Jail-Based Dialectical Behavior Therapy Program

By Patricia S. Sollock, MA, LCPC, CCHP

Posted on September 8, 2008 –

The Montgomery County Department of Correction and Rehabilitation, under the direction of the Department’s Mental Health Services, developed a jail- based Dialectical Behavior Therapy (DBT) program for adult inmates housed in the all-male Crisis Intervention Unit (CIU) of the Montgomery County Correctional Facility (MCCF) in Boyds, Maryland. This facility was awarded the 2007 Facility of the Year Award by the National Commission of Correctional Health Care for its comprehensive and holistic approach to treatment and rehabilitation of inmates.

As a background to issues that led to the development of the DBT program, it is important to highlight that approximately 25% of the inmate population suffers from mental illness and requires psychiatric treatment. On any given day, there may be 200 inmates on psychotropic medication. When booked into the jail, many of these individuals are so unstable and dysfunctional, that they cannot be safely housed in the jail’s general population. Once assessed by mental health staff, they are admitted to the jail’s CIU where they are assigned to a mental health therapist who will develop an Individualized Treatment Plan and coordinate all other ancillary treatment.

The CIU is a 36-bed mental health unit designed to provide a safe and humane environment for all inmates whose condition requires special supervision and management. The unit has four additional stripped-down cells to monitor individuals requiring one-on-one (arm’s length) or 15-minute observation. Compounding the complexity posed by this unit’s population, the CIU is the only housing area that bypasses the jail’s overriding security matrix used to classify inmates to minimum, medium or maximum security units. Consequently, the CIU population consists of a very heterogeneous group of individuals presenting with an array of offenses ranging from misdemeanors to serious felony crimes, and with multiple psychiatric disorders that span the entire Diagnostic and Statistical Manual of Mental Disorders and whose symptoms range from mild to severe and incapacitating. Exacerbating treatment and management challenges for both providers and correctional staff, most individuals in this unit cannot regulate their impulses or emotions and are highly prone to self-injury, parasuicidal and/or suicidal behaviors.

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Pre/Post DBT Trends

With this population in mind, and recognizing that Cognitive Behavior Therapy alone (the preferred treatment modality for many years) was not effective in decreasing or modifying the rising incidence of self-injury and suicidal behaviors that required emergent care, one-on-one supervision, involuntary hospitalization or Emergency Response Team (ERT) intervention, the DBT program began as a pilot project in 2005. Soon after the onset of the DBT pilot program and based on the promising results observed, four therapists were sent to the intensive DBT training sponsored by Behavioral Tech. However, as a result of staff turnover, new providers are encouraged to seek DBT training individually, and DBT techniques and practice are later reinforced during consultation groups that also serve as a venue for application of skills and enhancement of therapists’ capabilities. Most importantly, all security staff assigned to the DBT program undergo 40 hours of mental health training of which sixteen are dedicated to DBT principles and application of validation skills. This training is important since correctional officers play an important role in coaching and reinforcing DBT skills, a modification from standard DBT phone coaching. The resources currently committed to the jail’s DBT program include four licensed therapists (two Master level and two PhDs) under the supervision of the Mental Health Services Manager. These therapists coordinate all aspects of the inmates’ treatment including referrals to adjunct therapy such as pharmacotherapy, addiction services, reentry services, school, and/or any other therapeutic activities offered at MCCF.

The MCCF’s DBT program, albeit prudently modified for our correctional facility, was the first adult jail-based program in the nation that adhered to all components of standard DBT. The program offers individual therapy, DBT skills training, skills coaching, therapists’ consultation groups and ancillary therapy to approximately 16-20 participants at a time. To be eligible for DBT participation, these inmates must be fairly stable and willing to commit to all aspects of the program including homework, diary cards and other ancillary treatment. The skills groups include mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness. Each group is offered twice a week for eight weeks and an entire cycle of the DBT program may be completed in 6-1/2 months.

While modifications to standard DBT have been made for the MCCF’s DBT program, the specific program elements are met as follows:
Individual Therapy
Inmates attend weekly, one hour individual therapy sessions with their primary therapist. During these sessions, inmates go over homework assignments and review problematic behaviors experienced the previous week through behavioral chain analysis and review of other assessment tools.
DBT Group Skills Training*
MCCF therapists co-lead skills groups that, as noted previously, were modified in duration to facilitate completion of the program in 26 weeks. This modification was necessary because the maximum sentence (incarceration) at this facility consists of 18 months. Each group is 2 hours in duration and each module is offered in two separate sessions per week. The first session is aimed at skills acquisition; the second session is for inmates to review and practice the skills learned.
* Inmates who are discharged from CIU when deemed stable for general population living, may return to DBT Skills groups if the inmate demonstrates commitment and is deriving measurable benefits from the program. At MCCF, 90% of the inmates who leave CIU without finishing the program spontaneously request to be allowed to return without identifiable secondary gains.
Skills Coaching
A modification to standard DBT, skills coaching when therapists are not at the facility, is performed by the officers assigned to CIU. Officers are trained to reinforce the skills inmates are learning so they may apply them to real life and in-the-moment situations. This substitutes the telephone consultation by therapists since the CIU officers are in the mental health unit and in contact with these inmates 24 hours a day. Coaching is not psychotherapy and even in standard DBT, limits are clearly set by the therapists.
Therapist Consultation Teams
Applying and mentoring DBT skills, therapists have weekly consultation team meetings to seek insights, support/validation and to discuss concerns, treatment strategies and experiences with these very difficult-to-treat clients.
Ancillary Treatment
Additional groups and therapeutic activities are added to an individual’s treatment plan at the discretion of the primary therapist. At MCCF, pharmacotherapy is prescribed by a contract psychiatrist who evaluates and prescribes medication as indicated.

Approximately 3 months after the onset of DBT, the jail began experiencing a significant reduction in self-injurious behavior (including suicide attempts), major disciplinary infractions (some requiring ERT assistance), need for 15-minute watch (due to out of control behaviors), and involuntary commitments to state hospitals. As an added unintended benefit, staff overtime decreased since the need to provide one-on-one supervision of self-injurious inmates also diminished. Additionally, other county agencies outside of corrections have indirectly benefited from the jail’s DBT program due to the reduction in cost associated with transport of inmates to/from emergency rooms or state hospitals and because involuntary hospitalizations were significantly reduced. Outcome trends are reflected in the chart below.

Ms. Sollock is Chief of Mental Health Services, Montgomery County Dept of Corrections. Readers may contact her at patricia.sollock@montgomerycountymd.gov.