'Messy Women': A case study of the adaptation of Dialectical Behaviour Therapy for a group of difficult to engage offenders

A Dialectical Behaviour Therapy program was created for female offenders supervised by Wollongong Community Offender Services (COS). The cohort, nicknamed ‘Messy Women’ by case managers, had been difficult to engage in established offender programs or interventions, creating high levels of distress and frustration. Consultations with specialist psychologists indicated that these female offenders would likely meet the diagnostic criteria for Borderline Personality Disorder (BPD) and as such they could respond well to DBT. Following these consultations, the COS District Office, in partnership with the University of Wollongong Northfields Clinic, developed a modified DBT program and trialled its use for this particular client group over a ten month period from October 2010. This case study outlines (1) why a new approach was required with this client group, (2) the reasons for using DBT and the modifications that were made to the basic DBT approach for this client group, (3) the issues and challenges which arose during the delivery of the program in a community correctional setting and (4) the results of an initial evaluation of the program’s effectiveness. The results suggest that the DBT approach was well-received by both the female offenders and the COS staff and that it has had success in reducing some of the difficult behaviours characteristic of the client group. The program also appears effective in the management of these ‘messy women’ within a community corrections context in Australia. Australasian Journal of Correctional Staff Development (AJCSD) ‘Messy Women’: A case study of the adaptation of Dialectical Behaviour Therapy for a group of difficult to engage offenders 2 PART I: CONTEXTS Who are the ‘messy women’ and can we devise a better way to work with them? In 2007 Corrective Services NSW (CSNSW) staff at the Community Offender Services (COS) District Office in Wollongong, New South Wales, undertook a needs analysis in order to determine if there was a better way to address the needs of their difficultto-work-with female offenders. The impetus for this analysis was a challenge made by Bob Tsapsilis—then program manager for St John of God hospital in Burwood, NSW— who asked District Office staff who they thought were the most difficult and challenging clients to supervise in the community. Probation and Parole Officers (PPO) unanimously identified a group of high needs clients who they grouped under the sobriquet ‘messy women’. These clients were very difficult to supervise, were hard to place or retain in standard offender programs and often did not meet the criteria for on-referral to community based mental health services. Experienced PPOs expressed intense frustration at the difficulties of working with this group of women. They asserted that, while they had exerted a lot of effort to assist the women address their critical issues, they later felt manipulated or ineffectual. PPOs identified the following characteristics as common to these ‘messy women’:  have been in co-dependent, abusive relationships  had their children removed from their care by Department of Community Services’ intervention  had their first pregnancy (primagravida) at an early age  have been repeat victims or perpetrators of domestic abuse  were sexually abused when they were young  are manipulative, though often in genuine crisis  have problems with finances  have difficulties with getting transport for legal appointments  lack positive social support  had interrupted education  lack education and employment skills  have negative associates and links with criminal networks  have a pattern of unsatisfactory relationships  have low self-esteem  have mental health disorders especially anxiety and depression  have poor organisational skills  do not follow-through even when appearing motivated  have been dependent on Centre link benefits  have a history of conflict with government agencies  poor attendance in programs  have high rates of re-offence  have had repeated unsuccessful interventions  display aggression, uncontrolled weeping, attention seeking behaviour  are demanding of staff time. When presented with the above list, Tsapsilis suggested the characteristics of the ‘messy women’ fit a diagnosis of Borderline Personality Disorder (BPD) and advised that the Dialectic Behaviour Treatment (DBT) program may assist staff to manage this complex group. The American Psychiatric Association’s (1994, p.710) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes people with Borderline Personality Disorder as having a pervasive pattern of unstable and intense interpersonal relationships, poor self-image, affective instability and marked impulsivity beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following characteristics: 1. frantic efforts to avoid real or imagined abandonment. Note: Does not include suicidal or self-mutilating behaviour covered in Criterion 5. 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. identity disturbance: markedly and persistently unstable self-image or sense of self Australasian Journal of Correctional Staff Development (AJCSD) ‘Messy Women’: A case study of the adaptation of Dialectical Behaviour Therapy for a group of difficult to engage offenders 3 4. impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). Note: Does not include suicidal or selfmutilating behaviour covered in Criterion 5. 5. recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour 6. affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days) 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociative symptoms. Overview of Dialectical Behaviour Therapy Dialectical behaviour therapy was originally developed by Marsha Linehan to treat people with borderline personality disorder. DBT combines standard cognitivebehavioural techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice (Linehan 1993). Linehan’s (1993) DBT program is structured in such a way that participants are taught to develop skills across four main themes:  Core Mindfulness Skills – These skills are the ‘vehicles for balancing the “emotion mind” and “reasonable mind” to achieve a “wise mind”. [. ] The “mindfulness what skills” include learning to observe, to describe and to participate. [. ] The “mindfulness how skills” have to do with how one attends, describes and participates’ (Linehan 1993, p.63-64).  Interpersonal Effectiveness Skills – ‘This [module’s] goal is to teach clients how to apply specific interpersonal problemsolving, social and assertiveness skills to modify aversive environments and to obtain their goals in interpersonal encounters’ (Linehan 1993, p.70).  Emotion Regulation Skills – The aim of this module is ‘to understand one’s emotions, reduce emotional vulnerability and decrease emotional suffering’ (Linehan 1993, p.86).  Distress Tolerance Skills – This module is concerned with developing ‘skills for tolerating and surviving crises [and] skills for accepting life as it is in the moment’ (Linehan 1993, p.97). DBT emphasises four areas “that have not received as much attention in traditional cognitive-behavioural applications:  the emphasis on acceptance and validation of behaviour as it is in the moment  the emphasis on treating therapyinterfering behaviours of both client and therapist  the emphasis on therapeutic relationships as essential to the treatment  the emphasis on dialectic processes” (Linehan 1993, p.5). Chris Allan, Director of Northfields Clinic, University of Wollongong, agreed with Tsapsilis that DBT may be an appropriate and potentially successful program approach to working with this group of offenders. By early 2008, COS district office management had decided to investigate establishing an office based DBT program. The University of Wollongong offered to support the initiative by providing a clinical psychologist to co-facilitate the program, clinical supervision and basic evaluation tools and a partnership was established. Australasian Journal of Correctional Staff Development (AJCSD) ‘Messy Women’: A case study of the adaptation of Dialectical Behaviour Therapy for a group of difficult to engage offenders 4 Would DBT work for our clients? Anticipated Challenges In 2008-09 several meetings were held to examine the potential challenges involved in running a DBT program in a community corrections setting. A cursory review of the literature revealed that there were no studies that demonstrated whether the use of a DBT approach would work for this particular client group: that is, community supervised female clients who may have significant BPD traits complicated by comorbid issues likely to include anti-social personality traits, anxiety disorder and substance abuse. Several potential challenges to the successful implementation of DBT in a community corrections setting were identified in relation to: 1. Best Practice. DBT group therapy practitioners have developed best practice frameworks that recognise the need for intensive long term support of participants and facilitators, while also establishing firm boundaries around attendance. The elements of this approach include: (a) firm entry/attendance rules; (b) group matching; (c) clinical assessment prior to commencement; (d) concurrent oneto-one therapy; (e) clinical