Treatment and Intervention

Question 1

Treatment and rehab

Answer 1

• Terms often used interchangeably
• Oxford Dictionary of Law Enforcement (Gooch & Williams, 2015):
  
  • “Treatment aimed at improving an offender’s character or behaviour (including education, counselling, employment, training, etc.) that is undertaken with the goal of reintegrating the offender into society.”
• Home Office Policy paper (2015), Government Prison Strategy White Paper (2021)
• Increase in prison population over time
• 134 prisoners per 100,000 people in the general population in England & Wales (Sturge, 8th July 2024)
  88,263 (August 2024) – just under the useable operational capacity (89,383; Ministry of Justice, 2024).

Question 2

reoffending rates

Answer 2

• Proven reoffending rate ~ any offence committed in a one-year follow-up period that leads to a court conviction, caution, reprimand, or warning within one year or 18 months.
• Jan-March 2022 (England & Wales): 25.1% for adult offenders; 34.2% for juvenile offenders.
• Reoffending rates for violent offences > non-violent offences (Hunt et al., 2019; Motiuk & Belcourt, 1997)
  Between 30 - 45% for violent offending, between 11-14% for sexual offending (Beaudry et al., 2023; Dowden et al., 1999; Hanson & Morton-Bourgon, 2005)

Question 3

treatment models and rehab frameworks

Answer 3

• Treatment models - models to apply psychological principles and strategies to change the behaviour of offenders in clinical settings (Ward et al., 2007).
• Target offending risk factors or ‘criminogenic needs’, e.g. impulsivity, low self-control, crime-supporting attitudes.
• Rehabilitation theories - describe the aims, values, and principles of forensic interventions.
  Likened to a large map of a city outlining all the major landmarks (rehabilitation theory) versus a map of a specific area that shows how to navigate within a set of streets (treatment models; Ward et al., 2007, p. 89).

Question 4

treating violent offenders- general considerations

Answer 4

• Specialised vs non-specialised treatment (Polaschek & Collie, 2004) – different treatment needs?
• Offenders often have a history of a violent offence (general offending: Bourgon & Armstrong, 2005; Sex offenders: Newman, 2011)
• Heterogeneous nature of violent offenders – function of violence needs to be understood
  
  • For example, violence as a result of anger, rage, frustration versus to obtain physical or material needs (Feshbach, 1964)
    Treatment readiness – motivation (Polaschek & Collie, 2004) and responsivity to treatment (e.g., O’Brien & Daffern, 2016)

Question 5

crimogenic needs (Davies & Beech, 2018)

Answer 5

• Anger; hostility; impulsivity
• Empathy deficits
• Issues with interpersonal, problem-solving, or social information-processing skills
• Antisocial personality; antisocial companions; antisocial attitudes
• Relationship instability
• Substance abuse
• Education/employment
  Major mental health problems

Question 6

treatment programmes for violent offenders (Polaschek & Collie, 2004)

Answer 6

• Anger management
• Cognitive skills
• IPV interventions
  Multi-modal programmes

Question 7

Anger management (Novaco, 1975)

Answer 7

• Assumes that violence is caused by anger.
• Treatment focuses on:
  
  • Increasing awareness of anger
  • Increasing awareness of what triggers anger
  • Skills training, for example social skills and relaxation training
• Typically group-based,10 – 20 x 2-hour sessions.
• Limitations
  
  • Relationship between anger and violence is not well understood
  • Some studies show no relationship (e.g., Loza & Loza-Fanous, 1999) ~ might only occur in certain situations
  • Some violence exists without anger (e.g. sadism, instrumental violence; Howells, 2004)
  • More frequent, intense or longer episodes of anger tend to be the most dysfunctional (Novaco, 2011)
  • Need for other criminogenic needs to be addressed too (multi-faceted)
• Effectiveness
  
  • Dowden et al (1999)
    ○ 110 programmes in Canada, 3-year follow-up
    ○ 86% reduction in violent offending
  • Novaco (2013)
    ○ Review of the literature
    ○ ↓ rule violations, re-arrest rates, angry patient behaviours, verbal & physical aggression
  • Howells et al. (2002)
    ○ 200 male offenders in South and Western Australia (pre and post), compared with controls
    ○ Few sig findings, except for improving anger knowledge, readiness to change
    But, shorter and less intense programmes

Question 8

cognitive skills programmes

Answer 8

• Focused on thought patterns which may lead to offending and redirect these thought patterns into pro-social thinking and better problem solving.
• Usually delivered in groups.
• Programmes range from 3 months to 3 years.
• Limitations:
  
  • Not suitable for all offenders, e.g. those with learning difficulties (e.g., McClinton, 2009)
  • Might not work for serious high-risk offenders à cognitions may be too engrained (Ward & Nee, 2009)
• Example: think first (McGuire, 2005)
  Focused on problem solving, self-management, social interaction training, and values education.
• Focused on thought patterns which may lead to offending and redirect these thought patterns into pro-social thinking and better problem solving.
• Usually delivered in groups.
• Programmes range from 3 months to 3 years.
• Limitations:
  
  • Not suitable for all offenders, e.g. those with learning difficulties (e.g., McClinton, 2009)
  • Might not work for serious high-risk offenders à cognitions may be too engrained (Ward & Nee, 2009)
• Example: think first (McGuire, 2005)
  Focused on problem solving, self-management, social interaction training, and values education.
• Effectiveness
  
  • Tong and Farrington (2006)
    ○ Meta-analysis (16 studies, 4 countries)
    ○ 14% decrease in recidivism, in community & institutional settings; low and high-risk offenders
  • Friendship et al (2003)
    ○ Cognitive skills programmes in England and Wales, two-year follow up period
    ○ Significant reductions in violent reoffending
  • Falshaw et al (2004)
    ○ Prison-based cognitive skills programmes in England and Wales
    ○ 2-year reconviction rates (matched with control group)
    No significant differences

Question 9

multimodal programmes

Answer 9

• More intense, examine an array of issues
• More individualised, responsive to the needs of the person
• Assume that violence may be caused by multiple issues which should be targeted
• Multi-disciplinary teams, including psychologists, custodial, educational and programme staff
• At least 12 months, treatment usually in a group (individually if needed)
• Intensive à can be difficult to put into practice
  Typically only suited for high-risk offenders

Question 10

Violence prevention unit at Rimutaka prison, near wellington NZ (Polaschek et al., 2005)

Answer 10

• Intervention programme for high-risk violent offenders (voluntary, length of sentence not effected).
• Targets ‘hypothesised criminogenic needs of violent offenders’ (p.1616).
• Programme – closed groups of 10 men.
• Therapist team = a psychologist and rehabilitation worker.
• On arrival, 4 week assessment period to gain comprehensive understanding of social history, background, family and support systems, how each may function in a group (including motivation to change), offending history, risk factors, current offence, and reintegration needs on release.
• Assessment data collected by interviews, psychometric tests, questionnaires.
• Three programmes running at a time.
  
  • Approx. 330 hours of treatment
  • 4 x 3-hour group meetings
  • Weekly, for 28 weeks
  • Individual intervention for psychological issues.
• To plan for release – meetings with family members.
• Post-release follow-up – routine support from probation officers.
  Programme components
• Effectiveness
  
  • Polaschek (2011)
    ○ Evaluation of VPU in NZ; over 3.5 years
    ○ 112 medium and high-risk offenders matched with controls
    ○ Reconviction data: 10-12% fewer offenders in the treatment condition were reconvicted for a violent offence.
  • Serin et al. (2009)
    ○ Evaluation of ‘Persistently Violent Offender’ programme in Canada (144 hour long)
    ○ 256 men against 2 groups (AM & control group)
    ○ Completers just ask likely to reoffend as AM and no programme.
  • Cortoni et al (2006)
    ○ Evaluation of Violence Prevention Programme (VPP) in Canada (94 sessions)
    
    • 500 offenders against a 466 matched untreated controls
    • Follow-up at 6 months and one year
    • Those who completed VPP à significantly less institutional misconduct charges
      Those who did not receive treatment à Twice as likely to be reconvicted for a violent offence at one year follow-up

Question 11

treating sex offenders- crimogenic needs (Davies & Beech, 2018)

Answer 11

• Deviant sexual interests: for example (multiple) paraphilias, sexual preoccupation
• Distorted attitude
• Low levels of socio-affective functioning: for example, intimacy issues, lack of emotionally intimate relationships with adults, emotional congruence with children
  Problems in self-management: for example, lack of control over emotions and behaviour, impulsivity, poor problem-solving

Question 12

cognitive behavioural therapy

Answer 12

• Most common treatment for sex offenders (for a review, see Moster et al, 2008)
• Cognitive aspects
  
  • Cognitive distortions (e.g. blaming the victim, denial and minimisation, rape myth acceptance)
  • Other thinking patterns that might effect mood and behaviour
  • Coping with negative emotions, empathy for others
  • Therapy aims to encourage offenders to identify their own thinking patterns and develop skills to re-evaluate these beliefs/thinking patterns
• Behavioural aspects:
  
  • Alter behaviour through reward and punishment, modelling (demonstrating behaviour), and skills training (e.g. interpersonal skills such as assertiveness and communication)
    Comprehensive approach to treatment.

Question 13

relapse prevention

Answer 13

• Adapted from the addiction field (e.g. Marshall & Laws, 2003).
• Often used as an addition to CBT approaches.
• Self-management approach:
  
  • How to anticipate and cope with relapsing (having thoughts about offending, and re-offending)
  • Control over time across high-risk situations in the community.
• Limitations
  
  • Presumes all offenders have the same pathway to offending (Laws & Ward, 2006)
  • Negative focus, must avoid certain situations (avoidant v. approach strategy) ~ influences engagement (Mann et al., 2004)
• Effectiveness
  
  • Beech et al (2015)
    
    • Meta-analysis of 54 treatment studies (N = 14,694)
    • Systemic and CBT most promising in terms of reducing reoffending
  • Mpofu et al (2018)
    
    • Review of 10 studies
    • Moderate and high-risk sex offenders
    • Reoffending rates lower for CBT interventions compared to matched control groups
  • Harrison et al (2020)
    
    • Meta-analysis of 25 studies (N = 12811)
    • Significant reduction in sexual and violent reoffending, no significant effect on general reoffending

Question 14

Rehabilitation frameworks- risk needs responsivity framework (Andrews & Bonta, 1998)

Answer 14

• Risk principle: Level of treatment should be matched with risk à high risk = more treatment (at least 100 hours of CBT over 3-4 month period)
• Needs principle: Treatment should target criminogenic needs
• Responsivity principle: Is the treatment appropriate for that person? May impede learning? e.g. gender, learning styles, culture, diversity, motivation
• Professional discretion- Focuses on identifying, managing and reducing risk (risk-management approach)
• Limitations
  
  • Fails to motivate and engage offenders in the process (e.g. Ward & Beech, 2015)
  • External motivators such as parole might make people more likely to follow a treatment programme (Jones et al., 2006)
  • High attrition rates (30-50% e.g. Ware & Bright, 2008)
  • Those who drop out more likely to reoffend than completers (e.g. Hanson et al., 2002)
  • Focuses on avoidance goals, rather than approach goals
  • Limited attention to non-criminogenic needs (e.g. personal distress) à focussing on these might improve treatment outcomes
    Minimal focus on reintegration into society

Question 15

Good lives model (Ward & Stewart, 2003)

Answer 15

• General assumptions
  
  • Grounded in the ethical concept of human dignity and universal human rights; strong emphasis on agency
  • Strength-based approach: rehabilitation needs to 1) reduce risk but also 2) promote human needs and values through approach goals.
  • 11 classes of ‘primary goods’ (offenders have value certain states of mind, personal characteristics and experiences) (Ward & Gannon, 2006; Ward et al., 2007)
• Sexual offending as the result of attempting to satisfy primary goods (direct route) or a “ripple effect” that occurs when trying to satisfy one or more primary goods (indirect route)
• Treatment will:
  
  • Work out individual’s priorities/weightings and how to get secondary goods.
  • Identify criminogenic needs that might be blocking the achievement of the goods (e.g. substance abuse might prevent living a healthy life).
  • Devise a GL Treatment Plan, individual to the person.
• Mallion et al (2020):
  
  • Systematic review (N= 17)
  • GLM-consistent interventions as effective as standard RP programs, but also enhanced motivation to change, engagement in treatment and optimism for the future
  • Limited evidence for GLM assumptions
• Zeccola et al (2021):
  
  • Systematic review (N = 6)
  • Little evidence for the GLM to be effective in reducing reoffending
  • Some evidence that GLM increases motivation to desist from crime
    More rigorous and high-quality evaluations are needed

Question 16

general notes on effectiveness studies

Answer 16

• Generally, lack of evaluation for specific types of offenders (e.g. serious sexual and violent offenders)
• Inconsistencies in treatment programmes make it difficult to make comparisons.
• From Tong and Farrington (2006):
  
  • Need larger samples
  • Randomised control trials (including matching for individual risk levels)
  • Better measures for recidivism, not just official statistics (e.g. self-reports)
• Focus on process rather than outcome - change seen within treatment (Levenson & Prescott, 2014)
  Need to include other factors that might impact results, e.g. readiness to change (Henwood et al., 2015).

Question 17

Considerations of working with serious violent/sexual offenders (Ward & Wallis, 2018)

Answer 17

• Treatment readiness
  
  • Person and context factors that promote engagement and change.
  • For example, learning difficulties, cultural factors, denial.
  • Important to increase motivation to change.
• Therapeutic climate
  
  • Context in which treatment occurs, e.g. therapist characteristics, group dynamics.
  • Therapists’ style should be non-confrontational (Marshall et al., 2003).
• Treatment context
  
  • The environment in which the treatment is delivered in.
  • How supported the person feels/therapy is valued.
  • Often difficult in prison-based settings (e.g. Gannon & Ward, 2004).
    Important to develop a supportive environment and emphasise strength-based aims of treatment (Mann et al., 2009).

Question 18

costs of sexual offending

Answer 18

• Recognised as an international public health problem by World Health Organisation
• Costs of sexual abuse to victim
  
  • physical and psychological harm
  • teenage pregnancy
  • problematic parenting behaviours
  • adjustment problems in the victim’s later offspring
    Other costs include to public health and criminal justice services, loss of work days, reduced productivity

Question 19

risk factors for sexual offending (Hanson & Harris, 2000, 2001; Thornton, 2002)

Answer 19

• Risk factors: factors that help to predict recidivism, that is, whether a person convicted of a sexual offence will commit another offence in the future
• Four domains of risk factors that predict sexual offence recidivism:
  
  • Socio-affective function (e.g., intimacy deficits, emotion-regulation)
  • Self-management (e.g., impulsivity, recklessness)
  • Offence supportive attitudes (e.g., children enjoy sex)
  • Deviant sexual interests (e.g., sexually attracted to minors)
• Risk, Need, Responsivity
  Treatment should be proportionate to risk, treatment should target needs related to offending, consider how responsive people are to diff. treatment

Question 20

sex offender treatment

Answer 20

• Aim: to reduce the risk that an individual will commit another offence again in the future
• Sex Offender Treatment Program (SOTP)
  
  • Delivered to sexual offenders in England and Wales
  • Other similar programs delivered in other countries
  • Typically cognitive behavioural in approach
    Focus on reducing ‘risk factors’ related to sexual offence recidivism

Question 21

does sex offender treatment work?

Answer 21

• Unclear!
• Meta-analyses suggest that sex offender treatment does reduce sexual recidivism
  
  • 10.1 % in treated vs. 13.7 % in untreated offenders (Schmucker & Lösel, 2015)
    A report for the Ministry of Justice suggests that sex offender treatment may increase sexual recidivism (10.0% compared with 8.0%)

Question 22

what went wrong?

Answer 22

• Need to consider what is targeted in treatment and how
• Survey of sex offender treatment programs suggests that treatment my be targeting factors that are unrelated to sexual offence recidivism
  
  • e.g., denial, victim empathy
• Other factors that are related to recidivism are often not targeted
  
  • e.g., deviant sexual interests, self-regulation
    Gannon et al. 2019: treatment is effective but need to consider method of delivery, e.g., talking therapies may be useful for addressing certain risk factors, who delivers treatment, training etc.

Question 23

new suite of treatment programmes

Answer 23

• Movement away from treatment based on offence type
• New treatment programmes include Horizon and Kaisen
  
  • cognitive behavioural model
  • delivered to people depending on level of risk
• People with specific needs may attend more specialised modules
  
  • Healthy Sex Programme for people with paraphilic sexual interests
    Effectiveness of these programmes remains unclear, undergoing evaluation by HMPPS

Question 24

emotion regulation

Answer 24

• Known risk factor for sexual offence recidivism, theory and research suggests a causal role but may not be effectively targeted in treatment (Gillespie et al., 2012)
• Ability to implement intentional cognitive control over emotions
• What are emotions?
  
  • Spontaneous, not consciously provoked
  • Provide positive and negative valence
  • Goal directed
  • Involve multi-system changes (behavioural, autonomic, physiological)
• Two main strategies
  
  • Reappraisal
    ○ Form of cognitive change, think in different way about same situation
    ○ Dependent on higher order brain processes
    ○ e.g., an interview = an opportunity, not a test
  • Emotion Suppression
    ○ Form of response modulation, inhibit emotionally expressive behaviours
    ○ Effects on expressive behaviour and physiology
    ○ e.g., poker face
• Understanding a mechanism for change
• Measured brain activation in healthy male participants while viewing erotic film excerpts
• Participants asked to either:
  
  • respond in normal manner
    inhibit sexual arousal

Question 25

potential role of mindfulness

Answer 25

• Recommended for inclusion in sex offender treatment to address problems in emotion regulation (Gillespie et al., 2012)
• Origins in Buddhism and Eastern traditions
• Paying attention in the present moment, non- judgementally (Jon Kabat-Zinn, 1994)
• Three interacting components contribute toward enhanced self-regulation
• Can be developed through a variety of meditation exercises
  
  • e.g., mindful breathing, body scan meditation
• Increasingly incorporated in to Western medicine
  
  • Mindfulness-Based Stress Reduction (Grossman et al., 2004)
  • Mindfulness-Based Cognitive Therapy (Teasdale et al., 2000)
    But, limited support in forensic samples
• Few studies have examined specific problems in emotion regulation
• 397 offenders recruited from 15 prisons in Northern and central Italy:
  
  • Homicide (N = 86; 21.7%)
  • Violent, non-sexual (N = 159; 40.1%)
    Sexual (N = 68; 17.1%)

Question 26

generalised or specific impairments

Answer 26

• Sex offenders showed specific impairment in acceptance of emotional states
• More pervasive difficulties in the violent group
  
  • Higher levels of anger
  • Greater emotional non-acceptance
  • Evidence of alexithymia, difficulties identifying emotions
  • Some mindfulness problems, non-judgement, acting with awareness
    Homicide group may be relatively in charge of emotions

Question 27

existing mindfulness based studies

Answer 27

• Fix and Fix (2013)
  
  • Review reported benefits of meditation but noted methodological limitations
• Samuelson et al. (2007)
  
  • 2000 offenders took part in mindfulness based stress reduction
  • Exercises include body scan, stretching exercises, sitting meditation
  • Reported benefits across hostility, self-esteem and mood
• Verheul et al. (2003)
  
  • Benefits of Dialectical Behavior Therapy in borderline personality disorder
  • Mindfulness represents important component of DBT
    Development of acceptance based techniques for regulating emotions

Question 28

considerations in introducing mindfulness

Answer 28

• Potential difficulties introducing meditative practices
  
  • Unfamiliarity with meditation
  • Discomfort meditating in groups
• People may be differentially sensitive to mindfulness
  
  • Serotonin genes differentiate those who benefit most
• Definition, measurement and operationalisation
  
  • Only clear measurement technique = self-report
  • Limited by understanding, measurement validitycosts
    Difficult to evaluate change