2008; 68(2):262–280.
Rosenblatt JA, Rosenblatt A, Biggs EE. Criminal behavior and emotional disorder: Comparing youth
served by the mental health and juvenile justice systems. The Journal of Behavioral Health
Services and Research. 2000; 27(2):227–337.
Rutter, M. Promotion of resilience in the face of adversity. In: Clarke-Stewart, A.; Dunn, J., editors.
Families Count: Effects on child and adolescent development. Cambridge University Press; NY:
2006. p. 26-52.The Jacobs Foundation Series on Development
Sabol, WJ.; West, HC.; Cooper, M. Prisoners in 2008. U.S. Department of Justice, Office of Justice
Programs, US Bureau of Justice Statistics; Washington, DC: 2009. NCJ 228417
Samuelsson S, Herkner B, Lundberg I. Reading and writing difficulties among prison inmates: A
matter of experiential factors rather than dyslexic problems. Scientific Studies of Reading. 2003;
7(1):53–73.
Sandler, IN.; Wolchik, SA.; MacKinnon, D.; Ayers, TS.; Roosa, MW. Handbook of children’s coping:
Linking theory and intervention. Wolchik, SA.; Sandler, IN., editors. Plenum Press; New York:
1997. p. 3-40.
Sedlak, AJ.; McPherson, KS. Juvenile Justice Bulletin. U.S. Department of Justice, Office of Justice
Programs, Office of Juvenile Justice and Delinquency Prevention; Washington, DC: 2010. Youth’s
needs and services: Findings from the survey of youth in residential placement. NCJ227728
Seiffge-Krenke I, Klessinger N. Long term effects of avoidant coping on adolescents’ depressive
symptoms. Journal of Youth and Adolescence. 2000; 6:617–630.
Shelton D. Emotional disorders in young offenders. Journal of Nursing Scholarship. 2001; 33(3):259–
263. [PubMed: 11552553]
Sickmund, M.; Sladky, TJ.; Kang, W.; Puzzanchera, C. Census of Juveniles in Residential Placement
Databook. 2008. Online. Available: http://www.ojjdp.ncjrs.gov/ojstatbb/cjrp/
Sickmund, M. Juvenile Residential Facility Census, 2002: Selected Findings. Office of Justice
Programs, Office of Juvenile Justice and Delinquency Prevention; Washington, DC: 2006. NCJ
211080
Skowyra, K.; Cocozza, J. Blueprint for Change: A Comprehensive Model for the Identification and
Treatment of Youth and Mental Health Needs in Contact with the Juvenile Justice. Policy
Research Associates, Inc.; Delmar, NY: 2007.
Slaughter B, Fann JR, Ehde D. Traumatic brain injury in a county jail population: Prevalence,
neuropsychological functioning and psychiatric disorders. Brain Injury. 2003; 17(9):731–741.
[PubMed: 12850940]
Snyder, HN.; Sickmund, M. Juvenile offenders and victims: 1999 national report. U.S. Department of
Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention;
Washington, DC: 1999. NCJ 178257Retrieved July 2, 2010 from
http://www.ncjrs.org/html/ojjdp/nationalreport99/toc.html
Suris AM, Lind LM, Kashner MT, Bernstein IH, Young K, Worchel J. Aggression and impulsivity
instruments: An examination in Veterans. Military Psychology. 2005; 17(4):283–297.
Trestman, RL.; Gonillo, C.; Davis, K. Dialectical Behavior Therapy-Corrections-Modified (DBT-CM)
Skills Training Manual. University of Connecticut Health Center; Farmington, CT: 2004.
Unpublished treatment manual
Trupin EW, Stewart DG, Beach B, Boesky L. Effectiveness of a Dialectic Behavior Therapy program
for incarcerated juvenile female offenders. Child and Adolescent Mental Health. 2002; 7(3):121–
127.
Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and
negative affect: The PANAS scales. Journal of Personality and Social Psychology. 1988; 54:1063–
1070. [PubMed: 3397865]
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 1
Risk Scores for Treatment Planning Needs
Risk Score Medical Mental Substance Safety/ Education Vocational

Health Abuse Violence
Shelton et al.
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
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J Child Adolesc Psychiatr Nurs. 2011 May ; 24(2): 105–113. doi:10.1111/j.1744-6171.2011.00275.x.

Impact of a Dialectic Behavior Therapy - Corrections Modified

Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN[Professor][Director],

Robert Trestman, MD, PhD

particular management challenges, as these offenders have particular difficulty adjusting to

change by emphasizing the management of therapy-interfering behaviors and the

The Development Perspective. Several theories have emphasized a developmental trajectory

continues through midlife. The second type, adolescence-limited-offending originates in the

Importance of Coping. There is consensus that adolescence is a significant and distinct

Like other psychological qualities, coping strategies follow a developmental trajectory

typology were maladjusted in comparison to the other two groups, characteristically

the problems that contribute to problematic thoughts, feelings and behaviors.

Longitudinal studies examining the developmental pathways of youthful offenders have

In teaching each of the DBT-CM skills to incarcerated participants, examples relevant to

correspond to the correctional setting.

Additionally, a self-report basic demographic questionnaire designed for this study

indicating that correctional officers observed an improvement in aggressive and impulsive

Aggression and Violent Behavior. 2002; 7:215–235.

Risk Score Medical Mental Substance Safety/ Education Vocational

Minimal/none 42.3% 3.8% 11.5%

Mild 53.8% 3.8% 23.1% 84.6 38.5% 23.1%

Moderate 80.8% 34.6% 15.3% 53.8% 65.3%

Serious 11.5% 30.8% 7.6% 11.5%

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