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Women Offender Programs and Issues

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Implementing Choices at Regional Facilities: Program Proposals for Women Offenders with Special Needs

V. Dialectical Behaviour Therapy and Programming For Women with Emotional Distress Needs

Conceptual Basis for Dialectical Behaviour Therapy
Roots of DBT Approach
Applicability of DBT to Women Offenders With Emotional Distress Needs and Severe Behavioural Difficulties
Dialectical Behaviour Therapy Program Purpose and Objectives
Admission Criteria and Assessment Process
Dialectical Behaviour Therapy (DBT) Core Assumptions
DBT Behavioural Targets for Change
Components of DBT Treatment
Characteristics of the Physical Living Environment
Daily Living Expectations and Skills Application
Work, Learning, and Leisure Programs and Skills
Behaviour Management in the Living Environment
Bridging to Regular Houses
Bridging for Community Integration
Staffing Complement, Qualifications, and Roles
Staffing Training, Support, and Communication
Program Evaluation
Obstacles to Effective Implementation of the Program

 

Dialectical Behaviour Therapy represents one of the most prominent approaches to work with women with borderline personality disorder in North America and has clinical research utilizing controlled trials to support its effectiveness (see Linehan, 1993). It has been applied in forensic settings and appears to offer the most promise of available approaches for work with women whose emotional difficulties and behaviours are very problematic and resistant to change, particularly those with patterns of persistent self-destructive and/or suicidal behaviour. It is proposed that this model be utilized as the basis for a structured treatment program and living environment at Grand Valley Institution in Kitchener Ontario which should (1) serve women already present at Grand Valley who are not able to cope with life in regular houses due to their emotional distress and severe behavioural difficulties (e.g., the enhanced unit at Grand Valley is at present full), and (2) allow some women in maximum-security facilities (i.e., P4W) to be supported and maintained at regional facilities. It is proposed for Grand Valley because a preponderance of women with these difficulties are in Ontario and the priority is to support and manage women with high needs but low risk in the least restrictive environment that is appropriate. This approach could be applied at any regional or maximum-security facility if it proves valuable and the numbers warrant it.

A majority of the women with high emotional distress exhibit a combination of difficulties characterized by self-destructive, para-suicidal, and/or suicidal behaviour, emotional dysregulation, severe interpersonal relationship problems, unstable and low self-image, and cognitive disturbances and distortions. The DBT model is suited to these persons and the distribution of them across facilities is categorized in Table 2. However, there remains a small group of women with emotional distress needs (four persons at present) who are suffering from the acute symptoms of major mental illness. They deserve consideration before proceeding to outline the proposed DBT model for women with behavioural difficulties.

Those suffering from the acute phases of major mental illnesses would not be appropriate for a dialectical behaviour therapy program unless they suited the behavioural criteria once the acute symptoms of their illnesses were under control. Existing resources, assuming the PSR and DBT programs are in place, should serve the needs of this small group of women. At the regional facilities, either use of the enhanced unit with psychological and psychiatric supervision, or referral to a psychiatric hospital, if the difficulties are extreme, would be appropriate. P4W has similar options and a higher level of mental health expertise to cope with women with this constellation of needs at a maximum-security level. Once their acute symptoms are under control, it is important to assess (1) whether they are appropriate for a regular house at a regional facility, (2) whether they are appropriate for either the PSR of DBT programs given their additional difficulties, or (3) whether they require the treatment and structure of a maximum- security facility.

There is no indication that this very small number of women suffering from acute major mental illness will out grow existing resources in the foreseeable future. There is a negative correlation between serious criminal behaviour and major mental illness. Although on-going de-institutionalization of psychiatric hospitals could leave more of these women in the community in jeopardy, these illnesses are typically seen as appropriate and potentially responsive to mental health treatment by mental health professionals. These women are likely to be served in a crisis and less likely to end up in the correctional system. In addition, some of these women who have committed criminal acts are likely to be found not guilty by reason of insanity and placed on a forensic or general psychiatric unit.

Table 2: Women with Emotional Distress Needs-
Acute Major Mental Illness versus Severe Behavioural Difficulties

 

Nova

Springhill

Prison for

Women

Grand Valley

Totals

Acute Major Mental Health Needs at Medium-security      

2

2

Acute Major Mental Health Needs at Maximum-security    

2

 

2

Emotional Distress Needs: Potential for Medium-security  

1

3

4*

8

Emotional Distress Needs at Maximum-security  

1

1

 

2

Totals  

2

6

6

14

* It is very difficult to assess numbers in this category as Grand Valley staff presented 4 additional women with significant emotional distress who for the moment are doing better with special supports in the regular houses. These women might need more support over time through a special living environment, while those who are now unable to cope within the regular houses might improve. Given the rapid changes in emotional stability among women with this constellation of needs, it is difficult to predict an individual's need for a specific placement a number of months into the future.

The one area in which resources for serving women with major mental illnesses are clearly deficient is in the absence of nurses at the regional facilities who have additional psychiatric training and experience. This is inappropriate for serving women with major mental illnesses, even it there are only a few, and is also extremely problematic in the overall work of nurses with the entire population of offenders, regardless of whether they have special needs. There is a constant overlap between health, mental health, and substance abuse issues when women offenders seek health care at regional facilities such that nurses require training in all three areas. For example, nurses are the front-line staff who have to assess and react to self-injury, and consider the subtleties between legitimate physical complaints and drug or attention-seeking requests. The failure to adopt a holistic approach by integrating mental health and health expertise in the nursing positions contravenes key principles in both Creating Choices and the Mental Health Strategy.

Finding: Existing mental health resources, assuming that new resources are put in place for the DBT and PSR programs, are sufficient to serve the small number of women suffering from major mental illnesses with the exception of a serious deficiency in psychiatric nursing at the regional facilities.
Recommendation 15: New nurses hired within the regional facilities should be required to have psychiatric training and/or experience. Existing nurses should be offered an extensive inservice training program to upgrade relevant mental health and substance abuse expertise for working with women offenders. Existing psychiatric nurses at the Prison for Women would be helpful in defining the training program.

 

Conceptual Basis for Dialectical Behaviour Therapy

Linehan (1993) conceptualizes five areas of "dysregulation" in which women with borderline personality characteristics exhibit severe behavioural difficulties:

    ˇ emotional dysregulation: emotional instability, problems with anger, etc.

    ˇ interpersonal dysregulation: intense unstable relationships, efforts to avoid loss, etc.

    ˇ behavioural dysregulation: para-suicide, self-damaging behaviour, impulsivity, etc.

    ˇ cognitive dysregulation: rigid, dichotomous thinking, cognitive disturbances, etc.

    ˇ self dysfunction: chronic emptiness, low and unstable self-image, etc.

She places particular emphasis on addressing self-injurious behaviour and self-damaging acts, behavioural difficulties that are particularly prominent for women offenders with high emotional distress needs. Linehan (1993) views their difficulties from a biosocial perspective which includes emotional vulnerability and dysregulation as biological predispositions combined with an "invalidating environment" where a woman is taught not to properly label or trust her own emotional experiences. Histories of physical and sexual abuse are particularly characteristic of women with these difficulties, and abuse is in many ways the most extreme form of invalidation.

She notes the highly reactive and unstable nature of behaviour exhibited by these women which swings between...

    ˇ emotional vulnerability (extreme sensitivity and inability to cope with emotions) and self-invalidation (tendency to deny emotions, accept others' interpretations of events, simplify problems).

    ˇ active passivity (a helpless approach to problem-solving in which assistance is sought from others) and apparent competence (seeming ability to cope effectively on one's own).

    ˇ unrelenting crises and inhibited grieving (inability to experience emotions, a numbness to events).

 

Roots of DBT Approach

The DBT approach for working with these women is rooted in three philosophical and therapeutic traditions:

(1). Cognitive-Behavioural Approaches: DBT builds on a cognitive-behavioural foundation of work over the past two decades which has proven helpful in treating a wide range of psychological difficulties and mental health problems. These systematic, detailed and step-wise approaches to learning and change have given practitioners a solid framework through which to address difficult problems with clients, particularly in instances where they are motivated to work on the issues.

(2). Humanist Relationship Approaches: Linehan (1993) strongly argues that cognitive-behaviour treatment approaches alone, since they represent a technology of change, are insufficient for these women who have a great fear of change and a need for validation and acceptance. Thus Linehan's work also places emphasis on building trusting relationships with clients and accepting them as individuals. It is essential to find ways to validate their behaviour, while still working toward change. Practitioners must avoid the trap of blaming the victim for her problems which have their roots in her biosocial difficulties.

(3). Dialectical Theory: The final important element is based on the conceptualization of individuals' difficulties as extreme responses to problems, including the tendency to swing from one extreme to another. Drawing on eastern dialectical philosophy, Linehan emphasizes the need to validate divergent and potentially conflicting strategies in approaching a problem, representing a thesis and an antithesis, with the goal being to bring them together in a synthesis which recognizes the truth in both extremes. The individual must learn to balance antithetical approaches and find a middle path. Mindfulness practices represent an important tool in this work.

 

Applicability of DBT to Women Offenders With Emotional Distress Needs and Severe Behavioural Difficulties

A significant number of women with emotional distress needs characterized by severe behavioural difficulties have been unable to function in the group living environment of the regional facilities, or in the community. Their high levels of emotional distress result in "unrelenting crises" which upset others in the environment and create intense and unstable relationships. The tendency to self-injurious behaviour results in a need for supervision, upset in the living environment, and the need for a coherent staff response so as to reduce the likelihood of this behaviour increasing over time. The increased stress results in a cyclic increase in the distress of these women, as well as others, and more problematic and self-injurious behaviour to the point that the living environment becomes very unstable and explosive. In the community, these women have frequently exhibited similar patterns of difficulty and intermittent involvement with the mental health system. However, mental health professionals often become frustrated and feel hopeless in their efforts to help them address their problems, and as the result they may eventually be denied treatment or refused admission to psychiatric inpatient units. Criminal behaviour can provide another means to gain access to professionals who will care for them. In many instances these women may exhibit anti-social traits which result in behaviour that brings them in conflict with the law.

The following strengths are frequently present among these women and must be acknowledged in the program model:

ˇ Ability to Function Well at Specific Times in Specific Environments: Women with these needs can be very competent under specific regimes and circumstances and yet unable to function in other situations despite their "apparent competence." A valuable therapeutic response is to maximize and support their competence so that it can generalize to other circumstances and settings.

ˇ Trusting Relationships Provide Structure and Support: Linehan (1993) emphasizes this as a key strength that should be built on through providing these women with trusted individual relationships as a part of the treatment process. They do the best when they have valued significant others and/or trusted therapists who can effectively handle their crises and demands while supporting them to learn more effective coping strategies.

ˇ Moods and Mental State are Reactive to Internal and Environmental Cues: Individuals are very changeable and strongly influenced by their immediate environment. Support, consistency, and a sense of security facilitate positive behaviour while stress in the environment or difficulty with their relationships results in self-destructive behaviour and the inability to cope.

ˇ Strong Need for Others and Easily Influenced by Peers: These qualities represent strengths assuming they are living in environments where they have pro-social peers. For example, one woman at Nova has made very significant gains in the last year in large part because she was able to separate herself from a partner who appeared to have an extremely negative influence on her behaviour.

ˇ Responsive to Structure if it is not Perceived as Hostile: Structure provides a sense of security which is helpful to them as they learn better coping skills, and also allows for the development of trusting interpersonal relationships. However, if they or their peers view this structure as hostile (e.g., us versus them), they may also act out strongly against the program and staff.

ˇ Normal and Above Normal Cognitive Abilities: Emotional rather than cognitive difficulties typically define this group of needs. Their cognitive abilities can be a resource for growth and change.

ˇ Criminogenic Attitudes are Less Dominant and Open to Modification: These individuals have ended up in the correctional system primarily due to their inability to cope in the community, their deficits in coping and problem-solving skills, their lack of supports and resources, and their emotional disabilities, rather than due to anti-social attitudes and lifestyles. Where they have developed these attitudes, their desire for trusting relationships and susceptibility to influence by peers can be used to help them move to a more pro-social perspective.

ˇ Music, Art and Creative Expression are Valued Methods of Communication: Many of these individuals have a particular affinity and strength for communication through the creative arts, possibly because of the depth and richness of their emotional experiences.

The following limitations and/or skill and resource deficits frequently apply to women with this constellation of needs and must be recognized within the program model:

ˇ Sense of Hopelessness and Powerlessness: Their emotional vulnerability, unrelenting crises, coping difficulties, and past failures in helping relationships result in a sense that things will never improve, providing one important motivation for suicidal behaviour. This hopelessness must be overcome if the person is to grow and learn. It requires skilled staff and a living environment with hopeful, pro-social core values intrinsic to all activities that are modeled and lived by staff.

ˇ Emotionally Reactive, Have Difficulty Recognizing and Regulating Emotions: Their skill deficits in recognizing, labeling, and regulating their emotions result in extreme and impulsive behaviours. Training in these skills is an important element of effective support and treatment.

ˇ Peer Relationships Produce Stress Given Poor Relationship and Problem-Solving Skills: Connection to others is very important yet their weak relationship and problem-solving skills result in interpersonal conflict and a stressful environment in which they are unable to cope. Even medium sized groups (6-8 persons) increase the interpersonal confusion and potential for conflict.

ˇ Reactivity to High Stress Environments: Individuals tend to react quickly and impulsively to stressful situations and settings with difficult behaviours, particularly self-harm. They require a program structure and level of supervision which can reduce stress levels and provide staff support. However, this setting needs to support their independence and ability to effectively apply new coping skills.

ˇ Inadequate Strategies to Cope with Stress: One major source of the behavioural difficulties for these women is their lack of effective coping skills. Self-harm is often one ineffective and dangerous means to cope with stress. Effective skills-teaching in this area is imperative.

ˇ Past Failure and Low Self-Confidence Are Obstacles to Learning and Growth: New tasks and environments are associated with failure and thus learning programs and change must be based on slow, small incremental steps and personal successes.

ˇ Difficulty in Maintaining Long-Term Trusting Relationships: Although women with these needs particularly value trusting relationships, they often are so demanding of these relationships that others eventually reject them. This is a particular issue for practitioners working with these women if they do not have a high degree of support from peers and supervisors.

ˇ Difficulty in Transferring to New Environments without Consistent Relationships: It takes time and individuals may have great difficulty developing the trusting relationships which are essential to helping them to learn the coping skills required for independent functioning and success. They have difficulty making the transition to new environments because they lose their previous relationships and are confronted with their fears given past failures. They are often unable to ask for help from those they do not know or trust. It is important that the trusting relationships support them through the transition to a new environment, be it the regional facility or a community setting, if they are to make a successful adjustment. Strong practitioner values and interpersonal skills are essential to developing trusting relationships.

Dialectical behaviour therapy is directly applicable to working with women with this constellation of needs and behaviour difficulties, particularly given their pattern of self-harm and self-damaging behaviour. However, there may be some differences between these women and those that DBT originally focused on in that these women have had significant conflict with the law as the result of their behavioural difficulties. Linehan's work originated in a mental health context. Yet the hierarchy of behavioural targets for intervention via Linehan's approach is easily modified to give more priority to acting out anti-social behaviours if necessary.

A common dialectical behaviour therapy model to be shared across a multi-disciplinary staff team is also imperative given that these women offenders are extremely demanding and staff require on-going support from each other, a strong team, and administration, to maintain the hopeful core values and the detailed skill development that is required for success. These women frequently divide staff in terms of appropriate treatment responses, ranging from staff who may advocate unconditional support to others advocating a hard-nosed posture of challenge. One of the particular strengths of the dialectical approach is that it recognizes the elements of truth in conflicting staff responses, just as it does in the extremes of the women's behaviour. This allows a framework through which staff can synthesize and interpret their differences. Staff and administration require a clear program structure and framework to fall back upon when they confront the complex interconnections in working with women with these needs and difficulties.

 

Dialectical Behaviour Therapy Program Purpose and Objectives

The purpose of the dialectical behaviour therapy (DBT) program is to support women offenders with emotional distress needs and severe behavioural difficulties to live successfully in regional penitentiary facilities while gaining skills which will enable them to move to and experience satisfaction and success in regular housing at the regional penitentiaries, and/or in the community, reducing the likelihood of recidivism.

Objectives. By participating in the dialectical behaviour therapy (DBT) program, women offenders with emotional distress needs and severe behavioural difficulties will...

    ˇ increase coping, problem-solving, and communication skills in areas of need.

    ˇ function in a regional facility without persistent acting out difficulties.

    ˇ establish and follow through on a community correctional plan for release that will reduce the likelihood of recidivism.

    ˇ demonstrate increased self-esteem.

Finding: The dialectical behaviour therapy approach is the most appropriate and potentially effective programming model for individuals with emotional distress needs and severe behavioural difficulties such that they can reside in the least restrictive environment in a regional facility. Ontario has a disproportionate number of women with this constellation of needs.
Recommendation 16: Implement the dialectical behaviour therapy approach for women offenders with emotional distress needs and severe behavioural difficulties at Grand Valley Institution in Kitchener, Ontario through a specific program model which is appropriate for regional facilities. This model shall reflect the specific strengths and limitations of the women with this constellation of needs and be based on a specific purpose and set of objectives. Given the limited clinical resources presently at Grand Valley and the high demands on those who are present, it is recommended that senior staff from Prison for Women who are familiar with DBT approaches serve as consultants to Grand Valley Institution in setting up the DBT program.

 

Admission Criteria and Assessment Process

The following criteria are required for admission to this program:

1. Voluntary agreement by the individual woman to participate. It must be recognized that women with these needs are extremely changeable in their willingness to participate in any setting or set of activities and therefore their agreement should be developed over time through a trusting relationship in which they are encouraged to take time to understand their choices. The withdrawal of consent should also require time and working through a discussion process with a trusted person.

2. A medium- or minimum-security classification.

3. Recommendation for participation by the multi-disciplinary team at the regional facility responsible for assessment for specialized mental health programs based on:

    a. Significant deficits and needs in problem-solving, interpersonal communication, and coping skills exhibited by severe behavioural difficulties with respect to emotions, interpersonal relationships, observable behaviours, cognitions and/or sense of self. The individual is likely to exhibit self-destructive behaviour.

    b. Emotional needs and dysregulation rather than criminogenic attitudes and lifestyle are the most prominent causes of incarceration and acting-out behaviour.

    c. Requirement for on-going support and supervision by staff in the living environment to solve problems, cope with peer relationships, and/or manage inappropriate behaviours.

    d. Ability to perform basic life skills and household tasks.

    e. Cognitive abilities within the normal range. Not suffering from the acute phase of a major mental illness.

The multi-disciplinary team responsible for assessment for specialized mental health programs shall include the following positions and/or disciplines:

    ˇ psychologist

    ˇ registered nurse with psychiatric training and/or experience

    ˇ coordinator of the dialectical behaviour therapy program

    ˇ warden and/or deputy warden

    ˇ intake or case management officer

    ˇ team leader or director of programs

    ˇ community integration worker for the DBT program

    ˇ coordinator of the psychosocial rehabilitation program (if existing at the facility)

Linehan frequently identifies her approach as appropriate for persons with "borderline personality disorder." This diagnostic category is not strictly utilized in the admission criteria for this program for a number of reasons. First, Linehan (1993) legitimately criticizes standard diagnostic categories as being clinically and ideologically motivated, recommending a revised behavioural approach based on the clusters of difficulties with respect to emotions, interpersonal relationships, observable behaviours, cognitions and sense of self. Second, the "borderline personality" diagnosis has been problematic in recent years in that it has become somewhat of a fad diagnosis for women for whom the mental health system has been unable to provide effective treatment. Finally, the notion of "personality disorder" implies an on-going and permanent set of traits less amenable to treatment and change. This runs counter to an approach with hopeful core values which works toward positive behavioural change. It is preferable to leave the criteria for admission to a multi-disciplinary team with the expertise to assess women offenders and their behavioural difficulties on an individualized basis.

Inevitably, given the characteristics of women offenders, individuals will demonstrate a mixture of emotional distress needs and anti-social attitudes and behaviour, and it may be difficult to discern the more prominent set of needs. The prominent needs may also shift with time and the woman's experiences. It makes sense to begin with women who most clearly exhibit an emotional distress constellation of needs. DBT holds potential to address the needs of women with anti-social attitudes and behaviour if they are willing to establish a therapeutic relationship and commit to a treatment process, however these qualities are less likely with women with stronger anti-social attitudes. Women with anti-social attitudes who strongly resist a therapeutic process could easily sabotage the living environment for women who are appropriately placed. Over time, staff will gain DBT skills and experience and will be better able to judge the flexibility of the approach.

Finding: Matching the needs of individuals with the program goals and structure is essential to success. Inappropriate mixes of women offenders will compromise the effectiveness of the program and represent a major threat to its effectiveness. This is a particular problem given the potential for operational pressure to place inappropriate women in the program simply as a result of their needing higher levels of supervision.
Recommendation 17: A formal multi-disciplinary assessment process with admission criteria based on the consent of the woman offender, a medium or minimum security classification, significant coping, communication and problem-solving skill needs, and the need for staff supervision, is required for entry into the program. There must be an official, approved program description with clear admission criteria which requires staff at the regional facility to make the final decision on admission.

 

Dialectical Behaviour Therapy (DBT) Core Assumptions

Linehan (1993, pp. 106-107) identifies the following assumptions (core values) as essential to the DBT approach:

    1. Clients are doing the best they can.

    2. Clients want to improve.

    3. Clients need to do better, try harder, and be more motivated to change.

    4. Clients have not caused all of their own difficulties but they have to solve them anyway.

    5. Clients' lives are unbearable as they are currently being lived.

    6. Clients must learn new behaviours in all relevant contexts.

    7. Clients can not fail in therapy.

    8. Staff require support to work with these women.

Underlying themes that run through the treatment practices include the need for practitioners to maintain a hopeful approach and avoid blaming the women for their behaviour and difficulties. It is also important to obtain the offender's agreement and commitment to reduce their self-injurious behaviours and work toward a better future, even if they can not foresee success.

 

DBT Behavioural Targets for Change

DBT defines a hierarchy of behavioural targets for change across three stages of treatment such that the individual focuses moves from higher to lower priority targets as their control over their behaviours increases (Linehan, 1993; p. 167).

    ˇ Pretreatment: Orientation to treatment and agreement on goals

    ˇ Stage 1

    1. Decreasing Suicidal Behaviour

    2. Decreasing Therapy Interfering Behaviour

    3. Decreasing Quality of Life Interfering Behaviours4. Increasing Behavioural Skills

        ˇ Mindfulness Skills

        ˇ Interpersonal Effectiveness

        ˇ Emotion Regulation

        ˇ Distress Tolerance

        ˇ Self-Management

    ˇ Stage 2

    5. Decreasing Post-Traumatic Stress

    ˇ Stage 3

    6. Increasing Respect for Self

    7. Achieving Individual Goals

For women offenders, serious behaviour problems and/or anti-social attitudes within the institution (e.g. substance abuse, assault, verbal abuse, etc.) would likely be incorporated into the target of "quality of life interfering behaviours" which are those which "jeopardize any chance... of a life of reasonable quality" (Linehan, 1993; p. 177). These behaviours jeopardize the opportunity for the person for lower security classifications and early release as well as the ability of the person to remain in the community without engaging in criminal activity.

This hierarchy of behavioural targets provides the priority list for what is addressed through the treatment program, although there are distinctions as to which targets receive priority in each component of treatment. A particular strength of this approach is the emphasis on agreed upon behavioural priorities as women with these needs typically have an unending series of crises that make it extremely easy for both staff and offenders to lose focus on treatment priorities.

 

Components of DBT Treatment

1. Individual Counseling and Skills Coaching: This component involves regular individual counseling sessions with a DBT approach and behavioural targets. The priority is to develop a constructive and trusting relationship with an initial focus on reducing self-injurious behaviour and on maintaining the person in treatment. Keeping a person in treatment includes the need to maintain the commitment of the client as well as the counselor. Joint agreements, clear expectations, and the acknowledgment of difficult behaviours exhibited by both the offender and the counselor in relation to each other are discussed. The counselor must validate and help deal with the woman's on-going difficulties while coaching her to apply core skills (see below) to her daily problems. It is proposed that these sessions occur one to two times per week on a regular basis with a trained psychologist. A behavioural background is essential to this work as well as advanced clinical training given that there are high levels of clinical complexity and an on-going risk for suicide in working with these women on a regular, individual basis. It is important to set boundaries on these relationships so that the psychologist does not become responsible for the woman's problems and lose the focus on supporting her to learn new skills and function independently.

2. Structured Group Skills Training: Linehan (1993a) provides a specific group skills curriculum to help women develop core skills necessary to improve their coping and problem-solving abilities so as to meet their behavioural goals, reduce self-destructive behaviour, and improve their levels of functioning. The core skill areas are: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self-management. Skill development in these areas is directly linked to the needs of these women offenders. The group training process should occur twice per week in a structured group format where the focus is on learning skills in an educational context rather than addressing individual problems in a therapeutic context. This group process including up to eight participants should be led by two DBT workers with specialized training as group-skills facilitators. It is important for different staff members to take on the individual counseling and group training roles in order to communicate the distinction in the goals of the two components. The group skills program consists of presentations, practice, and homework relevant to applying the newly learned skills to daily activities and difficulties. One session per week may be devoted to the review of homework while the second session presents new material. Women frequently benefit from repeating the six-month program a second time as a means to solidify their understanding of the skills.

3. Brief Daily Meeting of Women in the Living Setting: The focus of this session should be to facilitate cooperation among the women in the living environment, to openly identify any key conflicts and provide an opportunity to utilize core skills to address them, and to organize household tasks. It should also be a forum through which the women can develop a sense of ownership in and responsibility for their living environment. Depending on the specific group of women, the agenda may need to be structured so as to avoid becoming consumed by individual crises and needs that are more appropriately addressed in individual counseling sessions. These sessions should be facilitated by the DBT workers.

4. Informal Staff Support and Consultation: Linehan (1993) argues that counseling and skills training sessions amount to the "practice field" for women with emotional distress while their daily activities are the "real" thing. Therefore, much as a sports coach would never dream of missing the actual game, so the individual counselor or skills trainer should be available (within reasonable, agreed upon limits) for informal coaching during the daily crises of these women's lives, whether the support person is actually present or consulting by phone. This consultation is critical to helping the woman actually apply the skills in real situations. It is up to the program team to determine who is responsible for particular issues with respect to this coaching process with a woman. It could in some instances be the psychologist conducting the individual counseling while in other instances it might be a DBT worker on a particular shift. It is important for coaching purposes that a DBT worker to be regularly accessible in the living environment.

The DBT program should also be available to women with high emotional distress needs whom may still be able to live in regular houses as long as they have regular support and structure through individual counseling and coaching, group skills training, and informal staff support and consultation. These women should participate in all elements of the program yet they should not take a place in the small group living setting. Overall, it is essential that there be a strong multi-disciplinary team overseeing the program, particularly the interrelationships between the various treatment components.

Finding: There are four interrelated components to conducting a DBT program and their must be overall effective coordination between them by the multi-disciplinary staff team.
Recommendation 18: The individual counseling and coaching, group skills training, daily meetings, and informal staff consultation components must be implemented in a coordinated manner by a multi-disciplinary staff team with specific training in the approach. The DBT program should also be accessible to a limited number of women with emotional distress needs who are able to cope in regular houses with the extra support provided by the program.

 

Characteristics of the Physical Living Environment

Women offenders with these needs require a small group living environment with a regular staff presence in order to minimize stress and allow for the time and space to implement the DBT process. It is proposed that it take the form of a one-story duplex, with each side serving up to four women. It should be built...

    ˇ to mirror the appearance of a house in a community context,

    ˇ to minimize dangerous objects in the environment in the event of acting-out behaviour,

    ˇ to provide regular staff supervision,

    ˇ to provide residents with a continuum of options and locales through which they can take greater or lessor responsibility, depending on the circumstances, for coping with stress and potentially explosive or self-destructive behaviour.

Careful planning involving architects, staff (including front-line staff and the DBT program coordinator), and women offenders, is required to simultaneously maintain a home-like appearance while minimizing dangerous objects and providing security for emergencies. Architects must take practical direction from experienced staff in defining the detailed elements of the house (e.g. types of lights, size of halls, ability to lock various areas, etc.). The program coordinator must be hired as soon as is possible and must be responsible for gathering and facilitating staff and offender input into the design. With respect to the offenders, gathering input will include the coordinator visiting women in maximum-security facilities who are potential candidates for the house, explaining future placement possibilities, and seeking their input into the design. A committee made up of the lead architect, the builder, the warden, and the DBT coordinator must have the final authority on all phases of the design and construction process.

Figure 3 presents a draft proposal for the duplex design. It is identical to the proposal for the PSR duplex with two exceptions. The bedrooms would not require the capacity to be locked down and the staff space would be a separate room. For the DBT duplex, there will not be a staff presence in the building at all times and there must be an ability to secure this area. The design should meet the following criteria:

ˇ A maximum of four clients per side in order to maintain a small group size while providing for adjacent dwellings so that staff can be shared. The two separate sides provide for flexibility in separating incompatible women. Although four persons per side is a small number, it must be recognized that increasing the size of the group is akin to an exponential increase in problems due to all of the new relationships which are introduced, rather than simply adding one additional person.

ˇ A home appearance which is attractive and bright and allows for women to decorate walls, have comfortable furnishings, and include plants. The interior design should facilitate women being able to make choices on the appearance of their home while decisions by one set of women can be altered by a later set (e.g., use of bulletin boards or picture frames in which images can be shifted).

ˇ Multiple quiet and separate spaces for women should be available while maintaining reasonable ability for staff to monitor the setting.

ˇ Facilities for therapeutic quiet (see below) should be available and buffered by staff space. They may be used for a woman at the discretion of the woman offender or as required by staff policies and procedures. An immediate bathroom facility should be available in the therapeutic quiet area so that a woman does not have to return to the main living environment.

ˇ Two small bathrooms for residents.

ˇ High quality sound insulation is required between the two sides of the duplex, between the bedrooms, and insulating the Den/Quiet Spot, so as to reduce the possibility of one person upsetting another. The quiet spot must be an attractive, peaceful, and relaxing room with good natural light.

ˇ A full kitchen should be available for preparing all meals and should open on to the rest of the house, yet be able to be locked when necessary (e.g., double doors might be used to close it off).

ˇ A dining area with a table for meals should be adjacent to the kitchen.

Figure 3: Proposed Floor Plan for the DBT Duplex Figure 3: Proposed Floor Plan for the DBT Duplex

ˇ Each side should have a backyard where women can establish their own sitting area and possibly a garden distinct from the broader compound. This area should not be fenced off.

ˇ Small offices should be provided for the coordinator and the community integration worker (CIW) as well as a shared back office to be used by DBT workers and clinical staff in the duplex so that staff roles are integral to the setting and maximize interaction with the women and staff. There should be an outside door into the staff lounge so that staff can come and go without having to move through the duplex.

ˇ The staff space should be divided by the main wall separating the sides of the duplex with a solid door in between the sections to maintain each setting as a separate living environment, while allowing staff to move quickly back and forth when needed. Staff should be provided with their own bathroom and a small lounge.

ˇ A multi-purpose meeting and program room should be provided for individual interviews and group DBT programming. It also provides a meeting space within the setting, allowing DBT workers to attend meetings while also providing staff supervision if necessary. It should have a movable room divider to separate the two halves.

ˇ The front and back doors should have an attached buzzer system which would warn staff of women leaving and entering the building if it is activated.

Finding: t is important to provide women with emotional distress needs and severe behavioural difficulties with a small group living environment which simultaneously provides a home-like appearance that mirrors community standards, while also insuring safety and security in instances of acting-out behaviour. Staff expertise and input from women offenders is required to balance these design criteria.
Recommendation 19: Plan and construct a duplex house with up to four women living on each side at the regional facility utilizing the proposed structure and criteria as a starting point for planning. he architects must utilize staff expertise, and input from relevant women offenders, to plan the house. The program coordinator must be hired as soon as possible such that the coordinator is able to facilitate staff and woman offender input into the design. A committee made up of the lead architect, the builder, the warden, and the DBT coordinator must have the final authority on all phases of the design and construction process.

 

Daily Living Expectations and Skills Application

The women offenders should be responsible for daily living tasks such as cooking, cleaning, laundry, and budgeting according to the same provisions as the regular houses. Based on the admission criteria of skills competency in these areas, they should not require practical assistance in performing these tasks. However, given their emotional instability and difficulties with relationships, there are likely to be difficulties in the process of working together and completing tasks. These difficulties will be valuable learning opportunities in which staff can coach and facilitate the women offenders to apply the core DBT skills to daily living problems. Relative to the PSR program, staff facilitation will involve assistance with problem-solving and coping strategies rather than hands-on teaching with respect to tasks. Staff should try to address relationship and problem-solving issues in the daily house meetings and allow the women to work out problems themselves to the greatest extent possible, but individual coaching and crisis intervention will likely be required in individual situations. The question of whether staff are present during periods such as meal preparation will vary with the needs and interactions of the women. It may be preferable to stay out of the setting to allow the women to interact on their own in some instances, while in other situations distant supervision through remaining in the staff office, or immediate staff presence and participation, may be appropriate.

Whereas in the PSR program, staff will be encouraged to eat with the women, this will be a daily decision with the DBT program, balancing the desire to maintain the setting as an independent living environment for the women with the value in informal interaction between the women and staff at meals. There should be budgetary provision for one staff member to eat with the women though it would be used less frequently than in the PSR program.

The amount of structure in daily schedules for individual women will vary with the needs of the women, but choice should be maximized within the boundaries of the individual being able to make safe choices for herself and others.

Informal interaction and leisure opportunities between individual women, and between individuals and staff are an important means to develop the trusting relationships and provide opportunities to address problem-solving and coping issues through the application of the core skills. Staff in the setting would be expected to participate in positive informal interactions so as to build relationships without fostering dependency.

Recommendation 20: Staff should utilize informal interactions as a means to foster trusting relationships with the women. Emphasis should be placed on using difficulties resulting from conflicts generated by relationship and/or daily living tasks as opportunities for individuals to apply their coping and problem-solving skills to practical situations. The amount of staff supervision may vary over time in relation to the specific grouping of women. It should balance needs for staff to develop strong relationships with the women, to provide for the safety of everyone, and to foster the independent functioning of the women.

 

Work, Learning, and Leisure Programs and Skills

Emphasis must be on insuring that they are fully integrated into the general population with respect to leisure opportunities as the expectation is that they will eventually move into a regular house or an unsupported community living situation.

Recommendation 21: Excepting their involvement in DBT specific program components, women in the duplex would participate in general programming in relation to their correctional plans like any other woman offender.

 

Behaviour Management in the Living Environment

The effective implementation of a positive DBT process, the investment of the women in the program, and the structure and support of the program and staffing should reduce behavioral difficulties over time. However, these women have long-term behavioural difficulties that will inevitably manifest themselves and they must be addressed effectively in a team context. For women with emotional distress needs, consequences must be immediate, direct, consistent, and based on natural contingencies. Specific approaches must be applied consistently across the staff team so that an individual knows what is expected of her.

There is a potential serious conflict between the emphasis on individuals taking responsibility for their behaviour utilizing DBT skills which is fundamental to these women establishing hope, confidence, and a stake in their own lives, and behavioural programs and consequences that staff utilize to manage difficult behaviours. Acting-out behaviours require consistency and actions which typically remove control from the individual woman and reinforce dependency. If staff interactions with individuals are dominated by behavioral plans then it is difficult to develop genuine and trusting relationships with them. There is a very fine line between the need to take consistent action to manage behaviour and contravening key values of the dialectical behaviour therapy program. Several important elements are required to effectively walk this fine line:

House Expectations and Natural Consequences: Any group of people requires basic expectations in order to live together in a cooperative manner and these expectations need to be clearly defined by the women and staff in the setting at the outset. Failure to live up to these expectations should invoke natural consequences as opposed to "personal" consequences aimed at behavioral control of the individual. For example, if a woman does not fulfill her meal preparation responsibilities and others fill in for her at the last minute, then she may have to take an extra turn in addition to repaying the turn she missed to make up for the inconvenience she caused others. This may need to be a standard policy or else relationship dynamics might result in one woman not wanting to invoke it in one instance in which she is filling in for a friend while she demands that it occur in another instance involving a woman with whom she is irritated. A "personal behaviour" consequence and a "natural" consequence may in some instances be very similar with respect to the actual result but the interpretation and process of developing them is different. In the first instance it is perceived as a staff response to control of an individual's behaviour while in the latter instance it is an expectation set by all of the members of the setting (including staff) and implemented by staff as a part of their role in the setting.

A Balanced Dialectical Approach: The dialectical behaviour therapy model specifically focuses on therapeutic skills which assist practitioners to balance and shift intervention strategies in relation to extreme behaviour exhibited by individuals in order to coax the women to move toward a middle behavioural path. Thus practitioners must balance acceptance and change, unwavering centredness (fixed positions) and compassionate flexibility, and nurturing and benevolent demanding (caring challenges). Staff expertise in applying these dialectical strategies should be particularly valuable in balancing actions to manage the potential conflict between behavioural control and independent functioning.

Multi-Disciplinary Team Meetings and Communication: The development of balanced and consistent approaches to behavioural problems is a very difficult task requiring multiple perspectives and a high level of communication among staff. This is particularly important in that women with high emotional distress needs are often experts at dividing staff and putting them in conflict with each other. Dialectical theory can be valuable in facilitating the staff communication process in that it recognizes the validity of diverse responses and provides a framework for staff to discuss and integrate them. Formal multi-disciplinary team meetings should be held weekly to discuss the progress of the women in the program and to serve as a means to coordinate efforts and work on projects in smaller groupings. They should involve all of the key staff members in the program including the coordinator, psychologist, nurse, community integration worker, as many DBT workers as possible, and as many other staff as is possible who are relevant to the current work. Specific steps must be taken to structure DBT workers' participation, and funds must be budgeted to allow for it. Scheduling options include:

    ˇ holding the meeting across the change of shift.

    ˇ providing compensatory time for staff attending the meeting to be used at a later point.

    ˇ meeting when the women are out of the house so that staff on shift can attend.

Careful Reflection on Staff Values, Interaction Styles, and DBT Values: It is imperative that staff reflect on their own values, DBT assumptions, and their own behaviour and style of interaction as a means to considering specific responses to behavioural issues. Difficulties may be avoided in some instances if staff intervene in a preventative manner, while in other instances it may be important to ignore the situation, or to recognize that the behaviour may only be problematic for the staff rather than for the functioning of the individual or the safety of the setting. These decisions and strategies require team communication, a shared vision of the program, and a foundation in dialectical behaviour therapy and behaviour management. Staff training and team building are important elements to achieving success.

Continuum of Quiet Options: Another key element of behaviour management is working with individual women in order to improve their coping and problem-solving skills with respect to specific stresses. They require a continuum of options through which they can take steps to apply the core skills to their stresses and control their behaviour, and/or ask for help from staff. There must be space to "get away" within the setting when they are under stress. The options should include:

    ˇ enabling their bedroom to be a relaxing spot through their ability to decorate and control its appearance, and by insulating it from sound from the rest of the setting.

    ˇ establishment of an outdoor quiet spot behind each side of the duplex where a woman can relax.

    ˇ provision of a den/quiet spot in the setting as an alternative refuge which is attractively furnished, well lighted, and insulated for sound.

    ˇ provision of therapeutic quiet, a safe room which can be locked and viewed by camera. A woman should be able to ask to enter therapeutic quiet for her own safety, or she may be placed there for her own safety by staff according to specific policies and procedures.

Recommendation 22: Staff must balance the need for hope and personal motivation inherent in dialectical behaviour therapy with the need to cope with offenders' behavioural difficulties. Setting the appropriate balance should involve the use of group defined house expectations, natural contingencies, dialectical concepts, multi-disciplinary team meetings, staff reflection on values and interaction style, and a continuum of quiet options.

Therapeutic Quiet: Therapeutic quiet is an essential element of the duplex design and must be regulated by specific procedures developed for the setting. Women with emotional distress needs may be at risk for self-harm such that they may seek or require short-term, externally locked control, be it for a few minutes or a few hours. However, lengthy isolation is counter-productive as the offender loses focus on why she is isolated and she may become more desperate, hopeless and dependent. Invoking segregation is often inappropriate and perceived as punitive for the circumstances, yet a brief therapeutic quiet option is required to insure the safety of the woman. The psychologist should work with the staff team in consultation with the institutional administration to define specific written procedures for the use of therapeutic quiet. The psychologist should consult with the programming team at the Prison for Women to draw on their expertise and experience with the use of therapeutic quiet with these women with special needs. It will be essential to train and support staff to use therapeutic quiet effectively. In some instances, women who may have been in other institutional settings where therapeutic quiet is very accessible for voluntary locked use, will need to be weaned toward utilizing less intrusive quiet options since therapeutic quiet is not a characteristic of the regular houses or community living settings.

Recommendation 23: Therapeutic quiet must be an essential element of the duplex design through which women can learn to better manage stressful situations, and through which they can be secured when a danger to themselves. Specific written procedures must be developed to monitor its use. Staff must be effectively trained in the use of therapeutic quiet.

 

Bridging to Regular Houses

It is essential to build in a program expectation that a woman will progress to a regular house if and when she has improved her behaviour so as to be able to function more independently, given that an independent level of functioning will be required of her upon release. The expectation of graduation and the positive recognition and sense of accomplishment that goes with it, must be a basic assumption and norm in the setting. Resistance to shifting to a regular house may be a difficult issue with some women as they will value the relationships they have developed in the DBT setting and fear change. The smaller group living situation of the duplex may also be attractive to them relative to the regular houses. An important element in facilitating this move will be insuring that the woman's individual relationships can be maintained with staff and that she can continue to participate in individual DBT counseling and group skills training after she leaves the duplex, if it is appropriate. In addition, the women in the DBT program should have the same daily task expectations as women in the regular houses and should be fully integrated into all programming as is appropriate to their interests and needs so that they develop relationships outside of the DBT program. Although the expectation of moving on is important, it is also likely that some women will be released before such a shift is advisable.

 

Bridging for Community Integration

Linehan (1993) notes the tendency for women with borderline characteristics to function at their best in stable relationships, and yet fall apart without them, as an important attribute of the grouping. One woman interviewed as a part of this research, who was planning to move to a medium-security facility, articulated this directly in noting that her major fear was that she would have to relate to new people, and that she would have great difficulty seeking help from them when she was in trouble. Fear of abandonment is also a key characteristic of these woman (Linehan, 1993) and though they must work through it, a slow change in relationships is required rather than an abrupt shift to a new setting.

The present relatively impersonal and abrupt community release process of handing a person to new community correctional staff and support persons across jurisdictions is a recipe for recidivism for these women precisely because it does not provide for an initial consistency in supportive relationships and then a gradual transfer of these relationships as a part of the transition to community settings. If transitions are not slow and supported by stable relationships, these women are likely to act out due to a fear of abandonment.

The key community integration worker must be based in the institutional program such that the foremost priority is to build a strong relationship with each individual woman to assist her in moving to the community. It is not possible to develop this type of relationship with these women if the worker is based in the community and can only come to the institution periodically. However, it is possible for an institution based worker, who has a strong relationship with the individual offender, to go to her home community and develop effective relationships with community support organizations and workers so as to facilitate the transition.

Community Integration Worker: A specific staff role and process is proposed for the DBT program which has the primary purpose of providing the bridge between the work in the penitentiary with the woman and the community living situation and support system of the woman upon release. The key elements of the "Community Integration Worker" role are:

    ˇ to develop a trusting relationship on an individual basis with the offenders through informal and formal interaction.

    ˇ to participate in the release planning process for the woman developed through the woman's partnership with her DBT worker.

    ˇ to assume primary responsibility for case management functions in consultation with her DBT worker once the individual enters the DBT program.

    ˇ to establish contacts and visit the release community to advocate for, negotiate, coordinate, and create support systems for release, in partnership with the woman based on her release plan.

    ˇ to provide education to persons and organizations who will provide community supports upon release with respect to the needs, goals, and experiences of the individual woman.

    ˇ to accompany the individual upon release and to support her in the community living situation for a transition period as is appropriate. This might involve remaining in the release community for a number of days.

    ˇ to visit the woman in the release community with some regularity while monitoring and continuing to educate and help problem-solve with key staff in the community support system.

The Community Integration Worker is essential to maximizing the likelihood of success in the woman adjusting to the support system upon release so as to reduce the potential for recidivism. This individual requires strong interpersonal skills to develop trusting relationships with the women, a hopeful, persistent and direct approach in order to advocate for resources, and sophistication in coordinating and educating community support workers.

The community integration worker would work with all offenders in the DBT program, some of whom might have participated in the program without ever living in the duplex, while others may have shifted to a regular house prior to release. There should be a limit of 14 women for the caseload of the community integration worker or else the person will be unable to fulfill the on-going support and bridging function for the women moving to the community.

Financial Resources for Community Integration. Each community release process and correctional plan will be unique to the needs of the individual and local resources. Standard community correctional centres with a majority of male residents and a large group living situation are most frequently inappropriate for the release of these women. To facilitate community integration and effective individual release plans, funds must be budgeted within the DBT program to allow for:

    ˇ frequent travel to communities across the region to facilitate release plans.

    ˇ travel on an occasional basis by key community support workers in order to facilitate an understanding of the woman's experience within the penitentiary setting.

    ˇ additional contracted, community workers to support the women through a longer transition process in the community if necessary.

Finding: The present correctional release process is ineffective for women with emotional distress needs and severe behavioural difficulties due to its failure to provide a bridge of consistent relationships for the women from the penitentiary to community settings. These women require consistent relationships to make a successful transition across settings. Behavioural gains made in the DBT program will be lost, including a greater likelihood of recidivism, if there is not consistent and effective support provided in transitions.
Recommendation 24: There must be an alternative release model in which a community integration worker builds a strong relationship with the individual woman in the penitentiary and then uses this relationship as a bridge to establishing her in a community setting. The community integration worker must be based in the institution in order to develop the strong relationship with the individual offender that is required for success. Sufficient funds must be provided to support this community integration process. Consistent relationships with DBT staff must also be maintained if a woman moves from the DBT duplex to a regular house within the penitentiary.

 

Staffing Complement, Qualifications, and Roles

The following staff complement is proposed for the DBT program for a maximum of eight woman offenders living in the setting and six living in the general population. This complement is above any existing staff already present in the penitentiary. The complement should be:

    ˇ 1 full-time program coordinator/psychologist (or DBT specialist)

    ˇ 1 DBT worker on the day and evening shifts, seven days per week with an additional DBT worker on the five weekday shifts (one of these DBT workers should be a psychiatric nurse, and their should be the ability to call in a second DBT worker on a shift if required)

    ˇ 1 community integration worker

    ˇ 1 FTE psychologist, preferably 1/2 time each for 2 persons

    ˇ 1 night security staff (may not be required depending on the individual offenders in the house)

    ˇ 1 day per week for an evaluation consultant (preferably this would be an additional 1 day per week for the psychologist, if either one has the required skills)

    ˇ consulting general physician, psychiatry, chaplaincy, First Nations Elders, and community resource persons as per any offender

This complement is high relative to the existing complement of the regional facilities. However, it must be recognized that the purpose of this program is to transfer and maintain high-needs offenders presently in maximum-security facilities to the regional facilities. This staffing complement is low relative to the resources presently provided within maximum-security facilities. A significant part of the reason that these women have not been in, or have had serious difficulties in regional facilities, is because there have been inadequate staff resources to support them.

Program Coordinator Role and Qualifications. The program coordinator should have the minimum qualifications of...

    ˇ a registered psychologist with expertise in cognitive-behavioural approaches or a graduate- trained mental health practitioner with extensive expertise and experience in DBT,

    ˇ demonstrated skills and interest in working with women with serious emotional distress,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ an interest in and willingness to commit to a dialectical behaviour therapy approach,

    ˇ strong, demonstrated organizational and interpersonal skills to manage and facilitate the multi-disciplinary team.

It is essential that the program coordinator be fully committed to a DBT approach in order to provide appropriate leadership and supervision to the team. There should be a strong preference for a person who also has experience in corrections. Recruitment of a competent individual to fulfill this role, as well as the other psychologist roles, may be difficult because psychologists are generally scarce in corrections in Ontario. An active recruitment process will be required and it should include consultation with persons across North America who are specialists in DBT. A Ph.D. psychologist with correctional and behavioural experience should play a key role in the recruiting and selection process in consultation with the psychologists and management team at Grand Valley Institution. The hiring team must also include a person with particular knowledge of DBT and familiarity with DBT networks. Access to psychology and DBT networks will be an important resource in conducting a successful search. The coordinator must be hired first in order that the person can take the lead role in hiring all other program staff in consultation with the Grand Valley management team, and senior staff at P4W who are familiar with DBT programming with these women.

The coordinator must be responsible for the overall direction of the program and supervision of the staff, particularly with respect to clinical treatment issues. This position should be approximately half time leadership and administration and half time clinical work with the women offenders. The coordinator is expected to take on an individual caseload of four women for individual DBT work. The coordinator should work cooperatively with staff members and the woman offenders to define the program.

DBT Worker Role and Qualifications. The DBT workers should have the minimum qualifications of...

    ˇ a university degree in a social sciences, human services, or health field, and/or equivalent,

    ˇ demonstrated skills and interest in working with women with serious emotional distress,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ demonstrated, effective interpersonal skills,

    ˇ an interest in and willingness to commit to a dialectical behaviour therapy approach.

Preference should be given to workers presently at the facility if other qualifications are equal. One DBT worker should be a nurse with psychiatric training in order that this expertise be an integral part of the staff team.

Individuals should be required to voluntarily apply for these positions and they should be interviewed and selected through a formal hiring process. Additional casual DBT workers will need to be hired to fill in occasional spots in the rotation and to be available to move into the program quickly if full-time DBT workers leave with little notice or take leaves of absence. These casual DBT workers should receive the full DBT training but should be assigned other duties in the facility if possible when they are not required in the program. Overall, the staffing should be allocated so as to minimize regular part-time workers as they increase the size of the staff team and make team consistency and communication more difficult.

The DBT workers should work exclusively in the program on a three-year term basis on day and evening shifts. At the end of that term it would be the decision of the coordinator in consultation with the DBT worker as to whether the person would continue for another term or shift to another role in the facility. This would provide the opportunity for rotation and relief for individuals as work with these woman offenders can be extremely draining over time. It also would give the opportunity to provide a cross-pollination of ideas and concepts between the DBT program and staff working with the general population.

The DBT worker role should involve direct, informal support work and coaching with the women in the setting, primary responsibility for DBT group skills training programming, individual case management with one or two individual women, and monitoring of the setting as required. The DBT workers should report to the program coordinator and must participate in the full DBT training program.

Night Supervision and Staffing. The level of supervision required on the night shift is difficult to specify as it depends on the individual needs of women in the duplex. It is expected that regular checks on rounds may be sufficient at least some of the time, but if individuals are upset, there may be a need to provide direct supervision through the night in the house. The capacity must exist to call in staff for this function.

If night staffing becomes an on-going need, the night shift should not be staffed by DBT workers from the program. The night shift does not provide an opportunity for them to carry out their key roles of building relationships and providing programs to the women. If they are placed on the night shift, it will require more program DBT workers to staff the duplex which in turn results in more staff with whom the women in the house must develop relationships, and these staff would be present during the days less frequently. This does not meet the needs of the women offenders who have difficulty developing relationships with larger numbers of staff and who require a consistent approach from a small staff team. Staff communication and informal consultation become more difficult, particularly with respect to facilitating a weekly meeting with most of the staff present on the day shift. If required on a regular basis, the duplex should be staffed at night by a different set of workers whose function is to provide supervision if a woman is upset or wakes up. These staff must be regular Correctional Service of Canada employees who are able to intervene with the women when required.

Psychologist Role and Qualifications. The psychologist(s) should possess the following qualifications:

    ˇ registration as a psychologist,

    ˇ demonstrated skills and interest in working with women with serious emotional distress,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ an interest in and willingness to commit to a dialectical behaviour therapy approach,

    ˇ demonstrated, effective interpersonal skills.

The psychologists (if there are two) should each be responsible for individual work with five women offenders in addition to participating in and supporting other clinical aspects of the DBT program. It would be preferable to have psychologists who would be working in the facility in other roles such that they would have a full-time presence at the facility.

Community Integration Worker. The community integration worker should possess the following qualifications:

    ˇ a master's in social work and/or equivalent,

    ˇ demonstrated skills and interest in working with women with serious difficulties/disabilities,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ strong, demonstrated, interpersonal and advocacy skills,

    ˇ creative initiative in problem-solving,

    ˇ training and/or experience in developing and coordinating community resources,

    ˇ an interest in and willingness to commit to a dialectical behaviour therapy approach.

The community integration worker would serve fourteen women and the role has been described previously.

Spirituality. Dialectical Behaviour Therapy views recovery as a holistic process with a foundation of positive values. A commitment to spirituality is an important pillar of support that should be strengthened in relation to the women's interests. The chaplain can play a valuable role through developing individual relationships with the women and supporting their spirituality.

Psychiatric Nurse Role. It is important to have a registered nurse with additional psychiatric training and/or experience as a member of the staff team and this could be assured by requiring this expertise of one DBT worker, who would likely work a greater percentage of day shifts. The nurse should take responsibility for coordinating work with the institution's health care nurses and physicians for the women in the program. Physical complaints and drug-seeking behaviour are very common among women with these needs. It is complex and important to separate out legitimate uses of medication from drug seeking and it is difficult for doctors during brief consultations to gain the full picture without the presence of a well-informed nurse. The nurse is responsible for ensuring there is a consistent team approach to medical treatment.

Support for Cultural Diversity. Given the small group context, an individual woman from a First Nations, African-Canadian, or other distinct minority culture is likely to be isolated from her own cultural context in her living situation. It is essential to involve resource persons who can share and support her culture as an integral part of the treatment process. Provision must be made for key support persons to participate in elements of the DBT training process in order that they appreciate the approach, and recognize its strengths and limitations in relation to the woman's cultural background.

Finding: High quality and committed staff are essential to an effective program. They must be committed both direct work with difficult women and to the DBT program model. Although staffing is expensive for a program for these women with special mental health needs, insufficient or poorly trained staff will result in failure. This staffing level is lower than the level of a maximum-security facility where these women would otherwise be maintained.
Recommendation 25: It is essential to select staff with strong interpersonal skills and values for work with these women while allowing for a mix of expertise to provide for diverse perspectives. Programming will be most effective if there is a small, multi-disciplinary staff who can support each other and provide a consistent approach to work with the women. Core staffing should include a program coordinator/psychologist, one DBT worker on day and evening shifts, a second psychologist, a community integration worker, and a program evaluation consultant. Night shift staff, if required, should not be DBT workers in the program and should be limited to a security and supervision function. Core part-time staff positions should be avoided wherever possible as their intermittent presence makes communication and coordination more difficult. It may be difficult to fill the coordinator position and it is recommended that senior staff from the Prison for Women assist with the recruitment and hiring process for key staff, as well as a professional with specific DBT expertise..

 

Staffing Training, Support, and Communication

Staff Training. Dialectical Behaviour Therapy is a precise, logical approach that requires practitioners who have a fundamental grounding in the approach and the skills to apply it. Staff must bring a strong values foundation and set of interpersonal skills to the work and then must receive detailed training to be able to apply the approach with women who have great difficulties and can be extremely demanding of staff. An intensive staff training program for the program coordinator, psychologists, and DBT workers should include:

    ˇ a multi-week DBT training curriculum

    ˇ two weeks devoted to team building, program planning and evaluation, and selected mental health topics and communication skills

The DBT training curriculum should be developed in consultation with Marsha Linehan and DBT specialists based at the University of Washington. It should include practical experience, supervision and feedback as well as participation in formal training sessions. A team curriculum will be required but there may also be the need for distinct packages for different staff roles in order to supplement it:

    ˇ the program coordinator, as well as other key staff, if they have limited experience in DBT, should spend time visiting DBT programs which involve correctional populations. These may be suggested by the DBT specialists at the University of Washington.

    ˇ DBT workers may require a training program on basic cognitive-behavioural techniques if the DBT curriculum assumes that background. DBT workers may also require specific additional training and supervision with respect to teaching the group-skills curriculum.

    ˇ direct supervision and feedback, possibly involving videotaped sessions should be provided to the psychologists conducting the individual sessions with the women offenders.

A number of options may be appropriate for structuring a full training package but it must be in-depth and provide the opportunity for staff to learn through the practical application of the concepts and skills in direct work with female offenders. The Senior Project Manager for Mental Health Services at National Headquarters has already coordinated an introductory DBT workshop for Correctional Service of Canada staff. Her expertise and relationships in working with the DBT trainers at the University of Washington should be utilized in defining and coordinating the training process.

A brief one-two day training program should be provided for potential night security staff, the chaplain, health nurses, contract programmers, relevant Elders and community resource persons, etc. This program should be organized and facilitated by the program coordinator. Staff hired from outside the correctional system would be expected to participate in the standard training programs for work with women in corrections which are required of all staff.

Support and Communication. The program coordinator, staff team, and the institutional administration must recognize the importance of on-going team support and communication to make this program effective as these women are extremely demanding on staff. Staff can quickly lose perspective and patience if they do not have communication and support within the team and from the broader facility. There should be a peer supervision process for those providing individual counseling with the women and it might include an experienced therapist from outside the program in order to provide an independent and fresh perspective. This commitment to team and communication must come from the individual staff but it requires an administrative context in which the legitimate use of staff time for team meetings, informal consultation, and support is recognized and supported. In particular, there must be opportunities on a regular basis for all of the key staff to meet together at one time. This requires funds to bring in or replace DBT workers.

Finding: Effective staff-training and support is essential to the success of the program and the ability to attract and retain quality staff.
Recommendation 26: All core staff must participate in a DBT training program designed in consultation with DBT specialists at the University of Washington. plus two weeks of training on team-building, program planning, evaluation, and selected mental health topics. A brief training program should be provided for auxiliary staff. There must be on-going commitment and resources for staff communication and support, including supervision and peer support for the individual therapists.

 

Program Evaluation

Given that this program represents a major new initiative involving high-needs women, program evaluation must be built into the process from the outset and should include a blending of qualitative and quantitative approaches with process and outcome measures. There are two options for obtaining program evaluation expertise. Preferably, a psychologist would have significant program evaluation expertise (possibly with some continuing education) and could design and carry out the evaluation in consultation with the team and the women. In the developmental phases of a program there are particular benefits to internal evaluation processes in that they encourage the staff team to build a continuous quality improvement ethic into all of their work on a daily basis. However, if there is no one with this particular expertise on the team, then an external contract should be tendered for a professional to design and complete the evaluation work in consultation with the staff team and the women offenders. It is expected that the evaluation would require one day per week for the first two-year period. If the psychologist took on the evaluation role, they would require an additional day per week to fulfill the task.

Finding: Program evaluation is essential to program improvement and accountability.
Recommendation 27: Either the psychologist or an external consultant should design and conduct the program evaluation in consultation with the staff team and the woman offenders.

 

Obstacles to Effective Implementation of the Program

The following issues could become major obstacles to the implementation of an effective program and therefore must be recognized and strategically addressed from the outset:

1. Failure to hire and/or maintain quality staff. Strategies to avoid this problem include:

    ˇ the provision of adequate time and attention to hiring, including an active recruitment process.

    ˇ ensuring there are individuals on the hiring committee who have direct experience working with these women and this type of program.

    ˇ drawing on existing staff who have demonstrated exemplary performance for the DBT workers positions.

    ˇ an administrative and resource priority on providing time for staff training, support and communication.

2. Conflicts with broader penitentiary policies and requirements. Potential strategies to avoid these problems are:

    ˇ a clear vision and written program description recognized throughout the institution which allows for a relatively high level of program autonomy.

    ˇ a formal, documented multi-disciplinary admission process with clear criteria that is honoured at the institutional, regional, and national levels.

    ˇ initial start-up planning time involving the administration and staff team in order to identify and problem-solve with respect to potential policy conflicts.

    ˇ a flexible administrative approach to the program and a willingness to support staff judgment.

    ˇ a staff team with correctional experience that recognizes policy concerns in a penitentiary.

    ˇ on-going efforts by the staff team to educate other staff and women offenders about the purpose, practices, and challenges of the program. Recognition by the staff team of the potential of resentment from other staff with respect to new resources for a new program when existing resources are limited.

    ˇ program participation in regular communication forums at all levels in the institution.

3. Inability of the staff team and the local administration to control planning decisions. Potential strategies to avoid this problem are:

    ˇ ensuring that staff are hired and in place in advance of program-start-up. This includes hiring key staff as soon as possible, even if they perform some other functions initially while the planning and implementation process gathers momentum. Pressure must be resisted to proceed too quickly given the priority on transferring individual women out of maximum-security environments.

    ˇ ensuring that there are effective mechanisms for staff control and input into the building design at a detailed level so that the structure reflects programming and security needs. Problems in the physical structure can be a permanent drain on the program and staff.

    ˇ ensuring that the program has flexibility with respect to policies and procedures wherever appropriate.

4. Ineffective team communication processes and insufficient support for staff. Potential strategies to avoid this problem are:

    ˇ ensuring that the program coordinator is a skilled group facilitator and that there is attention to team building initially and on a continued basis.

    ˇ providing sufficient time for team meetings and informal consultation. Insure that DBT workers are available to attend team meetings.

    ˇ providing effective staff training and expect a commitment of all staff to work within a DBT philosophy and to utilize it as a framework to discuss differing staff perspectives with respect to the individual women.

    ˇ supporting a program atmosphere which allows staff to take risks and make mistakes in a team context.

    Recommendation 28: Specific strategies must be adopted from the outset to overcome these obstacles to the effective implementation of the PSR program with women offenders..