International Journal of Law and Psychiatry 32 (2009) 288–293

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International Journal of Law and Psychiatry

Evidence-based practice in group work with incarcerated youth

Ashley Quinn, Wes Shera ⁎University of Toronto, ON, Canada

⁎ Corresponding author. University of Toronto, FactoWork, 246 Bloor Street West, Toronto, Ontario, Canada Mfax: +1 416 978 7072.

E-mail address: wes.shera@utoronto.ca (W. Shera).

0160-2527/$ – see front matter © 2009 Elsevier Ltd. Aldoi:10.1016/j.ijlp.2009.06.002

a b s t r a c t

a r t i c l e i n f o

Keywords:Evidence-basedIncarcerated adolescentsBest practicesPsychoeducational groupDialectical behavior therapy

As a result of the Youth Criminal Justice Act's increased focus on restorative justice, treatment, rehabilitation,and reintegration of youth, many more juvenile offenders require mental health services while resident inyouth detention facilities [Youth Criminal Justice Act (2002, c.1). Ottawa: Department of Justice Canada.Retrieved September 19, 2008 from http://laws.justice.gc.ca/en/Y-1.5]. Several common characteristics suchas violence, aggression, and other antisocial behaviors, associated with criminal behavior, have beenidentified among male and female offenders. Dialectical behavior therapy, originally developed by Linehan[Linehan, M. M., 1993a. Cognitive–behavioural treatment of borderline personality disorder. New York:Guildford Press] for chronically parasuicidal women diagnosed with borderline personality disorder, hasbeen successfully modified for use with other populations, including violent and impulse-oriented male andfemale adolescents residing in correctional facilities. The intent of this article is to encourage the wider use ofdialectical behavior therapy (DBT) with young offenders. It includes an extensive review of the evidence-baseto date and describes some of the creative modifications that have been made to standard DBT programformat to meet the particular needs of various groups in both Canada and the United States. In keeping withthe movement toward more evidence-based practice, the authors argue that DBT is a promising approach ingroup work with incarcerated adolescents and should be more widely used.

© 2009 Elsevier Ltd. All rights reserved.

1. Introduction

In North America, we have seen a significant increase in theincarceration of young offenders. In Canada, children and youth'scriminal behavior is governed under the jurisdiction of the YouthCriminal Justice Act (Youth Criminal Justice Act [YCJA], 2002, c.1). It isparamount that incarcerated young offenders learn skills that enablethem to be successful in their long-term efforts to reintegrate intotheir communities. All sentencing decisions should take into accountthe offenders' potential and opportunity to rehabilitate. Under theprevious Young Offender's Act (1985, R.S., 1985, c-Y1), sentencingoptions were loosely defined, which unfortunately led to an over-reliance by Youth Justice Courts on secure custody as a sentence. Thisresulted in a high number of youth being incarcerated. Canada and theUnited States have the highest youth incarceration rates in theWestern world (Doob & Sprott, 2005). The YCJA addressed this issueby developing clearly defined sentencing options and guidelines,including a new “alternative measures program”, which allows judgesto hold youth accountable for their offence in the least restrictivemanner. The most restrictive sentence that an offending youth canreceive is secure custody. Although secure custody is considered an

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appropriate sentence for emotionally dysregulated and violent youth,it is also essential that they be treated with respect and givenopportunities to rehabilitate and reintegrate into their communities(Doob & Sprott, 2005). The Declaration of Principle, section 3, of theYCJA states that each youth has the right to a timely intervention thatreinforces the links between the offending behavior and its con-sequences. The Act also emphasizes that treatment be tailored to theneeds of the person in custody according to their level of development(YCJA, 2002, c.1). The intent of this article is to review the emergingevidence on the use of dialectical behavior therapy (DBT) forincarcerated youth and identify relevant new directions for programdevelopment and research. This article will discuss how DBT meetsthe requirements set out for incarcerated youth under the YCJA and isan appropriate intervention for incarcerated youth to assist with theirrehabilitation during incarceration. This intervention also has thepotential of increasing their ability to function in the community oncereleased. More research is needed to assess the impact of thisintervention on youth and their behavior in the community. We arenot proposing that DBT directly reduces recidivism, but rehabilitationis an important goal of the YCJA andwe need to assist youth to succeedupon re-entry into their communities. DBT may be a contributingfactor in the reduction of recidivism.

The need for appropriate mental health treatment in securecorrectional facilities for youth has been well documented in theliterature (Fazel, Doll, & Langsrom, 2008; Rosenblatt, Rosenblatt, &Biggs, 2000; Ulzen, 2003; Ulzen & Hamilton, 1998). Offenders with

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mental health issues have difficulty adjusting to prison rules androutines and are more likely to incur violations and accumulatedisciplinary consequences while incarcerated. They are frequentlycharged with self-harm, threatening behavior, refusing orders,insolence and vulgarity, throwing urine or feces, assault, battery,disorderly conduct, and destruction of property (Human RightsWatch, 2003). These reported violations reflect the behavior andexperience of many youth in secure facilities and are indicative of theiremotional, behavioral, and cognitive difficulties. Without appropriatetreatment, these difficulties will most likely persist, causing theindividual continual crises, both internally and with others (Berzins &Trestman, 2004; Fazel et al., 2008).

Although the relationship betweenmental health and recidivism iscomplex, mental health disorders have long been implicated inrecidivism among delinquent youth, with studies consistently notingthe high prevalence rate of psychiatric disorders in incarcerated adults(Abram & Teplin, 1991; Cottle, Lee, & Heilbron, 2001; Fazel & Danesh,2002; Kasen et al., 2001; Langan, Schmitt, & Durose, 2003). It has beensuggested that this is due to a lack of appropriate mental healthtreatment (Abram & Teplin, 1991). Several studies have demonstratedthat a high percentage of both boys and girls with criminal chargesalso have co-occurring behavioral, emotional, and substance usedisorders which typically lead to violent and aggressive antisocialbehaviors (Abrantes, Hoffman, & Anton, 2005; Chitsabesan et al.,2006; Dixon, Howie, & Starling, 2004; Fazel et al., 2008; Lederman,Dakof, Larrea, & Li, 2004). This is particularly problematic in securecorrectional facilities for two reasons. Firstly, residents with theseemotions and behaviors create a sense of chaos in the facility andsecondly, are unpredictable with regard to behavioral outbursts.While incarcerated, these behaviors receive consequences (i.e. solitaryconfinement) and as a result, many residents miss out on opportu-nities such as school, recreational activities, peer relationships, andother rehabilitative services (Trupin, Stewart, Beach, & Boesky, 2002).Awide range of interventions have been usedwith incarcerated youngoffenders but the evidence regarding their effectiveness is limited.One approach that is demonstrating significant effectiveness inrehabilitation is dialectical behavior therapy (DBT). As we movetowards evidence-based practice in youth justice correctional facil-ities, it is critical to further investigate DBT as a potential grouptreatment for incarcerated youth.

2. Dialectical behavior therapy

Although many therapies and programs have attempted to treatindividuals who display aggressive and/or self-injurious behaviorsand poor impulse control, dialectical behavior therapy (DBT) was andremains the first empirically supported treatment for individuals withunstable emotions, cognitive disturbances, self-harming behavior,chronic feelings of emptiness, interpersonal dysfunction, poorimpulse control, and anger management (Linehan, Armstrong, Suaraz,Allmon, & Heard, 1991).

DBT is based on the philosophical notion of “dialectic”which refersto the posing of a force and a counterforce, whose compromise leadsto their resolution. The therapist attempts to teach a form of dialecticalthinking that is intended to replace dichotomous (right vs. wrong)thinking patterns that are employed in intra and interpersonalconflicts (Linehan, 1993b). Dichotomous thinking patterns lead torigid beliefs that disable the individuals from responding construc-tively in conflict situations. Dialectal thinking enables individuals toproblem-solve in the midst of conflict by considering other alter-natives to their strongly held beliefs.

DBT is comprised of both group therapy and individual therapy,each with their own focus: group therapy focuses primarily onpsychosocial skills training and individual therapy focuses primarilyon motivational issues, including the motivation to stay alive, toreplace problem behaviors with skillful behaviors, and to build a life

worth living (Linehan, 1993a). The skills training group typicallyincludes four core modules: mindfulness, interpersonal effectiveness,distress tolerance, and emotion regulation. The Mindfulness Modulefocuses on giving attention to the present moment and targets self-dysregulation and identity confusion by emphasizing self-awareness.The Interpersonal Effectiveness Module teaches assertiveness andother interpersonal skills, to help deal with conflictual situations andto get what one wants and needs in a manner that maintains respectfor self and others. When a problem arises in the skills group, one ofthe group leaders will work through the issue with the groupmembers involved so that the group can continue. The group workerswill try to keep all members in the group, as long as safety ismaintained. This is what makes DBT different from other traditionaljuvenile justice programs and groups, where group members are sentout of the group for disruptive behavior. In DBT, group time is used tosolve problems occurring in the group. This allows for hands-on,present-centered learning to take place. The Distress ToleranceModule focuses on using strategies to tolerate distress, withoutmaking it worse by engaging in impulsive, self-destructive behavior. Itemphasizes distraction and self-soothing techniques, as well asstrategies that help individuals “radically” accept traumatic eventsin their lives. The Emotion Regulation Module coaches participantshow to identify and describe emotions, how to reduce vulnerability tonegative emotions, and how to increase positive emotions. All fourskills modules are designed to increase adaptive behaviors andcognitions, while simultaneously decreasing maladaptive behaviorsand cognitions (Berzins & Trestman, 2004).

It is essential to have a collaborative working relationship betweenthe therapist and the client, starting with orienting the client to thetherapy program. This includes the recognition of themutual investmentand commitment to clear, precise treatment target goals, ongoingassessment, and data collection on current behaviors (Miller, Rathus, &Linehan, 2007). The relationship between the client and the therapist is acritical part of successful treatment and the time invested is used to builda therapeutic alliancewith the client. This is particularly important in thecontext of secure custody facilities with adolescents, where DBTintervention is not a “mandated treatment”. Resistance is expectedfrom clients and therapists must use the relationship and orientationtime topersuade theclient toparticipate in thegroup, evenwhen theydonot want to. It is crucial that the therapist and the client develop acollaborative commitment to do psychosocial skills training together.

During the orientation phase, members develop a contract toparticipate for a specified period of time. From the beginning, thetermination date is known by eachmember and is discussed in sessionsas appropriate. Strong attachments form among group members thatmay not be apparent on the surface. Specific terminating strategies arediscussed by Miller et al. (2007) and Malekoff (2004). Monthly follow-up “booster” sessions for 4–6months following the endof their programhave been effective in assisting former members to generalize the skillsthey learned in the DBT skills training group (Nelson-Gray et. al., 2006).Ideally, this follow-up should continue in the community.

Thepurposeof the skills traininggroup is to developgroupmembers'skills to enhance their ability to regulate emotional, interpersonal,behavioral, and cognitive dysregulation. Staff who are group leadersrespond in a manner that decreases groupmembers' negative reactionsand behaviors. Staff training not only informs and educates workers inDBT skills training, but also decreases specific staff behaviors that elicitnegative responses from residents. The presence of the following staffbehaviors leads to poor outcomes for residents: extreme rigidity orflexibility, poor interpersonal limits, favoritism, and extreme irreverence(Linehan, 1993a; Trupin et al., 2002). A decrease in these behaviors canbe achieved by reducing staff's reliance on punishment, restriction ofactivities, and isolation.

According toMacgowan (2006), evidence-based groupwork (EBGW)can be defined as the judicious and skillful application of the bestevidence, based on research merit, practice relevance, appropriateness,

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and the use of evaluation to ensure desired results are achieved. Evidenceestablishing support for social work in a group format began in the 1920sand has cumulatively developed as new methods of documentingevidence became available, such as meta-analytic methodologies andsystematic reviews.

EBGW is a balance of three central elements: 1) best evidence; 2)worker competence; and 3) evaluation. These elements are inherent inthe values and ethics of most professions. An EBGW framework servesas a guide to assess evidence on group work and provides tools for thegroup worker to assess, evaluate, monitor, and improve their practice.It is not only important to assess the evidence on a particular type ofgroup, but also to assess the practical utility or relevancewith regard tothe values and needs of the individuals in a particular group. The groupworker should have the knowledge, skills, and expertise to apply theevidence in practice and should consider any obstacles to generalizingor disseminating the evidence in practice (Macgowan, 2006).

In the following section, the evidence for the applicability of DBTwithyouth is presented. Building on Pollio's (2002) guide to EBGW,weemployed a broader conceptualization of evidence to search theliterature. As suggested by Macgowan (2006), we searched withmultiple key terms (treatments for adolescents with conduct disorder,borderline personality disorder, mental illness and accompanyingsymptoms, as well as having involvement with the criminal justicesystem). The evidence was systematically collected via an electronicsearch of multiple journal databases (Social Work Abstracts, PubMed,PsycArticles, Psycinfo, and Cambridge Scientific Abstracts (CSA)). Theevidencewas then appraised utilizing the Quality of Study Rating Formand the Quantitative Study Quality Form (Gibbs, 2003). The quality ofthe sources from which these studies were located was assessedutilizing Cournoyer's Source Rating Rubric (Cournoyer, 2004).

3. Evidence-base to date

McCann, Ball, and Ivanoff (2000), state that several factorsempirically support the potential effectiveness of DBT in securecorrectional settings. The first factor is the high incidence ofpersonality disorder characteristics and antisocial behavior withinthis population. The second factor is that DBT is a thorough cognitive–behavioral treatment, which is highly structured with clear prioritiesfor target behavior goals and has been found to be effective inreducing recidivism with adults. Thirdly, managing life-threateningand aggressive behaviors is critical to the safe operation of acorrectional environment. Effective treatment of inmates can alleviatestress for corrections staff as well as for the inmates. The fourth factorconcerns staff burnout. The stress associated with dealing with violentinmates is exacerbated by the struggles of dealing with inmates whoexperience severe behavioral and emotional dysregulation. Correc-tional staff often label the symptoms of mental illness as bad behaviorand consequently resort to the use of punitive measures in an attemptto thwart the “bad behavior” (McCann et al., 2000).

Evidence suggests that groups provide a relatively non-threateningopportunity for individual clients to learn how to be in a group, whichis an important skill in our society (Linehan, 1993b). Harvey (2005)maintains that programs for youth should be formulated from a groupwork perspective because many youth depend on their peer groups asthey move through adolescence. It can be predicted that youthparticipation in DBT while incarcerated, will most likely result infewer restraints, decreased levels of punitive measures, and increasedparticipation in available activities/programming (Trupin et al., 2002).

A number of adult correctional facilities have documented positiveoutcomes by incorporating DBT treatment, sometimes with variousmodifications, in their treatment programs (Berzins & Trestman,2004; Cunningham, 2004; Laishes, 2002; McCann et al., 2000). Onlyone study (Trupin et al., 2002) has been conducted in a juvenilecorrectional facility. Trupin et al. (2002) conducted a controlled trialcomparing a treatment unit receiving DBT, a general population unit

receiving DBT and a general population unit receiving treatment asusual (TAU). This study followed the standard DBT format created byLinehan (1993b), while including new behavioral targets that weremore specific to current unit problematic behaviors and offense-related behaviors. Behavioral targets included life-threatening beha-viors, unit-destructive behaviors, and treatment-interfering beha-viors. They covered each module over a 4-week period of time. Thegoal of this group was to move members from severe behavioraldyscontrol to behavioral control. In order for this to happen,individuals had to decrease life-threatening behaviors and quality-of-life interfering behaviors (Trupin et al., 2002).

Unfortunately, this study reported a difference in training betweenthe two units receiving DBT. The treatment unit staff received the full80 h training, while the general population unit staff received only anintroductory 16 h of training. It is important to note that the unitreceiving less training had much poorer outcomes than the fullytrained unit. Participants were all female teens with a mean age of15 years and were recruited from three secure treatment units at aState of Washington Juvenile Rehab Administrative Facility. Therewere 60 participants in total: 22 from a Mental Health Unit; 23 from aGeneral Population Unit; and 15 from another General Population Unitas the control group. Participants were 50% White, 15% AfricanAmerican, 15% Native American, 10% Hispanic, and 10% other. Theaverage number of prior offenses for participants was six.

Pre- and post–intervention records were compared using thefollowing measures: the Diagnostic Interview Schedule for Children;The Child and Adolescent Functional Assessment Scale; Daily BehaviorLogs (including 1 year preceding the study); Community RiskAssessment Scores; and the Massachusetts Youth Screening Instru-ment. The researchers found a significant reduction in behaviorproblems during the 10-month period of the DBT study, (p=.01).Rates of staff's use of punitive measures were compared between the10-month study period and the 10-month time period prior to DBT.The results demonstrate that staff's punitive actions were significantlylower during the DBT period, (p=.04). By comparing rates ofparticipation in various in-facility programs, the researchers foundthat the number of youth participating in these rehabilitative servicesincreased during the DBT intervention. This study also reported asignificant decrease in serious behavior problems including suicidalacts, aggressive behavior, and class disruption among participants.Interestingly, there were no changes in participant and staff behaviorin the control group (Trupin et al., 2002). The limitations in this studycan be overcome in future research by ensuring that staff are equallytrained and participants are randomly assigned to DBT and control/comparative conditions.

Nelson-Gray et al. (2006) implemented the DBT skills traininggroup with non-suicidal outpatient adolescents who met the criteriafor oppositional defiant disorder (ODD). Although this study was notdone with incarcerated youth, the youth in this study have mentalhealth characteristics that are similar to the incarcerated youth thatweare proposing would benefit from this type of intervention. Partici-pants were recruited from public/private schools, the juvenile justicesystem, community mental health centers, university psychologyclinics, T.V. and radio announcements, group homes, community socialworkers, and posters in public facilities. Thirty-two youth (85% male,15% female), with a mean age of 12.6 years, completed the 16-weekprogram. Participants were 42% African American, 40.5% White, and2.7% Hispanic. All participants met the criteria for oppositionaldefiance disorder, 34% alsomet diagnostic criteria for conduct disorder,and 31% had comorbid attention deficit hyperactivity disorder. Thegroups were 2 h per week for 16 weeks, with 5–9 members in each.There were two leaders per group (trained graduate student co-therapists) and a graduate student assistant who escorted youth to thegroup room.

Pre- and post-measures included the Diagnostic Interview Sche-dule for Children; the Child Behavior Checklist; Youth Self-Report; the

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Behavioral and Emotional Rating Scale; and the Child DepressionInventory. After comparing pre- and post-treatment measures of theparticipants' caregivers, statistical significance was found in the follow-ing areas; improved functioning; increase in interpersonal strength(p=.0001); reductions in externalizing behaviors (p=.0075); andreductions in ODD symptoms (p=.0004). Participant's pre- and post-treatment measures demonstrated statistically significant reductions indepressive symptoms and internalizing behaviors (p=.0015; Nelson-Gray et al., 2006).

In terms of clinical significance, 77% of the participants who werein the clinical range at pre-treatment were in the non-clinical range onpost-treatment measures. According to caregiver measures, 71% ofparticipants demonstrated significant clinical improvement. Accord-ing to participant measures, 91% of the participants in the clinicalrange pre-treatment were in the non-clinical range on post-treatmentmeasures. DBT was found to decrease negative behaviors as well asincrease positive behaviors. This study demonstrated that DBT can besuccessfully applied with beneficial outcomes to this population(Nelson-Gray et al., 2006). Unfortunately, there was no comparisongroup or waitlist control group in this study. Future research shouldinclude randomized controlled trials in order to demonstrate treat-ment efficacy. The researchers suggest the use of additional measuresto evaluate family functioning and cohesiveness (Nelson-Gray et al.,2006).

Miller, Wyman, Huppert, Glassman, and Rathus (2000), examinedthe overall effectiveness of the four DBT skills modules withadolescents. Again, this study did not involve incarcerated adoles-cents, but the participant treatment needs resembled those ofincarcerated youth, including emotional dysregulation, intrapersonaland interpersonal dysregulation, self-harming behaviors, suicidalideation and suicidal behaviors. Participants included 27 adolescentswithin an Adolescent Depression and Suicide Program in New York.Participants were 85% female and 15% male, with an age range of 14–19 years and mean age of 16.7 years. The participants were 59%Hispanic, 33% African American, 3% Caucasian, and 5% identified asother. Participants were selected for DBT based on the followingcriteria: 1) engaged in parasuicidal behavior within the past 16 weeksor reported current suicidal ideation and 2) met the diagnostic criteriafor borderline personality disorder (BPD) or a minimum of 3 BPDfeatures, as measured by the Structured Clinical Interview for DSM-IIIR Personality Disorders, Borderline Personality Module (SCID-II).

Participants received 12 weeks of treatment that included weeklyindividual therapy and a weekly multifamily skills training group.Subjects were evaluated pre- and post-treatment utilizing the LifeProblems Inventory (LPI), a 60 item self-report designed to assess theseverity of the four problem areas of DBT. This measure hasdemonstrated internal consistency and convergent validity. At week12, participants completed the DBT Skills Rating Scale for Adolescents(Miller et al., 2000). The researchers found that the differencesbetween pre- and post-LPI scores demonstrated a statisticallysignificant (p=.001) reduction of symptoms in all four problemareas: confusion about self; emotional instability; interpersonalproblems; impulsivity. Although limited by relying solely on self-report measures and a small sample, this study does provide somesupport for the use of DBT with adolescents (Miller et al., 2000).

Rathus and Miller (2002) conducted a quasi-experimental inves-tigation of an adaptation of DBT with a group of suicidal adolescentswith features of borderline personality. Subjects were 111 consecutiveoutpatient admissions to an Adolescent Depression and SuicideProgram in New York. Eighty-two participants were assigned to thetreatment as usual (TAU) control group and 29 to the DBT treatmentgroup. Adolescents in the DBT group had a mean age of 16.1 years andare 93% female. The participants in the TAU group had a mean age of15.0 years and are 73% female. Both groups were equally comprised of67.6% Hispanic, 17.1% African American, 8.1% Caucasian, 0.9% Asian,and 6.3% identified as other. Twenty-one percent of the total sample

was on psychotropic medication including antidepressants, moodstabilizers, neuroleptics, and anxiolytics. Participants were included inthe study if they met the following criteria: 1) suicide attempt withinthe last 16 weeks as measured by the Clinical Interview or currentsuicidal ideation as measured by the Harkavy–Asnis Suicide Survey(HASS) and the Scale for Suicidal Ideation (SSI), and 2) a diagnosis ofborderline personality disorder or a minimum of three borderlinepersonality features as measured by SCID-II. Participants who metonly one criterion were assigned to the TAU control group.

The DBT condition was comprised of weekly individual and aweeklymultifamily skills training group for 12 consecutiveweeks. TheTAU conditionwas comprised of 12weeks of 2×weekly individual andfamily sessions. During this time, individual therapists utilized asupportive approach with the purpose of resolving current problemswith the participants and their families (Rathus & Miller, 2002).

The following measures were used to examine pre- and post-treatment differences: HASS; Beck Depression Inventory (BDI); LifeProblems Interview (LPI); SSI; Symptom Checklist 90—Revised (SCL-90); Schedule for Affective Disorders and Schizophrenia, child version(K-SADS); SCID-II; number of psychiatric hospitalizations duringtreatment; number of suicide attempts during treatment; andtreatment completion rate. Results indicated that 13% of participantsin the TAU condition were admitted for psychiatric hospitalizationduring treatment, which was significantly higher than the DBT group(0%). Forty percent of participants in the TAU group completed12 weeks of treatment, which was significantly less than DBT groupcompleters (62% Rathus & Miller, 2002).

According to the pre–post-analysis, changes within the DBT groupconsisted of: significantly decreased suicidal ideation (p=.026);significant reduction of overall symptom levels (p=.023); andsignificant reduction in total number of symptoms endorsed byparticipants (p=.006). On individual scale scores, significant decreasesoccurred in the following areas: anxiety (p=.048); depression(p=.004); interpersonal sensitivity (p=.017); obsessive–compulsive(p=.006). Analysis of LPI scores revealed significant pre–post-decreases in all of the four problem areas: confusion about self(p=.007); impulsivity (p=.005); emotion dysregulation (p=.006);interpersonal difficulties (p=.047; Rathus&Miller, 2002). The results ofthis study are limited by the lack of random assignment to treatmentconditions, resulting in a non-equivalent comparison group.

Each of the above described studies provides a useful contributionto our understanding of how DBT could be used with young offendersin secure correctional facilities. These studies are unique in theirweaknesses in design and execution, most notably the lack ofcomparison/control groups and the use of random selection andassignment. In spite of these shortcomings, there are generallypositive outcomes associated with DBT, which provides a solidrationale for using and evaluating this approach with young offendersin secure correctional facilities.

As pointed out earlier in this article, there are a number of similarcharacteristics between the populations in the studies reviewed andyoung offenders in secure correctional facilities. One importantdifference between these populations is the context in which theyare located, one is in the community and the other is in an institutionalsetting. This contextual factor has been found to be an importantconsideration in running groups (Toseland & Rivas, 2009). Althoughincarceration is a much more restrictive environmental context thancommunity-based treatment facilities, the proposed DBT interventionwill continue to be a voluntary program. Typically, an initialorientation phase includes an opportunity for participants to decideif they want to continue with the group.

The actual design of a DBT programwill be unique to the particularparticipants and institution inwhich it is being provided. Regardless ofthe program design, it is critical that we do good quality research thatincludes adequate comparison control groups, random selection andassignment, and reliable and valid measures. It is also important to

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note that other valuable sources of evidence are available, such asqualitative studies, including the documentation of program imple-mentation, and the practice wisdom developed by those working inthis field. Some of this expertise is captured in the programmodifications described in the following section.

4. Program modifications

DBT has been successfully modified to treat both incarcerated maleand female youth suffering from symptoms associated with borderlinepersonalitydisorder, conductdisorder, oppositional defiantdisorder andantisocial personality disorder, such as behavior dysfunction, self-harm,violent aggression, and poor impulse control (Berzins & Trestman,2004). The ColoradoMentalHealth Institute (CMHIP) added anEmotionRegulation Module to address the emotional insensitivity (lack ofempathy) among inmates, characterized as antisocial behavior. Thismodule focuses on increasing emotional attachment and increasingmindfulness of consequences to others. The skill taught was “RandomActs of Kindness”. The researchers also added a Crime Module forgraduates of the Skills Training Group. Graduates would continue on tothe Crime Group, which focused on completing a behavioral analysis oftheir crime(s); role reversal (taking the place of the victim); anddeveloping a relapse prevention plan that includes specific DBT skills.During this time, members present a comprehensive chain of analysis oftheir crime to the group (McCann et al., 2000).

Mondford Psychiatric Unit developed an abbreviated version of thestandard DBT. They also added connections to criminal behaviorthroughout eachmodule (Berzins & Trestman, 2004). The abbreviatedversion would be useful for custody and detention residents whoselength of stay is uncertain or short. The U.S. Medical Center for FederalPrisoners uses the standard DBT format (Linehan, 1993b), but allowsgroup leaders to modify in the moment, in order to create thenecessary linkages between the skills and criminal behaviors. Inmatesare offered a voluntary skills review group, an assertiveness group andteam building skills. To date, there are no documented empiricaloutcomes (Berzins & Trestman, 2004).

Correctional Services of Canada provides DBT in three differentforensic settings for female offenders. They use the standard DBT(Linehan, 1993b), and have added a “Bridging Module”, which focuseson difficulties with breaking the crime cycle, using behavioral chain ofanalysis to help offenders understand the links that have led to theircriminal behavior. This module is similar to the Crime Module addedby the CMHIP (Berzins & Trestman, 2004).

The Churchill Unit (Corrections Canada), located in Saskatchewan,includes an Intensive Healing Program that is designed to addressthe needs of those women who have historically been difficult tomanage in regular facilities due to their mental health problems,characterized in part, by the behaviors they exhibit. This treatmentapproach is highly individualized. The treatment team helps eachmember understand and transform the thoughts and behaviors thatare often the source of their problems, while at the same time rein-forcing the acquisition of new skills and coping strategies (Laishes,2002). Program leaders also discuss the importance of the “ther-apeutic milieu”. Creating this environment requires that all staff betrained in Dialectical Behavior Therapy andmodel positive and appro-priate behavior.

Hummingbird House (Corrections Canada), Edmonton, is a struc-tured living environment for a maximum of eight minimum and/ormedium security womenwith significant mental health and emotionaldysregulation issues. The DBT skills group is held each weekdaymorning, while the remainder of the day and weekends allow thewomen the opportunity to practice their new skills in a relatively safeenvironment. Residents include amixture ofwomenwho are there for ashort time towork on specific problems andwomenwho are there long-term to make significant lifestyle changes (Cunningham, 2004).Corrections Canada has developed a national training curriculum in

DBT, with specialized modules. This training is provided by NationalHeadquarters, Health Services. They have developed a comprehensiveassessmentandevaluationpackage for usewith theprogram, but todatenone of these evaluations have been published (Correctional Service ofCanada, 2002).

Miller, Rathus, Linehan, Wetzler, and Leigh (1997) modifiedLinehan's (1993a) standard DBT in order to meet the needs of suicidaladolescents in an inner-city outpatient clinic. Five major changesincluded: 1) reducing the program treatment time from 1 year to12 weeks; 2) reducing the number of skills taught in order to facilitatelearning the content in the shortened time frame; 3) making thelanguage more developmentally appropriate on the skills handouts;4) including parents in the skills training group, with the purpose ofimproving adolescents' often invalidating and dysfunctional environ-ments by teaching them skills they may use to coach their youth; and5) including parents and other family members in individual therapysessions when major issues arise.

Turner, Barnett, and Korslund (1998) found that when adolescentsare deficient in the skills taught in DBT, their families are usuallydeficient in these skills as well. This creates specific challenges to theadolescent who is trying to practice new skills. These adolescents areoften met with ineffective and invalidating responses, which are mostlikely going to discourage the adolescent from using the skills again.Including the family is not always practical in all settings, althoughteaching DBT skills to all family members tends to create a betterenvironment for the adolescent to participate (Miller & Glinski, 2000).More recently, Miller et al. (2007), published an updated adaptation ofDBT to directly address the needs of suicidal adolescents. The concept ofsuicide is broad and is intended to include many types of suicidalideation, suicide attempts, non-suicidal self-injurious behaviors, emo-tion and behavior dysregulation. They also outline how to involve familymembers inDBTskills trainingwithyouth (Miller et al., 2007). Includingthe incarcerated youth's parents and/or caregivers, would be animportant component of successfully integrating incarcerated youthback into their communities.

5. Conclusion

Evaluation is an integral aspect of group work practice and shouldfocus on both process and outcomes. Specific tools have beendesigned in order to monitor client progress, their attainment ofgoals, and to keep the therapist informed about progress made outsideof the sessions. Macgowan (2006) suggests several resources thatprofessionals can access to monitor and evaluate their work andprogress with the group. Concoran and Fischer (2000) provide a widerange of instruments to measure factors such as behavioral change,self-esteem, and skill development. The instrument package that isselected should specifically relate to the original objectives of thegroup. Group workers can assist in the documentation of effectivenessby more systematically reporting their methods, techniques, andchanges in a way that can be replicated by others (Macgowan, 2006).The provision of increased financial support, by provincial and federalgovernments, to promote high quality implementation and evaluationof these programs is essential.

We have reviewed how the new Youth Criminal Justice Act hasinfluenced youth justice courts across Canada. The vision of this newActis for more therapeutic and clinically driven interventions for troubledyouth, with a focus on rehabilitation and reintegration back into thecommunity. A review of the literature on the mental health needs ofincarcerated youth has demonstrated the profound need for clinicalexpertise and appropriate treatment to be included in the youth justicesystem.While this is a major area for the future development of a rangeof evidence-based practices, some promising approaches are emerging.One of these, Dialectical Behavior Therapy within a group context, is anempirically sound intervention, which addresses the specific needs ofincarcerated youth. DBT has been found to: reduce problematic

293A. Quinn, W. Shera / International Journal of Law and Psychiatry 32 (2009) 288–293

behaviors, such as suicidal acts, aggressive behaviors, and classdisruption; decrease punitive measures used by staff; and reduceexternalizing and internalizing behaviors (Nelson-Gray et al., 2006;Trupin et al., 2002).

TheYouthCriminal JusticeAct (2002, c.1), clearly provides amandateand principles to facilitate the rehabilitation of incarcerated youngoffenders and promote reintegration back into their communities. Someof the factors impeding the implementation of this approach incorrection facilities include a lack of training and inadequate resources(Ulzen & Hamilton, 1998; Trupin et al., 2002). Many juvenile correctionfacilities are operated by child mental health services, but are stillemploying corrections staff with little or no training specific to themental health needs of the youth who reside in these facilities. Actionsneeded to respond to these barriers include: partnership and commu-nication betweenmental health professionals and corrections staff, andtraining for corrections staff regarding the mental health needs ofincarcerated youth. A supportive environment within juvenile correc-tional facilities provides incarcerated youth with opportunities torehabilitate, and will also improve the likelihood of successfulreintegration back into their communities.

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