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DBT in an outpatient forensic setting
International Journal of Law and Psychiatry 35 (2012) 311–316
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International Journal of Law and Psychiatry
DBT in an outpatient forensic setting L.M.C. van den Bosch a,⁎, M. Hysaj a, P. Jacobs b a b
Centre for Personality Disorders Jelgersma, Oegstgeest, The Netherlands Psychiatric Hospital Pro Persona, The Netherlands
a r t i c l e
i n f o
Available online 5 May 2012 Keywords: Forensic psychiatry Borderline personality disorder Dialectical behavior therapy Outpatient treatment
a b s t r a c t Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidencebased treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings. © 2012 Elsevier Ltd. All rights reserved.
Since the introduction of DSM-III (American Psychiatric Association, 1980), personality disorders are recognized as a special diagnostic entity with special treatment needs. Ever since, a large variety of treatment programs have been developed. Literature reviews show that cluster B personality disorders, and especially borderline personality disorder (BPD), are the subject of growing interest for researchers and therapists (Gabbard, Beck, & Holmes, 2006). High levels of comorbidity exist between BPD and different types of Axis I disorders, with substance abuse being the most prominent. In general, this is seen as a factor that contributes to the difficulties found in treatment. In addition to these complicating comorbid problems, the creation of a working alliance with BPD patients is often seen as extremely difficult. BPD can be characterized as a ‘relationship’ disorder, in that patients show an incapability to regulate interpersonal relationships, and/or learn from them (Linehan, 1993). However, a growing body of literature shows that treatment for BPD is possible and effective (for example Bateman & Fonagy, 2008, 2009; Giesen-Bloo et al., 2006; Linehan et al., 2006; McMain, 2010; McMain et al., 2009; van den Bosch, Koeter, Stijnen, Verheul, & van den Brink, 2005; Verheul, van den Bosch, Koeter, van den Brink, & Stijnen, 2003). These studies show that suicidal and selfdestructive behaviors, anger and substance abuse can be reduced
and compliance with therapy enhanced (mainly in terms of reduced dropout rates). Both psychodynamic and behavioral treatment programs show significant reductions of symptoms after 1–1.5 years of treatment (Verheul & Herbrink, 2007). Due to these positive results, the negativistic attitude in the 1990s toward treatment of dually diagnosed borderline patients has changed into a more realistic one with obvious potential for an effective working alliance and clear, positive outcomes (van den Bosch & Verheul, 2007). The situation of borderline patients in forensic settings is less hopeful however. 1 Studies show that many of the crimes committed by these patients (e.g. arson, criminal damage and stalking), can be seen as manifestations of their psychiatric disorder (Coid, Kathan, Gault, Cook, & Jarman, 2001; Harmon, Rosner, & Owens, 1998; Purcell, Parsons, Halkitis, Mizuno, & Woods, 2001). For instance, a review of the epidemiology and treatment of borderline female forensic psychiatric patients (van den Bosch, den Haan, & Lammers, 2005), found that nearly 70% of the forensic patients with a diagnosis of BPD have committed ‘crimes’ of a very impulsive nature, and meant to seriously harm themselves. For example, 39% of these patients were convicted for arson and the goal of the fire setting was an attempt to commit suicide. A total of 60% of this patient group phoned for help and called the police directly after the incident. Although 44% had no history of criminal behavior, and the majority (70%) had an extended treatment history, they were still sentenced to more than
⁎ Corresponding author at: Alexander Hegiusstraat 15, 7412 XN Deventer, The Netherlands. Tel.: + 31 620490230. E-mail address: [email protected] (L.M.C. van den Bosch).
1 Forensic: persons on parole or probation, but also persons who have yet to be adjudicated, or stay in a residential forensic psychiatric hospital, who are being seen in an outpatient clinic.
1. Introduction
0160-2527/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijlp.2012.04.009
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4 years' imprisonment, followed by compulsory treatment of more than 5 years (van den Bosch, den Haan, & Lammers, 2005). Paradoxically, the focus in forensic psychiatry is not on the effective treatment of BPD problems, but on the prevention of criminal recidivism using general psychiatric care and aggression-focused therapies. Although not supported by empirical data on clinical or etiological characteristics, forensic patients with a borderline personality disorder are believed to be more complex than patients with a borderline personality disorder in regular mental health settings. This perhaps explains why our literature search showed that over the last 15 years only 1 study focused on the treatment of BPD patients in forensic settings (schema focused therapy: Bernstein & Arntz, 2009). Unfortunately, no results of this study were published. Some attempts, however, are being made to change the repressive atmosphere in forensic psychiatry into a more therapeutically beneficial one for both patients and staff. Dialectical behavior therapy (DBT) seems to be especially helpful (Berzins & Trestman, 2004; de Ruiter & Trestman, 2007; McCann, Ball, & Ivanoff, 2000). Some studies indicate that the implementation of DBT principles, particularly in residential forensic settings, seems to be beneficial for forensic patients and staff members (Evershed et al., 2003; Nee & Farman, 2005; Trupin, Stewart, Beach, & Boesky, 2002). To our knowledge, however, the question has yet to be raised of whether or not a program oriented to outpatient, borderline forensic patients is possible, let alone answered. Therefore the outpatient treatment clinic “De Tender”, which is part of the forensic psychiatric hospital Oldenkotte in the Netherlands, has created a DBT program for forensic psychiatric patients. After a short clarification of the basis of the treatment program (fundament of dialectical behavior therapy, and some of its core principles), this report will describe the sociodemographic, clinical, treatment process, and treatment data from an open study among male and female forensic patients with BPD and compares these data with those of BPD patients in a non-forensic mental health setting. This study aims to answer the following questions:
environment. According to the biosocial model, the patient cannot change his behavior because he cannot effectively deal with emotional stimuli. Individuals with BPD miss essential interpersonal skills concerning self-regulation. The environment however, sees this lack of skills as a lack of commitment to change, or as an act of willfulness. As a result the patient develops a self-concept that includes selfinvalidation and is self-defeating. Transaction between emotional vulnerability and self-invalidation causes pervasive emotional deregulation that affects all levels of functioning: interpersonal, cognition, affect and behavior. In order to gain control over this deregulation, the patient engages in (self-)destructive behavior, which in itself creates even a higher level of vulnerability and self-invalidation. In other words, the cure becomes the problem. The patient then alternates between need for contact and help on one hand, and a strong rejection of other people and insistence on autonomy on the other hand. Therapists therefore need to teach the patient how to gain control over emotional vulnerability, without relapsing into a (self-)destructive behavior. Also, they need to stop the self-invalidating process and make the patient validate himself, that is: accept himself as he is. This simultaneous focus on applying both acceptance and validation strategies and change (behavioral) strategies to achieve a synthetic (dialectical) balance in the functioning of the patient is one of DBT's central principles. Dialectics, a core theory in DBT, is targeted at balancing acceptance and change, through teaching the patient how to become willing to deal with continuous change. In DBT, dialectical tension is used to teach the patient to stop dichotomous thinking by showing that everything has a positive and a negative side, and that tension creates the possibility for development (see also: Linehan, 1993; 199–220).
Dialectical behavior therapy (DBT) is a manualized twelve-month treatment that combines 4 modules: a. weekly individual cognitivebehavioral psychotherapy sessions with the primary therapist, b. weekly skills training groups lasting two–two and a half hours per session, c. weekly supervision and consultation meetings for the therapists, and d. phone consultation, where patients are encouraged to get coaching in the appliance of new effective skills by phoning their primary therapists either during or outside office hours. Individual therapy focuses primarily on motivational issues, including the motivation to stay alive and to stay in treatment. Group therapy teaches self-regulation and change skills, and self- and other acceptance skills.
2.1.2. The consultation-to-the-patient principle Another core principle that needs to be mentioned here is the ‘consultation-to-the-patient’ principle. Once the patient has signed the treatment contract, the patient in DBT is seen as a responsible individual who is capable of change. Because this principle has consequences for the application of the treatment, it is important to understand the vision on which it is based. In more conventional treatment programs, therapists and patients are easily caught in a paradox. The treatment is started on the assumption that the patient is capable of change and can take full responsibility. However, when the patient ‘fails’ to show enough change (for instance by getting in a suicidal crisis), the therapist intervenes, sometimes even against the will of the patient. When the therapist behaves this way, he demonstrates to the patient his loss of trust in the patient's capabilities, which probably leads the patient to actively self-invalidate, and in the long run can lead to a form of learned helplessness. Also, the therapist ‘conditions’ his patient, in that he makes clear that under certain circumstances, like with a suicidal crisis, he will abort the agreements in the treatment contract and act as ‘savior’. This can even result in reinforcement of crisis behavior. The consultation-to-the-patient principle clarifies the roles of patients and therapists. The therapist acts as coach and consultant and does not accept any power over the patient, nor does he intervene. Consequences of this principle are: the therapist does not speak about the patient with other professionals, nor with members of the social network of the patient, but advises the patient how to deal with professionals and other people. Another consequence worth mentioning is that in DBT ‘splitting’, a phenomenon often associated with BPD, does not occur. Differences in interpretation of the behavior or intentions of the patient will not lead to tension between professionals when the patient literally takes a central position.
2.1.1. The biosocial theory The biosocial model of DBT conceptualizes BPD as “a pervasive disorder of emotion regulation”, which is the consequence of the transaction between intrinsic emotional vulnerability and the invalidating
2.1.3. Treating the therapist When the patient wavers between helplessness and autonomy, it becomes difficult for therapists to determine where they stand in terms of the patient's behavior, resulting in the therapists finding
1) Are there clinical or etiological characteristics that distinguish forensic male from forensic female patients with BPD? 2) Are there clinical or etiological characteristics that distinguish forensic female patients from female patients with BPD in regular mental health settings? 3) Can standard DBT be implemented for female and male borderline patients in an outpatient forensic setting? More precisely, the question is whether it is possible to develop a working alliance with these forensic BPD patients, the effectiveness of which would be indicated by low attrition rates. 2. The treatment program 2.1. Dialectical behavior therapy: core principles
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themselves unbalanced in their own behavior. Because of this (unbalancing) behavior, and because of the consultation-to-the-patient principle, support of therapists is a necessary prerequisite when treating these patients. Dialectical behavior therapy is based on the assumption that a nonjudgmental attitude toward patients and their problems is needed that helps patients to reduce self-invalidation in order to firstly enhance therapists' own capacity for and competence in self-reflection and secondly, to create an effective working alliance. A nonjudgmental attitude sees the behavior of the patients as it is: within this context, at this moment. Being nonjudgmental makes it possible to inquire about the chain of events that led to the behavior and finally see the behavior, as strange or self-destructive as it may be, as meaningful. Also, the behavior can be seen as functional, as coping behavior that helps to reduce tension. For example, a patient engages in aggressive behavior (verbal threat). If the therapist is not capable of seeing this behavior as the most effective way of instantly reducing fear (or of keeping a therapist at arm's length), he will not be able to help the patient to change it. A verbal threat, though destructive, is effective but not very helpful in the long run. Therapists, therefore, need to come up with a very effective replacement behavior in order to motivate the patient to change. As long as a therapist thinks that the behavior is intended to disturb or manipulate him, he will be unable to correctly interpret the act and he will not be able to help the patient see the benefits of change. 3. Pilot study 3.1. Material and methods 3.1.1. Participants Two groups of patients were included in the study. Group 1 consisted of 29 forensic patients (10 males, 19 females) with BPD who were referred to a forensic outpatient clinic by probation and (forensic) psychiatric services, because of criminal behavior, although two patients (6.8%) had not been convicted. Group 2 consisted of 58 female BPD patients, who voluntarily participated in a DBT study in a regular mental health and addiction treatment service in The Netherlands (van den Bosch, Verheul, & van den Brink, 2001). For both groups the exclusion criteria were; chronic psychosis, bipolar disorder, and IQ b 80. 3.1.2. Assessments Sociodemographic characteristics were collected (age, employment status, in receipt of social benefits, marital status, and level of education). Also, some clinical characteristics and the number and severity of psychiatric problems were examined including; compulsory treatment/special conditions/probation service, crimes committed, number of BPD criteria (last year), number of ASPD criteria (last year), comorbid PTSD (last year), life-time presence of suicide attempts, life-time parasuicidal behavior, co-morbid alcohol and poly-drug use (last year), use of benzodiazepines (last year), use of antidepressants (last year), use of antipsychotics (last year), and use of other medication (last year). Finally, dropout rates were calculated. The SCID-I (Spitzer, Williams, Gibbon, & First, 1990) and SCID-II (First, Spitzer, Gibbons, Williams, & Benjamin, 1996) were used to diagnose DSM-III-R Axis I (APA, 1987), and DSM-IV Axis II disorders (APA, 1994), respectively. Data on self-destructive behavior were gathered by using the BPDSI (Borderline Personality Disorder Severity Index, Arntz et al., 2003). All assessments took place at the start of the treatment year. 3.1.3. Procedure A standard DBT program, focusing on life-threatening and suicidal behavior as primary treatment targets, was implemented in the experimental group “De Tender”. The decision to implement DBT was based on a growing body of opinion that dialectical behavior
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therapy seems to be beneficial not only for forensic patients, but also for patients with comorbid BPD (Lynch & Cheavens, 2008). The treatment program consisted of the four basic modules of DBT as described before: weekly individual psychotherapy (1 h), a weekly skills group training (2 1/2 h), if needed 24-hour phone consultation, and a consultation team for therapists and trainers. The creation of the consultation team was given priority. These weekly sessions, aimed at helping the therapists to solve the problems they are confronted with in treatment, function as a DBT framework for the therapists and strengthen the interconnectedness of the team members. Group 2, the ‘mental health’ group, followed the same treatment program. The only adaptation made was that therapists and patients needed periodically to report to the probation services together. All the individual therapists (in total 17: five in forensics and 12 in the other general mental health sample) and 6 trainers were trained intensively in a ten-day DBT course. All the patients followed DBT, which meant that they had one session weekly with their own individual therapist and a 2 1/2-hour group skills training session each week delivered by pairs of trainers. All therapists and trainers in both groups were continuously supervised in DBT by the first author, who is a member of the international DBT training group in Seattle. Supervision took place after the sessions without the patient being present. In supervision, the focus was on the application of the DBT core strategies (behavior therapy, validation and dialectical strategies). Treatment integrity was examined in two ways: the first author — as a trained adherence coder, scored a random selection of the videotaped sessions of the weekly individual therapy sessions of each therapist during the whole treatment year, using the adherence scale developed by Linehan (Linehan's adherence coding manual, Seattle, 1996). In addition to the coding, the session notes that were filled in after each therapy session by the individual therapists were examined when the treatment had ended. In these session notes, which are delivered in a standard format, the therapists fill in what kind of problem behavior has taken place, what problem behavior the session targeted, and what strategies they used. The session notes therefore give an overview over what DBT strategies are not used. The median adherence score on a 5-point Likert scale was 3.5 and 3.8 in the forensic and the mental health settings respectively, indicating an adequate level of DBT interventions and strategies. 3.1.4. Statistical analysis Differences between males and females in the forensic population were examined using the independent t-test. Differences between the female patients belonging to the two different study groups were also examined using an independent t-test. Because of the dichotomous nature of the data, no post-hoc tests were applied. This is an explorative study with a relatively small sample size. In order to prevent type II errors in this early stage of the investigation, we are reporting differences with a rather lenient level of significance (p b .05), i.e. no correction for multiple testing will be applied. All analyses were conducted using SPSS. 4. Results 4.1. Characteristics of forensic male and female BPD patient groups (Table 1) The average age of females in the forensic group was 35 years, which is slightly higher than that of the males (34 years). Sociodemographic characteristics of the forensic male and female patients were similar. However males showed non-significant higher percentages of being in receipt of social benefits and having a criminal past, defined as (former) contacts with the judiciary system (100% for males vs. 84% for females). The differences found regarding the nature of the crimes showed that in the forensic group, two patients (one male and one female), had been sentenced for attempted murder. The other reported crimes and offenses (arson, violence, violating the
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Table 1 Comparison of sociodemographic data, clinical and severity of symptoms between male BPD patients and female BPD patients in the forensic outpatient clinic. Variable
Sociodemographic data
Clinical characteristics Severity of symptoms
Process variable
Number Age Employment status Social benefit Marital status Level of education Compulsory treatment Crimes committed BPDSI mean score # BPD criteria %a # ASPD criteria %a Comorbid PTSD %a Suicide attemptsb Parasuicidal behaviorb Comorbid alcoholb Comorbid poly drugsb Use of benzodiazepinesb Use of antidepressantsb Use of antipsychoticsb Other medicationb Drop out %
Forensic males
Forensic females
Mean SD
Mean SD
10 33.6 .2 .70 1.4 .3 .3 1 26.3 2.8 (50%) 1.7 (70%) .42 (10%) .8 .4 .57 .16 .5 .7 .2 .84 .30 (30%)
7.66 .42 .48 1.6 .48 .48. 2.13 9.8 .42 .48 0.51 .422 .516 .5 .37 .527 .483 .422 .37 .483
19 34.84 .21 .47 1.47 .37 .52 .84 30.9 2.89 (95%) .68 (26%) .1 (42%) .95 .84 .6 1 .68 .68 .26 .5 .63 (21%)
8.83 .42 .52 1.84 .49 .51 .37 7.2 .46 .82 .31 .229 .375 .51 0 .48 .48 .45 .53 .49
df
t
p
27 27 27 27 27 27 27
−.376 −.064 1.15 −.106 −.356 − 1.15 1.321
.71 .95 .26 .916 .72 .26 .19
27 27 27 27 27 27 27 27 27 27 27 27
−.543 3.585 1.816 − 1.23 − 1.65 −.106 − 4.94 −.953 .084 −.365 2.030 − 1.73
.59 .001⁎⁎ .08 .23 .013⁎ .92 .000⁎⁎ .349 .93 .72 .052 .09
Employment status: number of patients out of work; marital status: number of patients being single; level of education: number of patients with only primary school; social benefit: number of patients on social benefit. a Clinical and severity of symptoms: lifetime. b Clinical and severity of symptoms: last year. ⁎ p b 0.05. ⁎⁎ p b .001.
Opium Act, compulsory shoplifting, reckless driving or driving under the influence, criminal damage, stalking) showed only a slightly different pattern with the males showing more violation of the Opium Act, violence and driving under the influence, and the females exhibiting more arson and stalking. Examination of the BPDSI severity score showed that the forensic females had significantly higher severity rates, were significantly more engaged in parasuicidal/self-destructive behavior, and showed significantly more BPD criteria when compared to the males (t = −1.6, p = .013, d = 27). Both females and males showed very high and similar percentages of attempted suicide in the last year (95% vs. 80%). The percentage of forensic male patients meeting antisocial personality disorder (ASPD) criteria, however, was significantly higher than for the females (t = 3.5, p = .001, d = 27). A similar percentage of male and female patients showed comorbidity with alcohol abuse (60% vs. 56%), while for drugs, a significantly higher percentage of males engaged in drug abuse (t = −4.9, p = .00, d = 27). Forensic females showed higher levels of comorbid PTSD (42% vs. 10%), but the difference was not statistically significant. Most of the forensic patients used some kind of medication. The forensic females tended to use slightly more of any kind of medication, but the difference between females and males only reached significance for the use of sedatives and for ‘other medication’, ranging from Lithium to Concerta, indicating that nearly all of the forensic patients received (a combination of) medication. Only 6% of the forensic patients dropped out during the first 3 months. This increased to 25% by the end of the first half-year (3 males and 4 females). However, 75% of the patients completed the whole program. 4.2. Comparison of female BPD in forensic and regular mental health services (Table 2) Sociodemographic characteristics of BPD patients in forensic and regular mental health and addiction treatment services were very similar. As expected, the groups differed on ‘compulsory treatment’ (t = 7.9, p = .00, d = 76). The number of forensic patients with a
‘criminal past’, defined as (former) contacts with the judiciary system and being convicted for a crime, was also significantly higher (t = 5.0, p = .00, d = 76). However, the nature of the ‘criminal past’ was highly comparable (arson, violence, compulsory shoplifting, reckless driving, stalking). All forensic females were sentenced to compulsory treatment, compared to none of the mental health group. Nearly all females of both groups showed more than 6 BPD criteria (95% and 100% respectively). No significant differences were found between the female groups in terms of severity of the borderline symptomatology (mean score of the forensic group 30.9 [7.2] vs. the mental health group 30.4 [9.8]), the presence of co-morbid PTSD, suicide attempts in the past year, and parasuicidal/self-destructive behavior. Also, no difference was found concerning drug abuse. However, significantly more comorbid alcohol abuse occurred among female BPD patients in the regular mental health and addiction treatment services compared to the forensic female patients (t = 2.1, p = .032, d = 76). Surprisingly, mental health and forensic female patients meeting ASPD criteria (26% and 37%) showed a significant difference in the number of ASPD criteria met, with the non-forensic females showing the higher number (t = 2.1, p = .035, d = 76). Finally, mental health female BPD patients used significantly more ‘other’ medication than the forensic group. Comparison of dropout rates was limited to those female patients who engaged in DBT treatment in both samples. No differences were found for dropout (forensic 21% vs. mental health 26%).
5. Discussion The results indicate that it is possible to provide DBT in a forensic setting as the patients are not dissimilar, whether the patient is court mandated or not. The findings also indicate that the clinical and etiological differences between forensic BPD patients and borderline patients from general mental health settings are relatively small. Female BPD patients in a forensic outpatient DBT group are clinically very similar to female BPD outpatients in a DBT treatment group in a regular mental health and addiction treatment setting.
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Table 2 Comparison of sociodemographic data, clinical and severity of symptoms between female BPD patients in forensic and regular mental health services. Variable
Sociodemographic data
Clinical characteristics Severity of symptoms
Process variable
Number Age Employment status Social benefit Marital status Level of education Compulsory treatment Crimes committed Mean BPDSI score #BPD criteria%a #ASPD criteria%a Comorbid PTSD %a Suicide attemptsb Parasuicidal behaviorb Comorbid alcoholb Comorbid poly drugsb Use of benzodiazepinesb Use of antidepressantsb Use of antipsychotics.b Other medicationb Drop out %
Forensic females
Mental health females
Mean SD
Mean SD
N = 19 34.84 .21 .47 .32 .37 .53 .37 30.9 .95 .68 26% .42 42% .94 .84 .58 .16 .68 .48 .42 .84 .21 (21%)
8.8 .42 .512 .48 .49 .51 .08 7.2 .20 .82 .51 .23 .37 .51 .37 .48 .11 .097 .37 .42
N = 58 35.3 .17 .37 .26 .31 0.0 .45 30.4 1.0 .36 37% .47 47% .93 .83 .31 .34 .88 .50 .42 .24 N = 27 .12 (26%)
df
8.6 .38 .49 .45 .46 0.0 .06 9.8 .00 .48 .50 .25 .37 .46 .48 .33 .65 .05 .43 .33
t
p
76 76 76 76 76 76 76
.08 .401 .774 .16 .509 7.992 5.009
76 76 76 76 76 76 76 76 76 76 76 76
− 1.7 2.143 −.402 .232 .116 2.186 − 1.51 − 2.03 1.083 −.089 5.501 .994
.93 .69 .44 .83 .61 .00⁎⁎ .00⁎⁎ .00 .035⁎ .689 .817 .91 .032⁎ .136 .046 .282 .93 .000⁎⁎ .323
Employment status: number of patients out of work; marital status: number of patients being single; level of education: number of patients with only primary school; social benefit: number of patients on social benefit. a Clinical and severity of symptoms: lifetime. b Clinical and severity of symptoms: last year. ⁎ p b 0.05. ⁎⁎ p b .001.
As expected, forensic BPD patients had more contact with police and the judiciary system than BPD patients in the regular mental health services, but the nature of the crimes was very similar. Finally, female BPD patients in the regular services more often reported alcohol problems than forensic female BPD patients; a finding that is directly related to the fact that half of the mental health group was recruited from substance abuse services. Substantial differences were observed between male and female forensic BPD patients in DBT groups. Compared to female (mental health and forensic) BPD patients, male forensic BPD patients meet fewer BPD criteria, and the level of self-destructive behavior and the BPD problem severity, as measured with the BPDSI, is lower compared to females. Moreover, male patients less frequently report suicide attempts, show more co-morbid ASPD, less co-morbid PTSD, and use benzodiazepines less frequently. In short, the male BPD patients have a different psychopathological profile than female BPD patients, with lower levels of typical borderline (related) problems and more ASPD-like problems. Forensic female patients seem to be referred not so much because of the antisocial aspects of their behavior, but because of the severity of their BPD problems. The study also showed that standard DBT can be implemented for female and male borderline patients in an outpatient forensic setting. Of all patients entering the forensic DBT program, 7 males (70%) and 15 females (79%) completed the program, resulting in an overall dropout rate that is very similar to the DBT program for female BPD patients in a regular mental health and addiction treatment setting (24% forensic group vs. 26% mental health/addiction group). It should be mentioned that none of the forensic patients committed suicide during the treatment and that no homicidal or physically violent behaviors were reported in the groups during the treatment. Therefore, the conclusion is justified that the forensic DBT patients can develop a therapeutic alliance in a DBT program. One specific problem, however, that showed up in applying DBT in the forensic setting, needs to be mentioned. In DBT in general, suicidal behaviors (including threats and gestures), are treated as a coping behavior associated with pain and suffering. Based on the consultationto-the-patient principle (Linehan, 1993), the DBT therapist will not
intervene unless it seems highly unlikely that the patient himself can take action, or when the risk of suicide is too imminent. However, in contrast to the mental health and substance-abusing patients, forensic patients showed homicidal behavior in addition to their ‘normal’ suicidal behavior. For the individual therapists, this created a problem because they had great difficulty in interpreting the behavior as a way of coping. As a result, much more between-session consultation and supervision were needed, as well as explicit support from the managers of the program. The concept of the consultation team, a one-team model, proved to be of extreme importance here. There are severe limitations that should be considered with regard to the results. First, the power of this study to detect group differences was limited due to the small sample sizes resulting in large confidence intervals. Second, although participation in the program was emphatically presented to the forensic patients as being entirely voluntary, nearly half of the patients entered the program while being subject to a court order. Therefore, it can be expected that some of the patients showed a high compliance rate because of perceived pressure from the court or the probation service, as opposed to any intrinsic motivation to join the treatment program. Third, we reported the percentages of the patients who were in contact with the judiciary system and the character of the crimes for which they were convicted. We did not take into account the crimes and offenses that were reported by patients for which they were not convicted. Patients in both groups, however, reported offenses to the clinicians that they had committed but that had not gone to court, sometimes because the general mental hospital decided not to press charges. Adding these acts to the ‘criminal acts’ could have changed the results and may have further diminished the differences between the two female groups. Finally, this article does not answer the question of whether DBT is effective in reducing the BPD symptomatology. This study is only a first pilot that hopefully leads to a controlled efficacy study among forensic BPD patients. Also, the question of whether standard DBT leads to changes in criminal behavior, or whether adaptations are necessary, remains unanswered. However, it seems fair to state that the empirical findings do at least support the feasibility of implementing DBT with forensic male and female borderline patients, even when comorbid with antisocial personality problems.
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6. Conclusion In conclusion, this study shows for the first time that sociodemographic and clinical differences between forensic and non-forensic (female) BPD patients are relatively small and that outpatient DBT for forensic BPD patients is feasible even in forensic BPD patients with co-morbid ASPD. It should be noted, however, that intensive supervision of therapists and explicit support from the managers of the program are a prerequisite. Acknowledgments We wish to thank the patients of the outpatient clinic “De Tender”, and the therapists for their cooperation. Also, we are grateful to Dr. Z. Otter for providing language help. References American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (Third Edition). (DSM III). American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (Third Edition Revised). (DSM III-R). American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth Edition Text Revision). (DSM IV-TR). Arntz, A., van den Hoorn, M., Cornelis, J., Verheul, R., van den Bosch, L. M. C., & de Bie, A. J. H. T. (2003). Reliability and validity of the Borderline personality Disorder Severity Index. Journal of Personality Disorders, 17, 45–59. Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 556–559. Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalizationbased treatment versus structured clinical management for borderline personality disorder. The American Journal of Psychiatry, 166(12), 1355–1364. Bernstein, D., & Arntz, A. (2009). Schema focused therapy for forensic patients with personality disorders: New research findings. European Psychiatry, 24(1), S94. Berzins, L. G., & Trestman, R. L. (2004). The development and implementation of dialectical behavior therapy in forensic settings. International Journal of Forensic Mental Health, 3, 93–103. Coid, J., Kathan, N., Gault, S., Cook, A., & Jarman, B. (2001). Medium secure forensic psychiatry services: Comparison of seven English health regions. The British Journal of Psychiatry, 178, 56–61. de Ruiter, C., & Trestman, R. L. (2007). Prevalence and treatment of personality disorders in Dutch forensic mental health services. The Journal of the American Academy of Psychiatry and the Law, 35(1), 92–97. Evershed, S., Tennant, A., Boomer, D., Rees, A., Barkham, M., & Watsons, A. (2003). Practice-based outcomes of dialectical behavior therapy (DBT) targeting anger and violence, with male forensic patients: A pragmatic and non-contemporaneous comparison. Criminal Behavior and Mental Health, 13, 198–213. First, M. B., Spitzer, R. L., Gibbons, M., Williams, J. B. W., & Benjamin, L. (1996). The structured clinical interview for DSM-IV Axis II personality disorders (SCID-II). New York: Biometrics Research Department New York State Psychiatric Institute. Gabbard, G., Beck, J. S., & Holmes, J. (2006). Oxford textbook of psychotherapy. Oxford: Oxford University Press.
Giesen-Bloo, J., van Dyck, R., Spinhoven, Ph., van Tilburg, W., Dirksen, C., van Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality disorder. Randomized trial of schema-focused therapy vs. transference-focused psychotherapy. Archives of General Psychiatry, 63, 649–658. Harmon, R. B., Rosner, R., & Owens, H. (1998). The science of sex offenders: Risk assessment, treatment, and prevention. sex and violence in a forensic population of obsessional harassers. Psychology, Public Policy, and Law, 4, 236–249. Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1996). Adherence scale for Dialectical Behavior Therapy. Unpublished manuscript. University of Washington, Seattle. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., & Heard, H. L. (2006). Two-year randomized trial and follow-up of dialectical behavior therapy versus therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757–766. Lynch, T. R., & Cheavens, J. S. (2008). Dialectical behavior therapy for comorbid personality disorders. Journal of Clinical Psychology, 64(2), 154–167. McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). DBT with an inpatient forensic population: The CMHIP forensic model. Cognitive and Behavioral Practice, 7, 447–456. McMain, S. F. (2010). What have we learned from a Canadian trial of DBT: Recent findings and implications for practice. ISITDBT Annual Meeting, Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Behavior Therapy. San Francisco. McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., et al. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. The American Journal of Psychiatry, 166, 12. Nee, C., & Farman, S. (2005). Female prisoners with borderline personality disorder: Some promising treatment developments. Criminal Behaviour and Mental Health, 15(1), 2–16. Purcell, D. W., Parsons, J. T., Halkitis, P. N., Mizuno, Y., & Woods, W. J. (2001). Substance use and sexual transmission risk behavior of HIV-positive men who have sex with men. Journal of Substance Abuse, 13(1), 185–200 (16). Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. (1990). Structured clinical interview for DSM-III-R (SCID). Washington, DC: American Psychiatric Press. Trupin, E. W., Stewart, D. G., Beach, B., & Boesky, L. (2002). Effectiveness of a dialectical behaviour therapy program for incarcerated female juvenile offenders. Child and Adolescent Mental Health, 3, 121–127. van den Bosch, L. M. C., den Haan, M. P. M., & Lammers, S. M. M. (2005). Vrouwen in de forensische psychiatrie. In C. de Ruiter, & M. Hildebrand (Eds.), ‘Behandelingsstrategieën bij forensisch-psychiatrische patiënten’. Cure & Care developmentTreatment strategies among forensic-psychiatric patients. Houten: Bohn Stafleu van Loghum. van den Bosch, L. M. C., Koeter, M., Stijnen, T., Verheul, R., & van den Brink, W. (2005). Sustained efficacy of dialectical behavior therapy for borderline personality disorder. Behavior Research and Therapy, 43, 1231–1241. van den Bosch, L. M. C., & Verheul, R. (2007). Patients with addiction and personality disorder: Treatment outcome and clinical implications. Current Opinions in Psychiatry, 20, 67–71. van den Bosch, L. M. C., Verheul, R., & van den Brink, W. (2001). Substance abuse in borderline personality disorder: Clinical and etiological correlates. Journal of Personality Disorders, 15(5), 416–424. Verheul, R., & Herbrink, M. (2007). The efficacy of various modalities of psychotherapy for personality disorders: A systematic review of the evidence and clinical recommendations. Internal Review of Psychiatry, 19(1), 25–38. Verheul, R., van den Bosch, L. M. C., Koeter, M. W. J., van den Brink, W., & Stijnen, Th. (2003). Efficacy of dialectical behavior therapy: A Dutch randomized controlled trial. The British Journal of Psychiatry, 182, 135–140.
Contents lists available at SciVerse ScienceDirect
International Journal of Law and Psychiatry
DBT in an outpatient forensic setting L.M.C. van den Bosch a,⁎, M. Hysaj a, P. Jacobs b a b
Centre for Personality Disorders Jelgersma, Oegstgeest, The Netherlands Psychiatric Hospital Pro Persona, The Netherlands
a r t i c l e
i n f o
Available online 5 May 2012 Keywords: Forensic psychiatry Borderline personality disorder Dialectical behavior therapy Outpatient treatment
a b s t r a c t Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidencebased treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings. © 2012 Elsevier Ltd. All rights reserved.
Since the introduction of DSM-III (American Psychiatric Association, 1980), personality disorders are recognized as a special diagnostic entity with special treatment needs. Ever since, a large variety of treatment programs have been developed. Literature reviews show that cluster B personality disorders, and especially borderline personality disorder (BPD), are the subject of growing interest for researchers and therapists (Gabbard, Beck, & Holmes, 2006). High levels of comorbidity exist between BPD and different types of Axis I disorders, with substance abuse being the most prominent. In general, this is seen as a factor that contributes to the difficulties found in treatment. In addition to these complicating comorbid problems, the creation of a working alliance with BPD patients is often seen as extremely difficult. BPD can be characterized as a ‘relationship’ disorder, in that patients show an incapability to regulate interpersonal relationships, and/or learn from them (Linehan, 1993). However, a growing body of literature shows that treatment for BPD is possible and effective (for example Bateman & Fonagy, 2008, 2009; Giesen-Bloo et al., 2006; Linehan et al., 2006; McMain, 2010; McMain et al., 2009; van den Bosch, Koeter, Stijnen, Verheul, & van den Brink, 2005; Verheul, van den Bosch, Koeter, van den Brink, & Stijnen, 2003). These studies show that suicidal and selfdestructive behaviors, anger and substance abuse can be reduced
and compliance with therapy enhanced (mainly in terms of reduced dropout rates). Both psychodynamic and behavioral treatment programs show significant reductions of symptoms after 1–1.5 years of treatment (Verheul & Herbrink, 2007). Due to these positive results, the negativistic attitude in the 1990s toward treatment of dually diagnosed borderline patients has changed into a more realistic one with obvious potential for an effective working alliance and clear, positive outcomes (van den Bosch & Verheul, 2007). The situation of borderline patients in forensic settings is less hopeful however. 1 Studies show that many of the crimes committed by these patients (e.g. arson, criminal damage and stalking), can be seen as manifestations of their psychiatric disorder (Coid, Kathan, Gault, Cook, & Jarman, 2001; Harmon, Rosner, & Owens, 1998; Purcell, Parsons, Halkitis, Mizuno, & Woods, 2001). For instance, a review of the epidemiology and treatment of borderline female forensic psychiatric patients (van den Bosch, den Haan, & Lammers, 2005), found that nearly 70% of the forensic patients with a diagnosis of BPD have committed ‘crimes’ of a very impulsive nature, and meant to seriously harm themselves. For example, 39% of these patients were convicted for arson and the goal of the fire setting was an attempt to commit suicide. A total of 60% of this patient group phoned for help and called the police directly after the incident. Although 44% had no history of criminal behavior, and the majority (70%) had an extended treatment history, they were still sentenced to more than
⁎ Corresponding author at: Alexander Hegiusstraat 15, 7412 XN Deventer, The Netherlands. Tel.: + 31 620490230. E-mail address: [email protected] (L.M.C. van den Bosch).
1 Forensic: persons on parole or probation, but also persons who have yet to be adjudicated, or stay in a residential forensic psychiatric hospital, who are being seen in an outpatient clinic.
1. Introduction
0160-2527/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijlp.2012.04.009
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4 years' imprisonment, followed by compulsory treatment of more than 5 years (van den Bosch, den Haan, & Lammers, 2005). Paradoxically, the focus in forensic psychiatry is not on the effective treatment of BPD problems, but on the prevention of criminal recidivism using general psychiatric care and aggression-focused therapies. Although not supported by empirical data on clinical or etiological characteristics, forensic patients with a borderline personality disorder are believed to be more complex than patients with a borderline personality disorder in regular mental health settings. This perhaps explains why our literature search showed that over the last 15 years only 1 study focused on the treatment of BPD patients in forensic settings (schema focused therapy: Bernstein & Arntz, 2009). Unfortunately, no results of this study were published. Some attempts, however, are being made to change the repressive atmosphere in forensic psychiatry into a more therapeutically beneficial one for both patients and staff. Dialectical behavior therapy (DBT) seems to be especially helpful (Berzins & Trestman, 2004; de Ruiter & Trestman, 2007; McCann, Ball, & Ivanoff, 2000). Some studies indicate that the implementation of DBT principles, particularly in residential forensic settings, seems to be beneficial for forensic patients and staff members (Evershed et al., 2003; Nee & Farman, 2005; Trupin, Stewart, Beach, & Boesky, 2002). To our knowledge, however, the question has yet to be raised of whether or not a program oriented to outpatient, borderline forensic patients is possible, let alone answered. Therefore the outpatient treatment clinic “De Tender”, which is part of the forensic psychiatric hospital Oldenkotte in the Netherlands, has created a DBT program for forensic psychiatric patients. After a short clarification of the basis of the treatment program (fundament of dialectical behavior therapy, and some of its core principles), this report will describe the sociodemographic, clinical, treatment process, and treatment data from an open study among male and female forensic patients with BPD and compares these data with those of BPD patients in a non-forensic mental health setting. This study aims to answer the following questions:
environment. According to the biosocial model, the patient cannot change his behavior because he cannot effectively deal with emotional stimuli. Individuals with BPD miss essential interpersonal skills concerning self-regulation. The environment however, sees this lack of skills as a lack of commitment to change, or as an act of willfulness. As a result the patient develops a self-concept that includes selfinvalidation and is self-defeating. Transaction between emotional vulnerability and self-invalidation causes pervasive emotional deregulation that affects all levels of functioning: interpersonal, cognition, affect and behavior. In order to gain control over this deregulation, the patient engages in (self-)destructive behavior, which in itself creates even a higher level of vulnerability and self-invalidation. In other words, the cure becomes the problem. The patient then alternates between need for contact and help on one hand, and a strong rejection of other people and insistence on autonomy on the other hand. Therapists therefore need to teach the patient how to gain control over emotional vulnerability, without relapsing into a (self-)destructive behavior. Also, they need to stop the self-invalidating process and make the patient validate himself, that is: accept himself as he is. This simultaneous focus on applying both acceptance and validation strategies and change (behavioral) strategies to achieve a synthetic (dialectical) balance in the functioning of the patient is one of DBT's central principles. Dialectics, a core theory in DBT, is targeted at balancing acceptance and change, through teaching the patient how to become willing to deal with continuous change. In DBT, dialectical tension is used to teach the patient to stop dichotomous thinking by showing that everything has a positive and a negative side, and that tension creates the possibility for development (see also: Linehan, 1993; 199–220).
Dialectical behavior therapy (DBT) is a manualized twelve-month treatment that combines 4 modules: a. weekly individual cognitivebehavioral psychotherapy sessions with the primary therapist, b. weekly skills training groups lasting two–two and a half hours per session, c. weekly supervision and consultation meetings for the therapists, and d. phone consultation, where patients are encouraged to get coaching in the appliance of new effective skills by phoning their primary therapists either during or outside office hours. Individual therapy focuses primarily on motivational issues, including the motivation to stay alive and to stay in treatment. Group therapy teaches self-regulation and change skills, and self- and other acceptance skills.
2.1.2. The consultation-to-the-patient principle Another core principle that needs to be mentioned here is the ‘consultation-to-the-patient’ principle. Once the patient has signed the treatment contract, the patient in DBT is seen as a responsible individual who is capable of change. Because this principle has consequences for the application of the treatment, it is important to understand the vision on which it is based. In more conventional treatment programs, therapists and patients are easily caught in a paradox. The treatment is started on the assumption that the patient is capable of change and can take full responsibility. However, when the patient ‘fails’ to show enough change (for instance by getting in a suicidal crisis), the therapist intervenes, sometimes even against the will of the patient. When the therapist behaves this way, he demonstrates to the patient his loss of trust in the patient's capabilities, which probably leads the patient to actively self-invalidate, and in the long run can lead to a form of learned helplessness. Also, the therapist ‘conditions’ his patient, in that he makes clear that under certain circumstances, like with a suicidal crisis, he will abort the agreements in the treatment contract and act as ‘savior’. This can even result in reinforcement of crisis behavior. The consultation-to-the-patient principle clarifies the roles of patients and therapists. The therapist acts as coach and consultant and does not accept any power over the patient, nor does he intervene. Consequences of this principle are: the therapist does not speak about the patient with other professionals, nor with members of the social network of the patient, but advises the patient how to deal with professionals and other people. Another consequence worth mentioning is that in DBT ‘splitting’, a phenomenon often associated with BPD, does not occur. Differences in interpretation of the behavior or intentions of the patient will not lead to tension between professionals when the patient literally takes a central position.
2.1.1. The biosocial theory The biosocial model of DBT conceptualizes BPD as “a pervasive disorder of emotion regulation”, which is the consequence of the transaction between intrinsic emotional vulnerability and the invalidating
2.1.3. Treating the therapist When the patient wavers between helplessness and autonomy, it becomes difficult for therapists to determine where they stand in terms of the patient's behavior, resulting in the therapists finding
1) Are there clinical or etiological characteristics that distinguish forensic male from forensic female patients with BPD? 2) Are there clinical or etiological characteristics that distinguish forensic female patients from female patients with BPD in regular mental health settings? 3) Can standard DBT be implemented for female and male borderline patients in an outpatient forensic setting? More precisely, the question is whether it is possible to develop a working alliance with these forensic BPD patients, the effectiveness of which would be indicated by low attrition rates. 2. The treatment program 2.1. Dialectical behavior therapy: core principles
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themselves unbalanced in their own behavior. Because of this (unbalancing) behavior, and because of the consultation-to-the-patient principle, support of therapists is a necessary prerequisite when treating these patients. Dialectical behavior therapy is based on the assumption that a nonjudgmental attitude toward patients and their problems is needed that helps patients to reduce self-invalidation in order to firstly enhance therapists' own capacity for and competence in self-reflection and secondly, to create an effective working alliance. A nonjudgmental attitude sees the behavior of the patients as it is: within this context, at this moment. Being nonjudgmental makes it possible to inquire about the chain of events that led to the behavior and finally see the behavior, as strange or self-destructive as it may be, as meaningful. Also, the behavior can be seen as functional, as coping behavior that helps to reduce tension. For example, a patient engages in aggressive behavior (verbal threat). If the therapist is not capable of seeing this behavior as the most effective way of instantly reducing fear (or of keeping a therapist at arm's length), he will not be able to help the patient to change it. A verbal threat, though destructive, is effective but not very helpful in the long run. Therapists, therefore, need to come up with a very effective replacement behavior in order to motivate the patient to change. As long as a therapist thinks that the behavior is intended to disturb or manipulate him, he will be unable to correctly interpret the act and he will not be able to help the patient see the benefits of change. 3. Pilot study 3.1. Material and methods 3.1.1. Participants Two groups of patients were included in the study. Group 1 consisted of 29 forensic patients (10 males, 19 females) with BPD who were referred to a forensic outpatient clinic by probation and (forensic) psychiatric services, because of criminal behavior, although two patients (6.8%) had not been convicted. Group 2 consisted of 58 female BPD patients, who voluntarily participated in a DBT study in a regular mental health and addiction treatment service in The Netherlands (van den Bosch, Verheul, & van den Brink, 2001). For both groups the exclusion criteria were; chronic psychosis, bipolar disorder, and IQ b 80. 3.1.2. Assessments Sociodemographic characteristics were collected (age, employment status, in receipt of social benefits, marital status, and level of education). Also, some clinical characteristics and the number and severity of psychiatric problems were examined including; compulsory treatment/special conditions/probation service, crimes committed, number of BPD criteria (last year), number of ASPD criteria (last year), comorbid PTSD (last year), life-time presence of suicide attempts, life-time parasuicidal behavior, co-morbid alcohol and poly-drug use (last year), use of benzodiazepines (last year), use of antidepressants (last year), use of antipsychotics (last year), and use of other medication (last year). Finally, dropout rates were calculated. The SCID-I (Spitzer, Williams, Gibbon, & First, 1990) and SCID-II (First, Spitzer, Gibbons, Williams, & Benjamin, 1996) were used to diagnose DSM-III-R Axis I (APA, 1987), and DSM-IV Axis II disorders (APA, 1994), respectively. Data on self-destructive behavior were gathered by using the BPDSI (Borderline Personality Disorder Severity Index, Arntz et al., 2003). All assessments took place at the start of the treatment year. 3.1.3. Procedure A standard DBT program, focusing on life-threatening and suicidal behavior as primary treatment targets, was implemented in the experimental group “De Tender”. The decision to implement DBT was based on a growing body of opinion that dialectical behavior
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therapy seems to be beneficial not only for forensic patients, but also for patients with comorbid BPD (Lynch & Cheavens, 2008). The treatment program consisted of the four basic modules of DBT as described before: weekly individual psychotherapy (1 h), a weekly skills group training (2 1/2 h), if needed 24-hour phone consultation, and a consultation team for therapists and trainers. The creation of the consultation team was given priority. These weekly sessions, aimed at helping the therapists to solve the problems they are confronted with in treatment, function as a DBT framework for the therapists and strengthen the interconnectedness of the team members. Group 2, the ‘mental health’ group, followed the same treatment program. The only adaptation made was that therapists and patients needed periodically to report to the probation services together. All the individual therapists (in total 17: five in forensics and 12 in the other general mental health sample) and 6 trainers were trained intensively in a ten-day DBT course. All the patients followed DBT, which meant that they had one session weekly with their own individual therapist and a 2 1/2-hour group skills training session each week delivered by pairs of trainers. All therapists and trainers in both groups were continuously supervised in DBT by the first author, who is a member of the international DBT training group in Seattle. Supervision took place after the sessions without the patient being present. In supervision, the focus was on the application of the DBT core strategies (behavior therapy, validation and dialectical strategies). Treatment integrity was examined in two ways: the first author — as a trained adherence coder, scored a random selection of the videotaped sessions of the weekly individual therapy sessions of each therapist during the whole treatment year, using the adherence scale developed by Linehan (Linehan's adherence coding manual, Seattle, 1996). In addition to the coding, the session notes that were filled in after each therapy session by the individual therapists were examined when the treatment had ended. In these session notes, which are delivered in a standard format, the therapists fill in what kind of problem behavior has taken place, what problem behavior the session targeted, and what strategies they used. The session notes therefore give an overview over what DBT strategies are not used. The median adherence score on a 5-point Likert scale was 3.5 and 3.8 in the forensic and the mental health settings respectively, indicating an adequate level of DBT interventions and strategies. 3.1.4. Statistical analysis Differences between males and females in the forensic population were examined using the independent t-test. Differences between the female patients belonging to the two different study groups were also examined using an independent t-test. Because of the dichotomous nature of the data, no post-hoc tests were applied. This is an explorative study with a relatively small sample size. In order to prevent type II errors in this early stage of the investigation, we are reporting differences with a rather lenient level of significance (p b .05), i.e. no correction for multiple testing will be applied. All analyses were conducted using SPSS. 4. Results 4.1. Characteristics of forensic male and female BPD patient groups (Table 1) The average age of females in the forensic group was 35 years, which is slightly higher than that of the males (34 years). Sociodemographic characteristics of the forensic male and female patients were similar. However males showed non-significant higher percentages of being in receipt of social benefits and having a criminal past, defined as (former) contacts with the judiciary system (100% for males vs. 84% for females). The differences found regarding the nature of the crimes showed that in the forensic group, two patients (one male and one female), had been sentenced for attempted murder. The other reported crimes and offenses (arson, violence, violating the
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Table 1 Comparison of sociodemographic data, clinical and severity of symptoms between male BPD patients and female BPD patients in the forensic outpatient clinic. Variable
Sociodemographic data
Clinical characteristics Severity of symptoms
Process variable
Number Age Employment status Social benefit Marital status Level of education Compulsory treatment Crimes committed BPDSI mean score # BPD criteria %a # ASPD criteria %a Comorbid PTSD %a Suicide attemptsb Parasuicidal behaviorb Comorbid alcoholb Comorbid poly drugsb Use of benzodiazepinesb Use of antidepressantsb Use of antipsychoticsb Other medicationb Drop out %
Forensic males
Forensic females
Mean SD
Mean SD
10 33.6 .2 .70 1.4 .3 .3 1 26.3 2.8 (50%) 1.7 (70%) .42 (10%) .8 .4 .57 .16 .5 .7 .2 .84 .30 (30%)
7.66 .42 .48 1.6 .48 .48. 2.13 9.8 .42 .48 0.51 .422 .516 .5 .37 .527 .483 .422 .37 .483
19 34.84 .21 .47 1.47 .37 .52 .84 30.9 2.89 (95%) .68 (26%) .1 (42%) .95 .84 .6 1 .68 .68 .26 .5 .63 (21%)
8.83 .42 .52 1.84 .49 .51 .37 7.2 .46 .82 .31 .229 .375 .51 0 .48 .48 .45 .53 .49
df
t
p
27 27 27 27 27 27 27
−.376 −.064 1.15 −.106 −.356 − 1.15 1.321
.71 .95 .26 .916 .72 .26 .19
27 27 27 27 27 27 27 27 27 27 27 27
−.543 3.585 1.816 − 1.23 − 1.65 −.106 − 4.94 −.953 .084 −.365 2.030 − 1.73
.59 .001⁎⁎ .08 .23 .013⁎ .92 .000⁎⁎ .349 .93 .72 .052 .09
Employment status: number of patients out of work; marital status: number of patients being single; level of education: number of patients with only primary school; social benefit: number of patients on social benefit. a Clinical and severity of symptoms: lifetime. b Clinical and severity of symptoms: last year. ⁎ p b 0.05. ⁎⁎ p b .001.
Opium Act, compulsory shoplifting, reckless driving or driving under the influence, criminal damage, stalking) showed only a slightly different pattern with the males showing more violation of the Opium Act, violence and driving under the influence, and the females exhibiting more arson and stalking. Examination of the BPDSI severity score showed that the forensic females had significantly higher severity rates, were significantly more engaged in parasuicidal/self-destructive behavior, and showed significantly more BPD criteria when compared to the males (t = −1.6, p = .013, d = 27). Both females and males showed very high and similar percentages of attempted suicide in the last year (95% vs. 80%). The percentage of forensic male patients meeting antisocial personality disorder (ASPD) criteria, however, was significantly higher than for the females (t = 3.5, p = .001, d = 27). A similar percentage of male and female patients showed comorbidity with alcohol abuse (60% vs. 56%), while for drugs, a significantly higher percentage of males engaged in drug abuse (t = −4.9, p = .00, d = 27). Forensic females showed higher levels of comorbid PTSD (42% vs. 10%), but the difference was not statistically significant. Most of the forensic patients used some kind of medication. The forensic females tended to use slightly more of any kind of medication, but the difference between females and males only reached significance for the use of sedatives and for ‘other medication’, ranging from Lithium to Concerta, indicating that nearly all of the forensic patients received (a combination of) medication. Only 6% of the forensic patients dropped out during the first 3 months. This increased to 25% by the end of the first half-year (3 males and 4 females). However, 75% of the patients completed the whole program. 4.2. Comparison of female BPD in forensic and regular mental health services (Table 2) Sociodemographic characteristics of BPD patients in forensic and regular mental health and addiction treatment services were very similar. As expected, the groups differed on ‘compulsory treatment’ (t = 7.9, p = .00, d = 76). The number of forensic patients with a
‘criminal past’, defined as (former) contacts with the judiciary system and being convicted for a crime, was also significantly higher (t = 5.0, p = .00, d = 76). However, the nature of the ‘criminal past’ was highly comparable (arson, violence, compulsory shoplifting, reckless driving, stalking). All forensic females were sentenced to compulsory treatment, compared to none of the mental health group. Nearly all females of both groups showed more than 6 BPD criteria (95% and 100% respectively). No significant differences were found between the female groups in terms of severity of the borderline symptomatology (mean score of the forensic group 30.9 [7.2] vs. the mental health group 30.4 [9.8]), the presence of co-morbid PTSD, suicide attempts in the past year, and parasuicidal/self-destructive behavior. Also, no difference was found concerning drug abuse. However, significantly more comorbid alcohol abuse occurred among female BPD patients in the regular mental health and addiction treatment services compared to the forensic female patients (t = 2.1, p = .032, d = 76). Surprisingly, mental health and forensic female patients meeting ASPD criteria (26% and 37%) showed a significant difference in the number of ASPD criteria met, with the non-forensic females showing the higher number (t = 2.1, p = .035, d = 76). Finally, mental health female BPD patients used significantly more ‘other’ medication than the forensic group. Comparison of dropout rates was limited to those female patients who engaged in DBT treatment in both samples. No differences were found for dropout (forensic 21% vs. mental health 26%).
5. Discussion The results indicate that it is possible to provide DBT in a forensic setting as the patients are not dissimilar, whether the patient is court mandated or not. The findings also indicate that the clinical and etiological differences between forensic BPD patients and borderline patients from general mental health settings are relatively small. Female BPD patients in a forensic outpatient DBT group are clinically very similar to female BPD outpatients in a DBT treatment group in a regular mental health and addiction treatment setting.
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Table 2 Comparison of sociodemographic data, clinical and severity of symptoms between female BPD patients in forensic and regular mental health services. Variable
Sociodemographic data
Clinical characteristics Severity of symptoms
Process variable
Number Age Employment status Social benefit Marital status Level of education Compulsory treatment Crimes committed Mean BPDSI score #BPD criteria%a #ASPD criteria%a Comorbid PTSD %a Suicide attemptsb Parasuicidal behaviorb Comorbid alcoholb Comorbid poly drugsb Use of benzodiazepinesb Use of antidepressantsb Use of antipsychotics.b Other medicationb Drop out %
Forensic females
Mental health females
Mean SD
Mean SD
N = 19 34.84 .21 .47 .32 .37 .53 .37 30.9 .95 .68 26% .42 42% .94 .84 .58 .16 .68 .48 .42 .84 .21 (21%)
8.8 .42 .512 .48 .49 .51 .08 7.2 .20 .82 .51 .23 .37 .51 .37 .48 .11 .097 .37 .42
N = 58 35.3 .17 .37 .26 .31 0.0 .45 30.4 1.0 .36 37% .47 47% .93 .83 .31 .34 .88 .50 .42 .24 N = 27 .12 (26%)
df
8.6 .38 .49 .45 .46 0.0 .06 9.8 .00 .48 .50 .25 .37 .46 .48 .33 .65 .05 .43 .33
t
p
76 76 76 76 76 76 76
.08 .401 .774 .16 .509 7.992 5.009
76 76 76 76 76 76 76 76 76 76 76 76
− 1.7 2.143 −.402 .232 .116 2.186 − 1.51 − 2.03 1.083 −.089 5.501 .994
.93 .69 .44 .83 .61 .00⁎⁎ .00⁎⁎ .00 .035⁎ .689 .817 .91 .032⁎ .136 .046 .282 .93 .000⁎⁎ .323
Employment status: number of patients out of work; marital status: number of patients being single; level of education: number of patients with only primary school; social benefit: number of patients on social benefit. a Clinical and severity of symptoms: lifetime. b Clinical and severity of symptoms: last year. ⁎ p b 0.05. ⁎⁎ p b .001.
As expected, forensic BPD patients had more contact with police and the judiciary system than BPD patients in the regular mental health services, but the nature of the crimes was very similar. Finally, female BPD patients in the regular services more often reported alcohol problems than forensic female BPD patients; a finding that is directly related to the fact that half of the mental health group was recruited from substance abuse services. Substantial differences were observed between male and female forensic BPD patients in DBT groups. Compared to female (mental health and forensic) BPD patients, male forensic BPD patients meet fewer BPD criteria, and the level of self-destructive behavior and the BPD problem severity, as measured with the BPDSI, is lower compared to females. Moreover, male patients less frequently report suicide attempts, show more co-morbid ASPD, less co-morbid PTSD, and use benzodiazepines less frequently. In short, the male BPD patients have a different psychopathological profile than female BPD patients, with lower levels of typical borderline (related) problems and more ASPD-like problems. Forensic female patients seem to be referred not so much because of the antisocial aspects of their behavior, but because of the severity of their BPD problems. The study also showed that standard DBT can be implemented for female and male borderline patients in an outpatient forensic setting. Of all patients entering the forensic DBT program, 7 males (70%) and 15 females (79%) completed the program, resulting in an overall dropout rate that is very similar to the DBT program for female BPD patients in a regular mental health and addiction treatment setting (24% forensic group vs. 26% mental health/addiction group). It should be mentioned that none of the forensic patients committed suicide during the treatment and that no homicidal or physically violent behaviors were reported in the groups during the treatment. Therefore, the conclusion is justified that the forensic DBT patients can develop a therapeutic alliance in a DBT program. One specific problem, however, that showed up in applying DBT in the forensic setting, needs to be mentioned. In DBT in general, suicidal behaviors (including threats and gestures), are treated as a coping behavior associated with pain and suffering. Based on the consultationto-the-patient principle (Linehan, 1993), the DBT therapist will not
intervene unless it seems highly unlikely that the patient himself can take action, or when the risk of suicide is too imminent. However, in contrast to the mental health and substance-abusing patients, forensic patients showed homicidal behavior in addition to their ‘normal’ suicidal behavior. For the individual therapists, this created a problem because they had great difficulty in interpreting the behavior as a way of coping. As a result, much more between-session consultation and supervision were needed, as well as explicit support from the managers of the program. The concept of the consultation team, a one-team model, proved to be of extreme importance here. There are severe limitations that should be considered with regard to the results. First, the power of this study to detect group differences was limited due to the small sample sizes resulting in large confidence intervals. Second, although participation in the program was emphatically presented to the forensic patients as being entirely voluntary, nearly half of the patients entered the program while being subject to a court order. Therefore, it can be expected that some of the patients showed a high compliance rate because of perceived pressure from the court or the probation service, as opposed to any intrinsic motivation to join the treatment program. Third, we reported the percentages of the patients who were in contact with the judiciary system and the character of the crimes for which they were convicted. We did not take into account the crimes and offenses that were reported by patients for which they were not convicted. Patients in both groups, however, reported offenses to the clinicians that they had committed but that had not gone to court, sometimes because the general mental hospital decided not to press charges. Adding these acts to the ‘criminal acts’ could have changed the results and may have further diminished the differences between the two female groups. Finally, this article does not answer the question of whether DBT is effective in reducing the BPD symptomatology. This study is only a first pilot that hopefully leads to a controlled efficacy study among forensic BPD patients. Also, the question of whether standard DBT leads to changes in criminal behavior, or whether adaptations are necessary, remains unanswered. However, it seems fair to state that the empirical findings do at least support the feasibility of implementing DBT with forensic male and female borderline patients, even when comorbid with antisocial personality problems.
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