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TRAUMA, VIOLENCE, & ABUSE

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Contextualist Perspectives in the Treatment ª The Author(s) 2020
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of Antisocial Behaviors and Offending: A DOI: 10.1177/1524838020939509
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Comparative Review of FAP, ACT, DBT,
and MDT

J. Carmelo Visdómine-Lozano1

Abstract
This article presents a comparative review of the application of four contextualist therapies in the treatment of antisocial behavior
and offending. The therapies reviewed are functional analytic psychotherapy (FAP), acceptance and commitment therapy (ACT),
dialectical behavior therapy (DBT), and mode deactivation therapy (MDT). A descriptive and comparative review was conducted
through a search carried out in both general and specific databases related to each therapy. We included a total of 44 studies
treating any type of antisocial behavior or offending. Results show that these interventions have been used to treat challenging
behavioral patterns, inmates’ institutional behaviors, exhibitionism, at-risk adolescents’ aggressive conducts, and offending
behaviors performed by juveniles who committed robbery and/or serious sexual offenses. The main conclusions are that the four
therapies show very positive outcomes: Although FAP and ACT have been used more sparsely, DBT and MDT have been
employed in a larger number of interventions and using more controlled comparative designs. The therapeutic components that
seem to be relevant to understanding in a transversal way how changes in behavior are achieved are acceptance/validation of
clients’ histories of neglect and abuse and clients’ commitment to behaving toward their valued directions in life.

Keywords
ACT, antisocial behavior, contextualist therapies, DBT, experiential avoidance, FAP, MDT, offending

The treatment of offending and antisocial behaviors is still a The systematic review by Gibbon et al. concluded that further
challenging question, especially in youngsters and adult sub- research was needed since the studies reviewed centered on
jects. It has been documented that serving a period of time in a substance misuse but not on specific antisocial behaviors.
secure facility does not necessarily result in a change of crim- Although there are slight nuances between the definitions of
inal behavior if there has been no intervention directed specif- “antisocial behavior,” “antisocial personality disorder,” and
ically toward relevant personality factors (Chen & Shapiro, “offending” or “criminal behavior,” there is an obvious com-
2007). mon background, which is the damaging of others’ rights, or, in
There are many ways of treating offenders’ behavior functional terms, the damaging of others’ reinforcers
(Underwood et al., 2006; Yates, 2013; Young, Greer, & (Visdómine, 2014). It can be said that antisocial behavior is
Church, 2017). Kazdin (2002) registered around 500 treatment often categorized as “criminal” or “offending” when the range
programs only for children and adolescents, although not all the of its damage is serious and exceeds the limits specified by law
programs fulfilled enough evidence-based criteria (Young (Hayes & Maley, 1977).
et al., 2017). In adults, traditionally, cognitive behavioral pro- As a general alternative to traditional clinical interventions,
grams have been said to be the most effective forms of treat- some authors have highlighted the development of various
ment for offending behaviors (Redondo et al., 1999); however, reformulated cognitive behavioral therapies, labeled “third-
studies performed in different countries have found that the generation behavior therapies” (Cautilli et al., 2005; Pérez-
effectiveness of cognitive behavioral interventions is mainly
a function of the quality of the intervention provided (Land-
1
enberger & Lipsey, 2005). In addition, a meta-analysis carried Instituciones Penitenciarias, Ministerio del Interior, Madrid, Spain
out by Gibbon et al. (2010) determined that contingency man-
Corresponding Author:
agement was the most effective intervention for people diag- J. Carmelo Visdómine-Lozano, Alcalá st., 40, Secretarı́a General de Institu-
nosed with “antisocial personality disorder” when these ciones Penitenciarias, Madrid 28014, Spain.
persons were cocaine addicts. But many issues remain open. Emails: [email protected]; [email protected]
2 TRAUMA, VIOLENCE, & ABUSE XX(X)

Álvarez, 2012), which are achieving promising results with treatment of multiaxial clinical disorders and are beginning to
regard to multiple behavioral disorders and could improve the be applied to inmates, as well as in treating several other pro-
quality of both traditional contingency management and cog- blematic behavioral patterns that can be understood as precur-
nitive behavioral therapies when they are applied to adults. sors of offending, inasmuch as many antisocial behaviors and
These third-generation behavior therapies can also be categor- offending can be considered parts of the same continuum (Reid
ized as contextualist because they derive from the principles of et al., 2002).
contextualism (Hayes et al., 2004).
In general, contextualism is defined as a “world hypothesis”
that considers any event as an “act in context,” that is, an Review of Contextualist Therapies Applied to
occurrence that is subject to the influence of contextual vari- Antisocial Behaviors and Offending
ables rather than to isolated mechanistic relations, reductionist Instead of accomplishing a meta-analysis, this article presents a
biological processes, or idealistic manifestations of intrap- qualitative, descriptive, and comparative review of the four
sychic constructs (Hayes, 1993). Consequently, the specific therapies mentioned above. The search was carried out in two
application of the principles of contextualism to clinical psy- general databases (PsycNet and ScienceDirect) and in the spe-
chology and behavior modification would consist of consider- cific databases offered by each therapy to detect the relevant
ing abnormal behavior as a product of learning and contextual studies with better accuracy than in the general databases as
variables as well. What these therapies add to both traditional well as to analyze in greater detail the major part of the studies
behavior modification and cognitive behavioral therapies is the examined. The only inclusion criterion was that the studies
key role assigned to verbal behavior in the development of comprised clinical applications, regardless of the methodolo-
cognition and personality and, therefore, the importance gical design followed by such studies. Firstly, a brief descrip-
assigned to the special kinds of contingencies and learning tion is given of the therapeutic components of each therapy.
interactions that give rise to human rule-following and complex Secondly, specific applications are presented. Thirdly, the main
verbal repertoires that are involved in both normal and abnor- limitations of each therapy are discussed. Finally, a discussion
mal behaviors (Cautilli et al., 2005; Hayes, 1989; Pérez- about the shared behavioral and cognitive processes responsi-
Álvarez, 2012; Zettle et al., 2016). Such contingencies and ble for the outcomes of the therapies is provided (see Table 1).
learning interactions must be understood as those interactions
with other persons that a child develops throughout their life
and that give rise to the behavioral functions governing such a Functional Analytic Psychotherapy (FAP)
child’s behavior through rules. For example, if a child’s parents
punish the major part of the child’s behavior, or neglect their
FAP Principles and Antisocial behavior
necessities and care, the parents will probably acquire general- The basic tenet of FAP is that behavioral changes in adults
ized aversive functions, and the child will probably develop should begin in a clinical setting, similar to the changes
thoughts about their parents with aversive functions, and they achieved by applied behavior analysis (ABA) in children’s
will respond to their parents by avoiding them in several ways. behaviors, in order to attain natural and long-lasting changes
Likewise, stimuli related to their parents will probably acquire (Kohlenberg & Tsai, 1991). The main difference between FAP
equivalent aversive functions, expanding the child’s avoidance and ABA is that FAP deals with problems of the self, that is,
pattern of responding. Conversely, if the child’s parents bal- with personality disorders through the management of the ver-
ance their interactions, and they only correct the child’s mis- bal behavior involved in the personality structure. FAP under-
behaviors in an appropriate fashion and, in addition, reinforce stands that problem behaviors that form personality disorders
alternative and appropriate behaviors, then it is quite likely that are learned behaviors that have been generalized from a wide
the parents will acquire both aversive and reinforcing functions range of life interactions. Therefore, they are behaviors main-
in a contextualized way, and the appraisals about their parents tained by consequences and under the control of stimuli. Some
shown by the child will be different. Thus, the understanding of fundamental stimuli that control such generalized behaviors are
the role and involvement of rules and verbal relations in these the rules that an individual has learned to follow. The formation
interactions is crucial. In this review, these special kinds of of the self as a subtle functional unit—or, in other words, as an
contingencies will be highlighted as outstanding elements that abstraction or verbal context in which all behavioral events are
could help to explain the behavior change and prevention of related (particularly, through rules)—is crucial to understand-
recidivism produced by these therapies. ing abnormal personalities. The therapist would typically be a
The therapies reviewed in this study are functional analytic relevant social agent commissioned to directly modify such
psychotherapy (FAP), acceptance and commitment therapy problematic patterns through the process of reshaping the sub-
(ACT), dialectical behavior therapy (DBT), and mode deacti- jects’ rule-following behavior.
vation therapy (MDT). Since the four therapies reviewed in this The key concept in FAP is that of “clinically relevant
article were not included in the reviews mentioned earlier, it behaviors” (CRBs). CRBs are responses that are equivalent
seems advisable to explore the initial results of such interven- to those produced in natural settings. Consequently, these beha-
tions as regards their modification of antisocial behaviors and viors can be adaptive or problematic. There are three classes of
offending. The majority of them have been employed in the CRBs. CRB1s are problem behaviors that occur during clinical
Visdómine-Lozano 3

Table 1. Contextualist Therapies and Their Therapeutic feelings related to problematic coping strategies, insofar as
Characteristics. these private events work simultaneously as discriminative and
Therapy Therapeutic Principles
aversive conditioned stimuli; an example could be to provoke a
sexual urge in a client through asking for him to think on
FAP 1. Functional analysis of clinically relevant behaviors (CRBs), children), (3) identifying the reinforcing or aversive effects
for example, aggressive and defiant responses, lies, of the therapist’s behavior relative to CRBs of the individuals
excitation, reject, arguments (e.g., to pick up a pencil from the client’s hand and realize that
2. Discrimination and differential reinforcement of CRB2s:
this fact produces an anger reaction in him), (4) behaving in
respectful responses, self-controlled behaviors,
confession of lies, reports of excitement without ways that reinforce naturally the individual’s behavior (e.g., to
immediate satisfaction, and so on spend additional time on session talking about common hob-
3. Provide adaptive behavioral interpretations (CRB3s) bies when the client shows respectful with the therapist, and tell
ACT 1. Functional analysis of the experiential avoidance related to the client that in those conditions is quite funny to stay with
each type of antisocial pattern: resentment, feelings of him), and (5) providing interpretations of variables that affect
injustice, rage, hate, self-blame, fear, dependence, the CRBs of the clients, in an attempt to install a verbally
rejection, abandonment, and so on
regulated generalized adaptive behavior (e.g., asking questions
2. Create creative hopelessness about the lack of success
derived from the attempts of control of aversive like “Do you realize that when you remember your childhood,
emotions by harming others’ reinforcers as it has just happened at this moment, your anger arises?”
3. Language defusion/self-perspective “What do you think you can do to be a better person when all
4. Values commitment that rage appears? What do you think you can do right now with
DBT 1. Validation of dialectic and extreme feelings of dependence your anger and sexual arousal?”). Newring and Wheeler (2012)
or rejection, self-harm, insults, menaces, and so on proposed the specific application of FAP to sexual offenses
2. Mindfulness of deregulated and extreme feelings and
through an analysis of the risk–needs dynamics followed by
emotions
3. Skills training to respond in a socially adapted way the youngsters to detect general antisocial dynamics that led to
4. Clinical support the expression of anger, aggression, impulsivity, and other
MDT 1. Validation and radical acceptance of experiences and attempts to regulate their emotional state by confronting others.
feelings of humiliation, aggression, reject, abuse, and so on In addition, these authors proposed analyzing specific CRB1s
2. Clarification and case conceptualization of the emotion- in eroto-pathic dynamics in order to identify when excessive
avoidance (through violence) cycle erotic behaviors interfered with prosocial goals as an avoidance
3. Redirection toward personal values
strategy to overcome uncomfortable emotional states.
Note. FAP ¼ functional analytic psychotherapy; ACT ¼ acceptance and com-
mitment therapy; DBT ¼ dialectical behavior therapy; MDT ¼ mode deactiva- FAP applications to antisocial behaviors. A first general search was
tion therapy. carried out in PsycNet and ScienceDirect databases. For this
search, the terms “FAP” and “Functional Analytic Psy-
chotherapy” were introduced in combination with “antisocial”
sessions and indicate that the therapist is functionally equiva- and “offending” in each database form, along with the date
lent to other social stimuli because they are able to prompt such criterion “all years” (search date: April 5, 2020). These terms
problematic behaviors. Examples of antisocial CRB1s would were introduced in the fields corresponding to “Title” and “key
be lying to the therapist about the reasons for the consultation, words” when the search was performed in the PsycNet data-
threatening the therapist if they do not provide accurate infor- base, and in the field “Title, abstract, and keywords” when the
mation, simulating a change of attitude, insulting or humiliat- search was performed in the ScienceDirect database. From this
ing the therapist, or even looking lasciviously at the therapist, search, only three results concerning the therapy were obtained
and so on. On the other hand, CRB2s are improvements in the in the PsycNet database; two of these results were repeated, and
individuals’ behavior that occur during the session. Examples the third one was related to MDT. ScienceDirect database gave
of CRB2s in antisocial behaviors could include confessing to two additional results with the abbreviation FAP, which were
lying to the therapist about the acts committed or informing the not related to the therapy, but neurological and genetic terms.
therapist of sexual excitement and urges to attack them. To retrieve more specific information concerning the applica-
Finally, CRB3s are the clients’ interpretations of the CRB1s tion of FAP, we referred to the bibliographic database in the
and CRB2s, that is, the rules maintaining their problematic https://functionalanalyticpsychotherapy.com/references/web
behaviors and the rules that control adaptive behaviors. site. We checked the papers included in this database on an
FAP comprises five basic therapeutic tools or techniques: individual basis to find the studies focusing on the topic. We
(1) watching for CRBs and identifying them (e.g., realizing explored the studies mentioned in the database as well as the
when a client’s glance is a menace, or when a client is feeling bibliographic references included in general reviews such as
anger and is able to make room to such emotions and continue those by Mangabeira et al. (2012), and Ferro and Valero
with the session), (2) evoking CRBs by presenting conditioned (2015); (see Table 2).
and discriminative stimuli (mindfulness is often employed as a In a preliminary application of FAP to antisocial patterns
means for retrieving the subjects’ private memories and consisting of aggressive-defiant behaviors, therapists worked
4 TRAUMA, VIOLENCE, & ABUSE XX(X)

Table 2. Contextualist Therapies and Their Applications to Antisocial Behaviors and Offending.

Therapy Studies Participants Clinical Design Antisocial Behaviors/Offending

FAP Gosch & Vandenberghe (2004) 1 Child and his parents Case report Aggressive and defiant behaviors
Romero et al. (2018) 5 Mothers (1 child each) Case series Mothers with aggressive and defiant
children
Páez & Luciano (2012) 1 Female adolescent Case report Rigid and challenging patterns
ACT Paul et al. (1999) 1 Young male Case report Exhibitionism
Luciano et al. (2011) 15 Adolescents Case series Impulsive/aggressive behaviors
Gómez et al. (2014) 5 Adolescents Case series Robbery, vandalism, street gangs, drugs
abuse
Livheim et al. (2020) 160 Youths ACT þ TAU/TAU Antisocial and disruptive behaviors,
anger, anxiety
DBT McCann et al. (1996) 35 Adult males DBT/Control group Violent offenses
Trupin et al. (2002) 22 Young females DBT/TAU Diverse (unspecified) offenses;
aggressions, disruptive behaviors, and
so on
Eccleston & Sorbello (2002) Males (unspecified) Case series Diverse (unspecified) offenses; self-
harm, suicide attempts, and so on
Bradley & Follingstad (2003) 24 Adult females DBT/Control group Diverse (unspecified) offenses
Evershed et al. (2003) 8 Adult males DBT/TAU Violent behaviors
Nee & Farman (2005) 16 Adult females DBT/Control group Arson, murder, attempted murder,
manslaughter, and other violent
offenses
Shelton et al. (2009) 63 Youths and adults Cohorts study Diverse (unspecified) offenses
Sakdalan et al. (2010) 6 Adult males Case series Violent crimes and challenging
behaviors
Moore et al. (2016) 27 Adult males Cohorts study Diverse (unspecified) offenses
MDT Apsche & Ward (2002) 14 Adolescents MDT/TAU Sexual offenses, and disruptive and
aberrant behaviors
Apsche & Ward Bailey (2004) 1 Male adolescent Case study Sexual offenses, aggressions, and
oppositional behaviors
Apsche & Siv (2005) 1 Male adolescent Case study Sexual assaults and suicide attempts
Apsche et al. (2005) 1 Male adolescent Case study Physical and sexual aggressions, school
problems, and animal torturing
Bass & Apsche’s (2014) review 24 Studies (734 adolescents) MDT/TAU Violent and sexual offenses
Note. FAP ¼ functional analytic psychotherapy; ACT ¼ acceptance and commitment therapy; DBT ¼ dialectical behavior therapy; MDT ¼ mode deactivation
therapy; TAU ¼ treatment as usual.

toward directly shaping the behavior of a child and establishing accessible, which it is not always feasible. Therefore, this study
a regime for contingency management training with the child’s is an example of the diversity of therapeutic means and popula-
parents (Gosch & Vandenberghe, 2004). Such contingency tions that can be a target for FAP, and this is the relevance of
management training fundamentally consisted of teaching the the report presented by Romero et al. (2018).
parents to reinforce differentially their child’s appropriate In addition, FAP was applied in another single-case study of
behaviors (e.g., to praise the child for making requests in a a 16-year-old adolescent that presented a very rigid and chal-
polite fashion and correct physical aggressions and other inap- lenging pattern of behavior (Páez & Luciano, 2012). The indi-
propriate conducts). The child insulted, screamed, kicked, bit, vidual presented a severe lack of concentration, ruminative
threw stones, and broke glasses as inappropriate behaviors or thoughts, impulsive and aggressive behaviors, attempts to
CRB1s, and the shaping of CRB2s through differential reinfor- manipulate others’ behavior, and isolation. At first, she refused
cement was more similar to traditional ABA, while the thera- to agree to therapy, which required a different initial approach
peutic work with the parents was more similar to FAP. from the therapist who treated such behavior as CRB1 from the
Similarly, Romero et al. (2018) successfully applied FAP in commencement of the treatment. A functional analysis
an analog case of mothers with children presenting disruptive revealed that the client had been overprotected throughout ear-
behaviors. The FAP intervention was equivalent to that lier stages of her infancy and had had access to an excessive
employed by Gosch and Vandenberghe (2004). Albeit this availability of positive reinforcement as well as to excessive
study presents an indirect way of intervening in children’s negative reinforcement through the avoidance of small frustra-
antisocial behaviors through their mothers, it shows how FAP tions, conflicts, and barriers. Subsequently, family attention
techniques serve for the modification of the variables underly- was directed toward other family members, which resulted in
ing such disruptive behaviors when such variables are the withdrawal of previous social reinforcers and triggered an
Visdómine-Lozano 5

aggressive reaction from the client. Some basic CRB1s on ACT

which the therapists focused were refusal to be in therapy,
ACT Principles and Antisocial Behavior
suspicions, and aggressive responses when the therapist
questioned or criticized the client’s behavior, arguments, The fundamental psychopathological concept of ACT is
intolerance to waiting, and difficulties in differentiating the “experiential avoidance,” which consists of a generalized
client’s own feelings from the feelings of others. The thera- inflexible rule-governed behavior that prevents a person from
pists provided contingencies to decrease such CRB1s (e.g., behaving consistently with their valued directions in life, due to
accepting and validating the client’s discomfort for being in constant and pervasive attempts to control uncomfortable
therapy, performing role-playings through which the client (aversive) private events (Hayes et al., 1999). The aversive
could identify different emotions and learn a flexible pattern private events present in antisocial experiential avoidance can
of responding, observing rage emotions evoked during ses- have the form of feelings of injustice, rage, inferiority, anxiety,
sion and asking for the client to choose helpful forms of rejection, dependence, abandonment, and so on. This experi-
behaving, stopping arguments and finding alternative ways ential avoidance is supported by four basic verbal contexts,
to continue the interaction) as well as rules to help the client according to ACT: (a) the context of evaluation, in which our
identify misadjusted behaviors and to break the relationship close social community teaches us that uncomfortable or
between social situations with aversive functions and such unpleasant events are “bad,” “undesirable,” “unnatural,”
CRB1s. “humiliating,” or “denigrating,” which can be useful in some
situations (e.g., painful sensations derived from the direct
application of a noxious stimulus over the skin), but not if those
labels are applied to one’s own private feelings, emotions,
Achievements and Limitations memories, thoughts, or beliefs; regarding antisocial behavior,
FAP proves useful in the management of antisocial behaviors the “bad” and “undesirable” events would be feelings of infer-
as well as in shaping alternative prosocial rule-following beha- iority, dependence, rage, resentment, and so on, which usually
viors in clients with different ages and levels of antisocial derive from experiences of abuse; (b) the context of fusion, in
patterns, though the earlier cases must be considered only as which the self and the behavioral contents (feelings, thoughts,
precursors or preoffending antisocial behaviors. As we can see, emotions, sensations, memories, etc.) are both placed at the
same level, particularly when some form of physiological acti-
although FAP leans toward direct contingency management
vation is involved, such that the avoidance of aversive condi-
during sessions (i.e., toward immediate differential reinforce-
tioned stimulation leads to the consolidation of physiological
ment, extinction, or correction of concrete relevant behaviors
arousal as a consequence of negative reinforcement (in antiso-
such as insults or menaces), the role of rule-following behavior
cial patterns, the individual does not take perspective from their
inside and outside therapy was a central question in the cases
own feelings of rage, resentment, rejection, deprivation, etc., or
described and indicates that the change promoted in such rule-
from the thought that others are the cause of the suffering; in
following patterns can be a reliable way to achieve behavior
this situation the person does not consider relevant nothing
modification and reduction of recidivism.
more than their rage, urges, and the necessity of satisfying
However, FAP requires a greater amount of basic research
them); (c) the context of reason-giving, in which the same
concerning the behavioral mechanism of its therapeutic com- social community teaches us that those private events
ponents. For instance, with regard to one of its components— (thoughts, beliefs, and feelings) are the causes of behavior
CRB1s—it can become dangerous for the therapist if they are (individuals performing antisocial behaviors believe that they
evoked without measuring their intensity (e.g., it can be nec- do it “because” their feelings push them to do it; one of such
essary to provoke emotions like rage or sexual excitement, but pervasive beliefs is that others deserve to be damaged as a way
if the intensity of these emotions is quite high at the beginning to overcome the aversive states described earlier and that these
of therapy, it is feasible that the client cannot be prepared to persons employ to justify their antisocial behavior; that is, these
not to assault the therapist), and conversely, if CRB1s are individuals think they are doing the correct when they harm
evoked to an exceptionally low extent, it is quite likely that others); and (d) the context of control, which implies the belief
they will not be equivalent to problem behaviors. In other that we must change, control, avoid, or make those events
disorders, this issue is less important than in antisocial beha- disappear as the only means to solve our psychological suffer-
vior, as CRB1s do not constitute a threat to the therapist. It ing (individuals performing antisocial behaviors think that
would be advisable to build a scale that could measure the behaving that way, i.e., harming others and their reinforcers,
strength of CRB1s when they are evoked and that could also is the only means to get rid of their feelings of rage, resentment,
assess the change. Finally, FAP needs to be compared to usual dependence, inferiority, etc.).
(pharmacological and cognitive) treatments in comparative These verbal contexts (i.e., negative evaluations of own
controlled trials since currently there are no data in this uncomfortable and disturbing thoughts and emotions; fusion
regard, and it seems necessary to know the aspects and extent and identification with such evaluations; reason-giving about
in which FAP can improve or even be an alternative to such the cause of the discomfort associated with emotions like rage,
usual treatments. humiliation, desire, and others; and control attempts oriented to
6 TRAUMA, VIOLENCE, & ABUSE XX(X)

eliminate discomfort through violence or antisocial behaviors) As an example of a specific application, Paul et al. (1999)
work as generalized sets for rule-following (rule-following treated an adjudicated exhibitionist who presented serious sub-
basically involved in the control attempts) and are not modified stance abuse and masturbated in front of several females. The
by changing a single belief–behavior relationship (e.g., to try treatment consisted of a combination of FAP and ACT strate-
not to think on hurting others when rage emotions appear or to gies, although acceptance techniques had a predominant role.
try to make disappear such emotions through hurting others and The client was trapped in a circle of controlling his urges to
their reinforcers). In other words, such verbal contexts are con- masturbate in public places, which were treated through differ-
figured in each individual’s personal history as generalized ent exercises and metaphors that put the client in contact with
relations between beliefs (in the form of evaluations, reasons, his thoughts, feelings, and sensations without controlling them
explanations, etc.), and other behaviors (control or avoidance through public masturbation or by substance use. This served to
attempts). The relevance of the self in psychopathology for stop the client’s antisocial avoidance responses and the nega-
ACT is that the self, as in FAP, is a verbal element that serves tive reinforcement derived. The therapists also improved the
to establish all the other relational contexts or frames, espe- emotional self-disclosure of the client, and they developed
cially the contexts mentioned that support control attempts and alternative interpersonal skills since the client had a very lim-
generalized experiential avoidance (Törneke et al., 2016). The ited set of social interactions. The client finally decreased his
consequence of behaving in accordance with such verbal con- public exhibitionism and substance use. He improved his aca-
texts is psychological inflexibility (Chawla & Ostafin, 2007; demic performance and developed several successful relation-
Hayes et al., 2006). There is enough evidence to support the ships with women.
involvement of generalized experiential avoidance and beha- Luciano et al. (2011) applied two protocols to two adoles-
vioral inflexibility in antisocial behaviors (see Amrod & cent groups (low and high risk). High-risk participants showed
Hayes, 2014; Birkley & Eckhardt, 2015; Eifert et al., 2006; serious antisocial behaviors characterized by impulsivity and
Moore, 2016; Santanello et al., 2017; Shorey et al., 2014; emotional deregulations. Protocol I centered on deictic rela-
Visdómine, 2014; Yavuz et al., 2016). tions only (i.e., being here vs. putting feelings and thoughts
Hayes et al. (1999) establish six fundamental therapeutic there), while Protocol II included deictic and hierarchical rela-
strategies to gain psychological flexibility and diminish experi- tions (i.e., distinguishing the self as context, in opposition to
ential avoidance: (a) promoting a creative hopelessness by feelings, thoughts, and emotions as contents), as well as regu-
suggesting the uselessness of the clients’ attempts to control lation examples (i.e., behaving in one direction, or in another,
their suffering, (b) making clients aware of their own control- according to short-term and long-term consequences). As Pro-
ling agendas, (c) practicing the defusion and deliteralization of tocol II was more effective than Protocol I for low-risk adoles-
language, (d) taking a perspective of the self as context versus cents, only Protocol II was applied to high-risk adolescents.
the psychological contents, (e) clarifying values, and (f) com- The results showed a reduction in the number of problematic
mitting to act in a valued direction. A contextual analysis of behaviors.
verbal behavior is a cornerstone in the therapeutic process, and Gómez et al. (2014) employed a more complete ACT pro-
therefore, multiple examples, metaphors, paradoxes, and exer- tocol in five high-risk adolescents who engaged in vandalism,
cises are employed (Luciano et al., 2004). robbery, involvement in street gangs, negativism and aggres-
sion toward classmates, undisciplined behavior with adults,
unpredictable mood, substance abuse, and truancy. They had
pursued previous unsuccessful treatments such as community
ACT Applications to Antisocial Behaviors and Offending work for social reintegration, social skills training, self-control,
The first general search carried out in PsycNet and ScienceDir- school support programs, and family interventions. A func-
ect databases included the terms “ACT” and “Acceptance tional analysis revealed that most of them had grown up in
Commitment Therapy” in combination with “antisocial” and families with low parental control, aggressive family models,
“offending” in each database form along with the date criterion mothers with psychiatric disorders, and fathers with alcohol
“all years” (search date: April 5, 2020). The fields filled for the dependence. The treatment consisted of setting a context of
search were the same as with FAP. From this search, 38 results responsibility between the therapist and the adolescents, con-
were obtained when the search was performed in the PsycNet fronting the effect of the adolescents’ antisocial control agen-
database, and 88 results were obtained when the ScienceDirect das, clarifying the values of the adolescents, and promoting
database was employed, although the major part of such results defusing skills. All participants improved their desirable beha-
when the term “ACT” was introduced was irrelevant since such viors and disruptive actions diminished after only 2 weeks of
term was confounded with the verb “act.” For the retrieval of treatment.
further and more specific information on the application of Finally, Livheim et al. (2020) compared the effect of ACT
ACT, we referred to the bibliographic databases in the when it was employed together with a usual cognitive beha-
https://contextualscience.org/publications and https://micpsy. vioral treatment program in a group of 91 antisocial youths in
com/publicaciones-terapias-contextuales/web sites. In the for- residential care, in relation to a group formed by 69 antisocial
mer, we searched specifically for the term “antisocial,” and in youths treated only with the usual therapeutic program.
the latter, we checked individually the studies cited in it. Through a quasi-experimental design, 12 hr of an ACT-based
Visdómine-Lozano 7

intervention was added to the usual treatment. The therapists behavior. Harvey and Rathbone (2014) have developed a spe-
conducted follow-ups at 2 weeks, 1 month, 6 months, and 18 cific application of this therapy to challenging behavior
months after baseline, and the results showed that the combined problems.
group (i.e., usual treatment þ ACT) achieved better outcomes
than the usual treatment group in different self-reported mea-
sures of anxiety, depression, self-concept, and psychological
DBT Applications in Antisocial Behaviors and Offending
flexibility, as well as a significant decrease in anger and dis- The general searches carried out in PsycNet and ScienceDirect
ruptive behaviors. databases were equivalent to the performed for FAP and ACT.
The total number of studies obtained was 42, albeit many stud-
Achievements and Limitations ies were the same. We retrieved additional information regard-
ing the application of DBT from the bibliographic database
The first step of ACT confirms that the role of verbal behavior hosted on the site http://behavioraltech.org/research/updates.
is basic in the development and maintenance of antisocial pat- We checked the studies included in that database on an indi-
terns and that the diagnosis of “experiential avoidance” seems vidual basis. In addition, Verhoeven (2010) describes some
to be useful in conceptualizing such patterns. Indeed, such specific applications to antisocial or criminal populations.
diagnosis has been absent up to now in this field, and it could In particular, nine relevant studies were finally selected.
improve the understanding and management of a diversity of McCann et al. (1996) worked with 35 primarily male inpatients
antisocial conducts. However, the ACT needs to be applied on five security wards who were confined for having commit-
more systematically. To date, there has been a limited number ted violent crimes (50% with BPD diagnosis, 50% with a diag-
of clinical studies. As happened with FAP, ACT interventions nosis of antisocial personality disorder). The DBT group (21
need to be compared systematically through controlled trials participants) achieved a significant decrease in depressed and
using other usual noncontextual treatments. hostile moods, paranoia and psychotic behaviors, as well as in
maladaptive interpersonal coping styles, in comparison to the
treatment-as-usual group.
DBT Trupin et al. (2002) treated 22 juvenile female offenders in a
mental correctional facility. Aggressions, parasuicide, and
DBT Principles and Antisocial Behavior class disruptions decreased in the DBT group, and the treat-
This therapy was developed by Marsha Linehan (1993) for ment significantly improved participation in on-campus thera-
borderline personality disorder (BPD). Suicide behaviors, peutic, educational, and vocational services.
extreme generalized emotional, interpersonal, and cognitive Eccleston and Sorbello (2002) provided a DBT skills group
deregulations, as well as troublesome regulation and experi- twice per week and individual therapy during 10 weeks to
ence of the self are key targets for DBT, which seeks to prison inmates (no sample size specified) with BPD traits or
decrease harmful actions and replace them with life- self-harm behaviors, and the participants achieved a significant
enhancing behaviors. To do this, it employs a dialectical pro- improvement on both depression and anxiety scales.
cess between the client and the therapist, and it balances the With regard to incarcerated women with a history of child-
dialectical relation between the clients’ extreme feelings of hood sexual and/or physical abuse, Bradley and Follingstad
dependence and rejection. This therapy presents the self as a (2003) assigned 24 participants to the treatment group (13
culturally constructed relational concept and understands real- completed) and 25 to a no-contact comparison condition (18
ity as a dynamic or dialectical integration of opposing forces completed) and evaluated treatment effects, using the Beck
(e.g., environment and individual). Depression Inventory, the Inventory of Interpersonal Problems,
DBT shows that personality disorders (specifically, BPD ) and the Trauma Symptom Inventory. The authors found signif-
involve the general behavioral subsystems of an individual, and icant reductions in post-traumatic stress disorder, mood, and
therefore, it distributes its intervention along five components interpersonal symptoms in the treatment group.
aimed at training five general functions: (1) training in mind- Evershed et al. (2003) studied eight males in a high-security
fulness and validation (i.e., the acceptance of being fully aware hospital with the diagnosis of BPD who underwent 18 months
of every moment and of every emotional state), in distress of DBT, while a control group of nine patients received the
tolerance, in interpersonal effectiveness, and in emotion regu- usual treatment available. The DBT group showed greater
lation; (2) enhancing motivation to apply these skills to specific improvements than the control group in the seriousness of vio-
challenges in their lives; (3) ensuring generalization with tele- lent behaviors and in hostility, cognitive anger, and anger expe-
phone or between-session coaching; (4) structuring the envi- rience scores.
ronment through problem-solving strategies; and (5) Nee and Farman (2005) worked again with incarcerated
supporting therapists with consultation teams. Neacsiu and women. The authors selected 30 inmate females, most of whom
Tkachuck (2016) have reported preliminary findings about the had had histories of physical and sexual abuse, relationship
involvement of DBT skills deficits and maladaptive coping in instability, and drug and alcohol problems, although only 16
different facets of psychopathy, which connects the DBT completed the study. The participants had a serious risk of
framework with the underpinnings of serious antisocial performing assaultive or threatening behavior. The treatment
8 TRAUMA, VIOLENCE, & ABUSE XX(X)

consisted of three short-format programs of DBT, which exploring their personal histories. What MDT therapists find
achieved gains in several self-report measures of personal feel- is that these individuals have long histories of sexual, physical,
ings, emotional control, custody adjustment, as well as and/or emotional abuse and neglect, as happened with several
improvements as regards the frequency and seriousness of vio- DBT studies (e.g., Bradley & Follingstad, 2003; Nee &
lent incidents inside a prison. Farman, 2005), and this finding coincides with the analysis
Shelton et al. (2009) treated 63 participants with impulsive performed from an ACT perspective. Apsche and Ward-
behaviors confined in correctional facilities in Connecticut. Bailey (2003) present MDT in the real case of an adolescent
Participants were assessed at baseline and at 4, 6, and 12 accused of sexually assaulting three children in his aunt’s
months. The therapeutic program consisted of a twice-weekly home, groping a teacher, and kicking his principal. Some of
skills group, followed by weekly 30-min case management his and his sister’s experiences of abuse included their mother
sessions. The participants appeared less physically aggressive sitting them in bleach because she thought that they were “too
at follow-up and demonstrated healthier strategies for coping dark skinned” and beating them with an electric cord and a
with distressing situations. baseball bat, as well as seeing how his mother cut his father
Sakdalan et al. (2010) carried out the application of DBT in with a knife.
six intellectually disabled offenders who exhibited challenging Besides validating the youngsters’ experiences as a way of
behaviors and had a history of violent crimes. They completed not punishing them for having experienced such aversive situa-
a 13-week adapted DBT group skills training program, and all tions, MDT exposes them to their memories and feelings and
participants attained significant improvements in dynamic clarifies their patterns of coping with threatening stimuli, redir-
risks, relative strengths, coping skills, and global functioning. ecting them to behaving in valued life areas instead of hurting
Finally, Moore et al. (2016) worked with 27 male prison others, which is what these adolescents do to avoid their aver-
inmates, although only 16 completed the 8-week DBT inter- sive private reactions derived from their histories. Unlike tra-
vention due to transfer to another correctional facility. Partici- ditional cognitive behavioral therapies, the key concept of
pants improved their coping skills, and the externalization of MDT, as in FAP, ACT, and DBT, is not to attempt to change
blame among the general population of the prison was reduced. the feelings and thoughts of these clients about the stimuli they
perceive as threatening or hateful. Such thoughts and emotions,
Achievements and Limitations no matter how unpleasant that they might be, are unchangeable
products of their lives. They cannot even change how they
As we can see, the case of the application of DBT in correc- perceive other stimuli now, to the extent that such perception
tional institutions has been predominant. Although some of the is a derived product of our verbal and relational human nature.
concepts of DBT need to be operationalized in functional They are told that they can only change the way they behave
terms, and the functional role of its therapeutic components when such feelings and perceptions appear, in order to have a
needs to be researched, it seems to be a useful therapy, ahead better life. Finally, MDT has also developed an intervention at
of usual cognitive behavioral interventions. Some DBT inter- a family level (Apsche et al., 2008), through which the therapist
ventions were applied to misadjusted behavior inside the facil- seeks to extend and generalize the treatment effects.
ities or prisons but not to recidivism outside such institutions,
and this is a deficiency that should be corrected through, for
example, a follow-up after release.
Application of MDT to Antisocial Behaviors and
Offending
MDT
This therapy consists of the most widespread application of
MDT Principles contextualist principles to serious violent behaviors, although
Finally, MDT is a contextually reformulated cognitive beha- paradoxically the search carried out in the general databases
vioral therapy, designed to intervene with juveniles presenting only gave five results. Hence, some specific reviews of the
serious physical and/or sexually violent behaviors (Apsche & therapy were checked.
DiMeo, 2010; Apsche & Ward-Bailey, 2003; Apsche et al., Houston et al. (2007) made a comprehensive review of dif-
2003; Apsche & DiMeo, 2012). MDT redefines the cognitive ferent applications of MDT that involved individual cases and
concept “modes” as a set of general beliefs that are a product of small groups. Since other reviews by Apsche take into account
past contingencies and that serve to adapt individuals to comparative studies that include groups with sample sizes
problem-solving situations in their lives. The authors of MDT larger than 17 participants, only the case studies and small
found that traditional cognitive therapy failed to treat these group studies mentioned by Houston et al. (2007) will be cited
youngsters because the patients perceived that the cognitive in the first place. Thus, one of the first applications of MDT in
therapist was attempting to change their behavior from the very adolescent sexual offenders was described in Apsche and Ward
system of defenses that they had developed to protect (2003), in which fourteen 12–19 years old youngsters partici-
themselves. pated. The juveniles were distributed into two groups (usual
Therefore, MDT puts into practice the radical acceptance treatment vs. MDT), and the MDT group achieved better out-
and validation of the perception of these adolescents by comes than the usual-treatment group in the reduction of
Visdómine-Lozano 9

aberrant behaviors and other self-reported measures of mood, Achievements and Limitations
cognition, and attitudes.
Given these results, MDT seems to be an appropriate tool for
Apsche and Ward Bailey (2004) described the case of a 13-
the contextual treatment of severe violent patterns, as pointed
year-old male who had committed numerous sexual offenses,
out by Bass et al. (2014). Moreover, it performs better than
and had had a history of extremely low physical and emotional
traditional cognitive behavioral therapy, as demonstrated in the
boundaries, and who had been sexually abused by a boy. After
controlled trials conducted by the authors. MDT has undoubt-
some previous pharmacological and residential treatments, the
edly benefited from generic advances made by previous con-
youngster and his family were delivered MDT, and the new
textual therapies such as FAP, ACT, and DBT and has
therapy showed useful in reducing aggressions and opposi-
successfully applied these developments to this special popu-
tional behaviors.
lation. However, some MDT concepts remain solely theoreti-
Likewise, Apsche and Siv (2005) presented the case of an
cal, as it happens with the concept “modes.” If they were
adolescent male who had committed several sexual assaults
translated and operationalized into more contextual and func-
and suicide attempts, and Apsche et al. (2005) detailed the case
tional terms, they would create a clearer path for further basic
of a 16-year-old male with physical and sexual aggressions to
research. Indeed, the concept “modes” could be conceptualized
peers, severe school problems, and who had practiced tortures
as “generalized operant classes.” In addition, we have not
to animals and sexual behaviors with them. In both studies,
found MDT clinical studies carried out since 2014, as if this
MDT achieved positive outcomes, particularly in the second
therapy had arrived at the end of its route, and it would not be
one, in which MDT was superior to DBT, which had been
able to provide further improvements and developments.
applied previously to the client.
As it has been said, other Apsche’s reviews account for
studies with sample sizes larger than those mentioned in Hous-
Conclusions: Effectiveness and Common
ton et al. (2007). Apsche (2010) reviewed and highlighted the
efficacy of MDT compared to classic cognitive therapy, focus-
Therapeutic Processes
ing on the reduction of the rate of physical and sexual aggres- Although these therapies have their own techniques and their
sions, suicide, and recidivism. Apsche et al. (2010) examined own way of labeling them, they share common functional ele-
21 MDT studies yielding a sample population of 573 male ments that, in our view, can be summarized as follows: (a) a
adolescents with various forms of serious violent patterns, of functional analysis of antisocial behaviors (offending and pre-
which 90% of participants had suffered all four types of abuse: offending antisocial behaviors), especially when they appear as
sexual, physical, verbal, and neglect. They demonstrated very generalized classes in adults (i.e., in the form of personality
good results of MDT in treating these adolescents. patterns), or, in other words, an examination of the conditions,
Bass and Apsche (2014) updated these results with a new stimuli, rules, and consequences that are involved in the
meta-analysis including 24 studies yielding a sample popula- prompting, maintenance, and generalization of antisocial beha-
tion of 734 male adolescents. This meta-analysis distinguished vior and offending; (b) a focus on acceptance (in the language
sexual offenders from individuals with conduct disorder. The of FAP and ACT) or validation (in the language of DBT and
analysis was carried out according to three categories: individ- MDT) of personal history and events that gave rise to such
ual studies, family studies, and mediation effects. For individ- antisocial behaviors; and (c) a redirection of their behaviors
ual studies, Cohen’s d showed large effect sizes in the reduction to alternative life values. These elements seem to be crucial
of physical aggression (1.86) and sexual aggression (1.94). For in treating generalized antisocial patterns from a contextualist
family studies, the total effect size for anger and its expression perspective (see Figure 1).
was 1.6, and 1.1 for property aggression. Finally, regarding The functional analysis of the antisocial behaviors per-
mediation effects (State-Trait Anxiety Inventory II and Child formed by an individual leads to identifying the specific func-
Behavior Check List), there was a significant reduction of all tional category to which such behaviors belong and, in turn, the
negative behaviors from commencement to posttreatment most effective contingencies to apply as treatment. That is,
(effect sizes for internalization and externalization were 0.8 such functional analysis allows us to know whether a given
and for total anger expression were 0.7). antisocial behavior responds, for example, to a history of pun-
Finally, a comprehensive review was performed in the same ishment contingencies (e.g., physical or sexual abuse), with-
databases that were employed for FAP, ACT, and DBT. The drawal and deprivation of previous reinforcements, or to
aim was to search MDT studies carried out after 2014. In both negative punishments (e.g., refusals and neglects). The target
databases (APA journals section of PsycNet, and Science for these contextualist therapies is not simply to decrease spe-
Direct), the terms “Mode deactivation” and “MDT” were alter- cific antisocial responses but rather to address the generalized
natively introduced along with the time interval “2015–2020.” underlying functional class which gives rise to such behaviors.
In the first database, none of the two studies found for each By “generalized functional class,” we mean all the disturbing
term was related with this therapy; and in the second database, private events (i.e., emotions, thoughts, beliefs, and feelings),
none of the 15,985 results found for the term “Mode deacti- the different forms of harmful behaviors related to them, the
vation” was related to the therapy, as well as none of the 8,167 rules controlling such harmful behaviors, and the stimuli upon
results found for the term “MDT.” which such private events, rules, and behaviors have been
10 TRAUMA, VIOLENCE, & ABUSE XX(X)

ANALYSIS TREATMENT

FAP FAP

Clinically relevant Clinically relevant

behaviors 1 behaviors 2 and 3

Uncomfortable private events ACT Uncomfortable private events DBT

(memories, feelings, sensons, DBT (memories, feelings, sensons,
ACT emoons, thoughts…) Acceptance emoons, thoughts…) Validaon
Extreme Values commitment Interpersonal
Experienal Defusion/Self as
dialeccal // BREAK // skill training
avoidance context
strategies

Harmful and offending behavior Harmful and offending behavior

directed towards others directed towards others

Validaon
Aggressive modes
Alternave values
of responding
MDT
MDT

Figure 1. Graphic representation of the therapeutic processes involved in the application of contextual therapies.

generalized. Nor is the aim to change or suppress the topogra- by promoting a verbal context (i.e., a set of rules) with various
phy of some private events like thoughts of vengeance, feelings ends: (a) to distinguish the hierarchical relation between the
of rage and abandonment, sexual fantasies, or physiological self and the psychological contents and (b) to undermine the
activations, contrary to the attempts of traditional cognitive motivational element of rules that control the avoidance
behavioral interventions. Instead, these possible private events through the establishment of a context of coordination between
are understood as part of the same functional class as the anti- avoidance strategies and the increase of undesirable private
social responses. Moreover, the functional analysis carried out events and negative consequences in life. The distinction
by these therapies reveals that these private events stem from between short-term agreeable consequences and long-term lim-
the “experiential avoidance” that the subjects perform through iting consequences resulting from antisocial behavior is a key
their antisocial responses, which serve to reinforce negatively element to undermine such avoidance strategies and the rules
the evocation of such aversive emotions upon given situations that control them.
and stimuli. Moreover, this functional diagnosis (i.e., experi- And finally, the third element, that is, redirection to alter-
ential avoidance) can be a new clinical tool that could help to native values, involves the establishment of a prosocial agenda
understand the origin and development of offending, in its through a verbal context that serves to alter the motivational
different forms. functions of both the consequences of antisocial avoidance
The second element, that is, acceptance or validation, con- (short term and long term) and the consequences of neglecting
sists precisely of breaking the vicious circle of antisocial valued areas of life. In sum, these therapeutic interventions
experiential avoidance. These therapies focus on stopping anti- employ the individual’s experiences to weaken the short-term
social responses to situations in which the previously men- effects of the generalized antisocial avoidance and to
tioned private events are evoked and do so through the strengthen, in a context of opposition to such avoidance, a new
acceptance of these private events. This acceptance involves set of generalized rules that could guide these individuals to
observing, recognizing, and allowing the presence of private prosocial values in different areas of their lives (see Table 3).
events without attempting to get rid of them. This is achieved This is why we consider that these therapies can improve
through different techniques such as meditation, mindfulness, traditional interventions based on contingency management, as
metaphors, or analogies related to both the situation of the well as why we think they can be an alternative treatment to
clients and the consequences of their antisocial behaviors in traditional cognitive behavioral attempts of behavior modifica-
their lives (e.g., a metaphor could be to compare the clients’ tion in adult offenders. With children, it is feasible to control a
situation with the fact of being trapped in quicksand, in such a sufficient amount of contingencies or to train their parents to do
way that the greater the antisocial behaviors performed by the it, as demonstrated by Gosch and Vandenberghe (2004) and
clients, the greater the quicksand trap) and exercises, as well as Romero et al. (2018). However, barring the cases of
Visdómine-Lozano 11

Table 3. Critical Findings. that we cannot know the extent to which one therapy is more
effective than other. Therefore, it would be advisable for the
Therapy Critical Findings
application of ACT, FAP, and MDT to adult subjects, as well as
FAP  Incoherence between past and present contingencies the employment of experimental comparative designs that
of reinforcement can produce antisocial behavior. could help to assess the differential impact of these contextu-
 Antisocial behavior can be treated by evoking it in alist therapies, compared to traditional cognitive or
the clinical setting.
community-oriented treatment programs. Finally, DBT has
 Contingency management and reshaping of rule-
following behavior are key processes in the change of been predominantly delivered in facilities and other institu-
antisocial behavior. tions, which limits the results of this therapy basically to insti-
ACT  Antisocial behavior and offending are part of the tutional behaviors, and therefore, DBT should incorporate
same continuum. more prolonged follow-ups once the participants were outside
 Aggression, violence, and offending develop as part such institutions. In sum, future research should include (qua-
of a class of experiential avoidance.
si)experimental comparative designs, adult participants, parti-
 Clarification of personal values increases the
effectiveness of defusion of emotional avoidance in cipants showing specific and different antisocial behaviors
the treatment of antisocial behavior. (both delinquent and nondelinquent), and larger follow-ups,
DBT  Borderline patterns are common in people among other issues of concern.
presenting antisocial behavior and offending. At any rate, the first steps given by the third-generation
 Nondisabled and intellectually disabled individuals contextualist therapies reviewed provide hopeful and promis-
can show equivalent emotional unbalances.
ing results, within a context of looking ahead to treating spe-
 Validation of emotional disturbances and dialectical
balancing of coping strategies show helpful in the cific young and adult antisocial behavior and offending.
treatment of problem behaviors.
MDT  Young sexual offenders usually have a history of
abuse and neglect.
 It is iatrogenic to instruct these individuals to try to Implications for Practice, Policy, and Research
forget their personal experiences.  To substitute traditional strategies of thought control and
 Validation and values redirection show attributions change for validation and acceptance
comparatively better than control-focused strategies
of usual cognitive behavioral therapies.
strategies.
 To introduce a stronger emphasis on redirection to per-
Note. FAP ¼ functional analytic psychotherapy; ACT ¼ acceptance and com- sonal values.
mitment therapy; DBT ¼ dialectical behavior therapy; MDT ¼ mode deactiva-  To help to distinguish disturbing emotions from the
tion therapy.
necessity of control them.
 To analyze interpersonal interactions inside the thera-
institutionalization or developmental retardation, adults are peutic context as a fundamental tool for promoting beha-
more difficult to treat successfully. They are independent and vior change.
autonomous, that is, their behavior has come to be regulated by  To introduce new contextualist therapies in prisons and
a complex set of rules (self-rules). In this case, it is perhaps facilities.
more useful to alter the function of such rules in context than  More treatment as usual–contextualist treatments com-
their form or topography. When adults are incarcerated, the parative studies are required.
contingencies responsible for their antisocial behavior are not  To design multiple baseline studies to analyze each con-
directly accessible, and consequently, these persons can also textualist therapy.
 To compare in applied settings the contextualist thera-
benefit from the therapies reviewed in this article. With respect
pies between them.
to this matter, a diversity of individuals improved their beha-
 To program larger follow-ups to study with further accu-
vior: children, adolescents, juveniles, males, females, and even
racy the rate of recidivism.
intellectually disabled individuals.
Nevertheless, we observe that paradoxically, those therapies
with better theoretical construction from a functional-
contextualist viewpoint (i.e., FAP and ACT) have a lesser num- Declaration of Conflicting Interests
ber of comparative interventions than those therapies with
The author(s) declared no potential conflicts of interest with respect to
more eclectic concepts (i.e., DBT and MDT), and it would be the research, authorship, and/or publication of this article.
advisable to balance this situation. In addition, other limitations
are both the lack of enough experimental/quasi-experimental
studies in the case of FAP and ACT, with the exception of Funding
Livheim et al.’s (2020) study, and the application of these The author(s) disclosed receipt of the following financial support for
contextualist therapies fundamentally to adolescents, with the the research, authorship, and/or publication of this article: This study
exception of the DBT applications. This limitation involves has not been funded by any public or private institution.
12 TRAUMA, VIOLENCE, & ABUSE XX(X)

ORCID iD treatment of adolescents. International Journal of Behavioral Con-

J. Carmelo Visdómine-Lozano https://orcid.org/0000-0002-2065- sultation and Therapy, 9, 4–8.
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J. Carmelo Visdómine-Lozano, PhD, is a senior technician in the
Visdómine, J. C. (2014). A contextualistic approach to antisocial per- Prisons Head Office (Instituciones Penitenciarias) at State Department
sonality. Journal of Criminal Psychology, 4, 163–184. of Spain (Ministerio del Interior), Madrid. His research on this field
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practices, and emerging models. International Journal of Beha- well as on criminal profiling, social and psychological conditions
vioral Consultation and Therapy, 8, 89–95. http://dx.doi.org/ related to extreme violent conducts like psychopathy, and advances
10.1037/h0100989 on the treatment of antisocial behaviors and offending.