A meta‐analytic review of the efficacy of psychological treatments for violent offenders in correctional and forensic mental health settings

Good-enough Care? How Patients' Perceptions of Counselors' Professional Skills Relate to Everyday Life in Forensic Long-stay Units

The overall goal of long-term forensic care is to strive toward acceptable levels of adaptation and quality of life (QoL) of the forensic patient in the institutional context. While the bulk of the literature has focused on the deleterious consequences of personality pathology in this regard, research investigating the contribution of the quality of the therapeutic relationship has remained rather scant. Assuming that the perceived competence of the direct counselor, as perceived by patients, forms an important aspect in this regard, the central aim of this study was to investigate the relationship between patients' perceptions of their therapist's professional skills, their self-reported maladaptive behavior on the ward, and their experienced QoL. To this end, we recruited patients (N = 60) in long-stay forensic units and investigated their perceptions of 10 specific skills displayed by their therapist, along a "too little-too much" rating scale. The results revealed that patients who had the overall impression that their counselor was equipped with an adequate set of professional skills showed less maladaptive behavior and perceived a higher QoL on the ward. Conversely, at a more specific competence level, only a positive relationship between a counselor's predictability and self-reported QoL was found. Taken together, these results highlight that an overall professional skill evaluation matters in the context of forensic patients' adaptation and QoL in their long-stay units, with the counselor's predictability serving as a crucial aspect in obtaining the most favorable outcomes.

Putting the usability of wearable technology in forensic psychiatry to the test: a randomized crossover trial

Introduction

Forensic psychiatric patients receive treatment to address their violent and aggressive behavior with the aim of facilitating their safe reintegration into society. On average, these treatments are effective, but the magnitude of effect sizes tends to be small, even when considering more recent advancements in digital mental health innovations. Recent research indicates that wearable technology has positive effects on the physical and mental health of the general population, and may thus also be of use in forensic psychiatry, both for patients and staff members. Several applications and use cases of wearable technology hold promise, particularly for patients with mild intellectual disability or borderline intellectual functioning, as these devices are thought to be user-friendly and provide continuous daily feedback.

Method

In the current randomized crossover trial, we addressed several limitations from previous research and compared the (continuous) usability and acceptance of four selected wearable devices. Each device was worn for one week by staff members and patients, amounting to a total of four weeks. Two of the devices were general purpose fitness trackers, while the other two devices used custom made applications designed for bio-cueing and for providing insights into physiological reactivity to daily stressors and events.

Results

Our findings indicated significant differences in usability, acceptance and continuous use between devices. The highest usability scores were obtained for the two fitness trackers (Fitbit and Garmin) compared to the two devices employing custom made applications (Sense-IT and E4 dashboard). The results showed similar outcomes for patients and staff members.

Discussion

None of the devices obtained usability scores that would justify recommendation for future use considering international standards; a finding that raises concerns about the adaptation and uptake of wearable technology in the context of forensic psychiatry. We suggest that improvements in gamification and motivational aspects of wearable technology might be helpful to tackle several challenges related to wearable technology.

The Risk, Need, and Responsivity Relevance of Working Alliance in a Sexual Offense Treatment Program: Its Intersection With Psychopathy, Diversity, and Treatment Change

The current study examined the self-reported working alliance of men attending a high intensity sexual offense treatment program and its associations with psychopathy, sexual violence risk, treatment change, and recidivism, in a Canadian sample of 317 incarcerated men followed up an average of approximately 10 years post release. Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-reported total, Task, Bond, and Goal scores were positively correlated with treatment related changes in risk, and inversely associated with Psychopathy Checklist-Revised (PCL-R; Hare, 1991; Wang & Hare, 2003) scores. The Affective facet of the PCL-R, representing the callous-unemotional features of the syndrome, uniquely predicted lower Bond and Goal scores controlling for the other facets. Cox regression survival analyses demonstrated that sexual violence risk predicted increased sexual recidivism while change predicted decreased sexual recidivism controlling for PCL-R total score; however, WAI scores (particularly the Goal component) were also unexpectedly associated with increased sexual recidivism. For violent recidivism, psychopathy, risk, and change incremented the prediction of general violence, while the WAI was not significantly associated with this outcome. A set of parallel analyses, stratified by Indigenous ethnocultural heritage, demonstrated some continuity, but also potential areas of difference, in substantive findings. Risk, need, responsivity implications of the working alliance for the treatment of high psychopathy correctional clientele, and how this may intersect with Indigenous heritage, are discussed.

VR-assisted aggression treatment in forensic psychiatry: a qualitative study in patients with severe mental disorders

Introduction

Improvements in virtual reality (VR) have made it possible to create realistic, virtual settings for behavioral assessment and skills training that cannot otherwise be accessed in a safe way in forensic psychiatric settings. VR interventions are under development but little is known how forensic psychiatric patients with severe mental disorders experience VR-assisted assessments or treatments.

Methods

The present study aimed to help fill this knowledge gap via qualitative interviews with seven patients with severe mental disorders at a high-security forensic psychiatric clinic who had completed the newly revised Virtual Reality Aggression Prevention Training (VRAPT). All participants were interviewed 12 weeks after the VRAPT intervention, and interview data analyzed with manifest inductive content analysis.

Results

Six manifest content categories were identified: 1. Therapeutic process, 2. VRAPT method, 3. VR technology, 4. Previous treatment experiences, 5. Challenges to treatment of aggression, and 6. Unexpected experiences. The participants had diverse experiences related to both the VRAPT intervention and forensic psychiatric care. Participants described a mixture of positive experiences in relation to VR-assisted role-plays, and less positive in relation to motivation for aggression-focused treatment and technological limitations.

Discussion

The present findings suggest further studies are needed on how to best implement VR-assisted treatments for aggression in forensic settings, and potentially further modification of treatment content in interventions like VRAPT.

[Patient Factors in Offender Treatment: Personality, Therapy Motivation and Outcome]

Using a systematic literature review according to the PRISMA criteria, patient factors of offenders were related to forensic outcomes. Searches were conducted in the PsycInfo and PSYNDEX databases; further relevant studies were taken from the bibliographies of studies that met the selection criteria. Only quantitative empirical studies for the period 1990-2021 were included. Findings from 31 studies on patient factors (personality, therapy motivation, therapy expectation, satisfaction with therapy) are reported. Patient factors could not always be consistently associated with outcomes. The clearest correlations were found between the expression of anti- or dissocial personality traits and/or psychopathy and (negative) therapy outcomes. Traits usually associated with antisocial developments (impulsivity, anger, rage, hostility) in some cases also correlated negatively with therapeutically desirable outcomes. Patient motivation for therapy should generally have a positive impact on the likelihood of successful forensic therapies, but not all relevant studies pointed in this direction. No studies were identified on the relationships between therapy expectancy or satisfaction and outcome. Based on general psychotherapy research, we suggest that offender therapy could benefit from broader approaches to studying therapy effectiveness.

Results From a Non-Randomized Pilot Study Evaluating the Impact of a Novel Group Treatment Program Targeting Aggressive Script Rehearsal and Emotion Regulation in a Sample of Incarcerated Males

This study compared the efficacy of a novel group-based aggressive script rehearsal treatment program with an emotion regulation program. Participants were 48 incarcerated adult males (28 in the script rehearsal program and 20 in the emotion regulation program). Outcomes, including the frequency of aggressive script rehearsal, aggressive behavior, and emotion regulation difficulties, were measured pre-and post-treatment and at 46 days (on average) after treatment completion, and 104 days (on average) following treatment completion. Linear Mixed Model analyses revealed no significant difference in the frequency of script rehearsal overtime for either program. There was a significant reduction in aggressive behavior associated with the script rehearsal program and a reduction in emotion regulation difficulties for both programs. Future iterations of this aggressive script rehearsal treatment program may benefit from greater intensity and incorporation of strategies that address the many cognitive, affective, and situational factors that trigger and maintain aggressive scripts.

Treatment of aggression regulation problems with virtual reality: study protocol for a randomized controlled trial

Background

Aggressive conduct among delinquents presents a pervasive issue, bearing substantial implications for not only society at large but also for the victims and the individuals displaying the aggression. Traditional approaches to treating aggression regulation deficiencies generally employ Cognitive Behavioral Therapy (CBT) in conjunction with analog role-playing exercises. A body of research supports the efficacy of various therapeutic models for aggression regulation, including Responsive Aggression Regulation Therapy (Re-ART). Role-playing within a therapeutic context has been shown to contribute significantly to reductions in violent reoffending. However, the practical application of these skills in real-world settings remains challenging due to the inherent risk of aggressive outbreaks. Additionally, the conventional role-playing scenarios, often conducted in a therapy room, lack contextual realism and may induce role confusion between the patient and the therapist. Virtual Reality (VR) technology could offer a viable solution to these limitations by allowing for skill training in both behavioral and cognitive domains within a realistic yet safe and controlled setting. The technology also facilitates real-time awareness of emotional states and tension levels in the patient. This paper describes the study protocol of a randomized controlled trial in which Re-ART offered in a virtual environment (Re-ART VR) is compared to Re-ART offered as treatment as usual.

Methods and analysis

Adult forensic outpatients with aggression regulation problems are randomly assigned to either Re-ART VR or Re-ART. The Controlling Skills, Influence of Thinking and Handling Conflicts modules will be offered to both groups during 3-6 months. Pre- and post-intervention measurements are performed. The primary outcome measurement is the degree of aggression regulation, while secondary outcome measurements include impulsivity and cognitive biases. Additionally, patient motivation and therapist motivation are expected to act as moderating factors.

Discussion

To date, scarcely previous research has been done on the effectiveness of VR in treatment of aggression regulation problems in forensic outpatients. Forensic outpatients who do not benefit sufficiently from mainly CBT-based interventions may benefit more from experiential learning. The unique capabilities of VR in this regard have the potential to enhance the treatment effect.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NL78265.018.21].

Neuropsychological assessment of aggressive offenders: a Delphi consensus study

Objective

This study explores the intricate relationship between cognitive functioning and aggression, with a specific focus on individuals prone to reactive or proactive aggression. The purpose of the study was to identify important neuropsychological constructs and suitable tests for comprehending and addressing aggression.

Methods

An international panel of 32 forensic neuropsychology experts participated in this three-round Delphi study consisting of iterative online questionnaires. The experts rated the importance of constructs based on the Research Domain Criteria (RDoC) framework. Subsequently, they suggested tests that can be used to assess these constructs and rated their suitability.

Results

The panel identified the RDoC domains Negative Valence Systems, Social Processes, Cognitive Systems and Positive Valence Systems as most important in understanding aggression. Notably, the results underscore the significance of Positive Valence Systems in proactive aggression and Negative Valence Systems in reactive aggression. The panel suggested a diverse array of 223 different tests, although they noted that not every RDoC construct can be effectively measured through a neuropsychological test. The added value of a multimodal assessment strategy is discussed.

Conclusions

This research advances our understanding of the RDoC constructs related to aggression and provides valuable insights for assessment strategies. Rather than suggesting a fixed set of tests, our study takes a flexible approach by presenting a top-3 list for each construct. This approach allows for tailored assessment to meet specific clinical or research needs. An important limitation is the predominantly Dutch composition of the expert panel, despite extensive efforts to diversify.

Pinpointing change in virtual reality assisted treatment for violent offenders: a pilot study of Virtual Reality Aggression Prevention Training (VRAPT)

Preventing relapse into violence and its destructive consequences among persistent re-offenders is a primary concern in forensic settings. The Risk-Need-Responsivity framework models the best current practice for offender treatment, focused on building skills and changing pro-criminal cognitions. However, treatment effects are often modest, and the forensic context can obstruct the delivery of interventions. Developing treatments for offenders should focus on the best method of delivery to make "what works work." Virtual reality (VR)-assisted treatments such as Virtual Reality Aggression Prevention Training (VRAPT) are a new and innovative approach to offender treatment. This pilot study followed 14 male violent offenders who participated in VRAPT in a Swedish prison context and measured changes from pre-treatment to post-treatment and 3-month follow-up in targeted aggression, emotion regulation, and anger. It also investigated potential impact factors (pro-criminal cognitions, externalizing behaviors, psychosocial background, and childhood adverse experiences). In Bayesian linear mixed effects models, participants showed a high probability of change from pre-treatment to post-treatment and to follow-up on all outcome measures. All outcome measures demonstrated a low probability of change from post-treatment to follow-up. Analysis of reliable change showed that participants' results ranged from recovery to deterioration. We discuss the implications of the study for VRAPT's impact on the target group, those who might benefit from the approach, and suggested foci for future studies in the field of VR-assisted offender treatment. The study was preregistered at the International Standard Randomized Controlled Trial Number registry (https://doi.org/10.1186/ISRCTN14916410).

Virtual reality aggression prevention treatment in a Dutch prison-based population: a pilot study

Background

Treating violent behavior in prisons comes with challenges, such as the inability to practice safely with triggering situations and motivational issues. A solution may be the use of Virtual Reality (VR). With VR, specific conditions or needs can be tailored for individual practice, it can enhance motivation and VR has proven to be a safe and effective tool in mental health treatment.

Objective

A pilot study was conducted to test the acceptability, feasibility, and preliminary effects of VR Aggression Prevention Treatment (VRAPT) in a prison-based population.

Methods

In total 17 detainees with aggressive behavior were included in this single-group pilot study. Acceptability and feasibility were assessed using qualitative measures for participants and therapists. Preliminary treatment effects were measured with self-report and observational measures on aggression, anger, emotion regulation, and impulsiveness.

Results

Participants and therapists were predominantly positive about VRAPT. Participants rated the sessions with an average satisfaction score of 9.2 out of 10 (SD = 0.3). Qualitative data showed that participants reported having learned to respond more adequately to aggressive behavior and gained insights into their own and others' triggers and tension. The combination of VR and theory was experienced as a strength of the treatment, as well as the ability to trigger aggression in VR which provided insights into aggression. However, the theoretical framework was found to be too complex, and more aggressive and personal scenarios should be incorporated into the sessions. Self-reported aggression, anger, provocation, emotion regulation, and observed verbal aggression decreased and seemed to stabilize after the treatment ended, with small to medium effect sizes.

Conclusion

VRAPT proved feasible and acceptable for most participants and therapists. An adapted treatment protocol called Virtual Reality Treatment for Aggression Control (VR-TrAC), will be used in a future RCT to investigate the effects of the treatment in a prison-based population.

A systematic review of the efficacy of psychological treatments for people detained under the Mental Health Act

WHAT IS KNOWN ON THE SUBJECT?: International reviews have looked at therapy outcomes for patients on mental health wards, showing it is associated with reduced emotional distress and readmission. Reviews have not looked at which specific treatments are most effective. No review has been done in England and Wales for patients detained specifically under the Mental Health Act.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

The paper gives an overview of the limited evidence in England and Wales. The paper shows which therapies have been measured. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Larger studies are needed across all types of patient wards in England and Wales with random allocation to types of therapy and longer-term follow-up. More studies are needed where researchers are not aware of the therapy being delivered. More studies need to use a mixture of patient and clinician outcome measures. Outcomes should also measure incident, readmission and reoffending rates. More evidence is needed from patients who are female, non-white and who are diagnosed with depression and anxiety.

ABSTRACT

INTRODUCTION: The efficacy of psychological interventions delivered under the Mental Health Act (1983) (MHA) in England and Wales is unclear. While meta-analyses have reviewed acute and forensic psychological interventions in wider geographical areas, there has been no review specifically in the unique MHA context.

AIM

A systematic review was conducted of psychological outcomes for inpatients detained under the MHA in England and Wales.

METHOD

Diagnoses and type of psychological intervention were not restricted, provided a psychological outcome measure was used. Studies were identified through APA PsychInfo, MEDLINE, CINAHL and Academic Search using a combination of key terms. Data extraction included effect direction, statistical significance, intervention type, format and duration, study size, inpatient setting, control group and study quality.

RESULTS

High-quality evidence was sparse. Some improvements were found in overall well-being, self-esteem, social functioning, problem-solving, substance use, anger, offending attitudes, fire-setting, violence, anxiety, depression, personality disorder and psychosis. However, the overall evidence base is lacking.

DISCUSSION

Larger-scale randomized controlled trials are needed across secure, acute and learning disability inpatient settings in England and Wales with longer term follow-up, blind assessors and both self-report and clinician-rated measures, as well as incident, readmission and reoffending rates. Greater representation is needed of females, non-white groups and affective disorders.

CLINICAL IMPLICATIONS

The efficacy of psychological interventions for inpatients detained under the MHA in England and Wales remains unclear. Clinicians are encouraged to use relevant outcome measures in relation to treatment goals, to monitor the efficacy of interventions being offered to this client group.

RELEVANCE TO MENTAL HEALTH NURSING

This paper highlights the current body of evidence for psychological interventions in inpatient settings within England and Wales, which is an environment in which mental health nursing plays an important role in patients' recovery. This evidence is also particularly important as there is a shift in clinical practice to training nursing staff to deliver some of the low-intensity psychological interventions, such as behavioural activation, solution-focussed therapy and motivational interviewing.

Effectiveness of a program for the development of socio-emotional competences in people admitted to a penitentiary center

The purpose of this paper was to evaluate the effectiveness of a program for the development of social and emotional competences and self-esteem among a group of inmates at a penitentiary center, as well as to determine the possible correlation between the variables of the program (social skills, emotional competences, and self-esteem). The objective was to equip inmates with social competences in emotional regulation strategies that would be useful to them in the penitentiary center and, at the same time, facilitate their future social inclusion. In order to measure the pre- and post- treatment variables, the Social Skills Scale, the Perceived Emotional Intelligence Scale (TMMS-24), and the Rosenberg Self-Esteem Scale (RSES) were administered to a group of 51 inmates in a penitentiary center. The experimental group consisted of 29 inmates, with 21 forming the control group. The pretest-posttest ANOVAs showed that the program led to a significant (p < 0.01) increase in: (1) positive social behaviors; (2) emotional competences; (3) self-esteem. Positive correlations were also observed between the three variables. The results suggest the importance of implementing programs for the promotion of the socio-emotional development of people incarcerated in penitentiary centers.

Treatment Evaluation in Forensic Psychiatry. Which One Should Be Used: The Clinical Judgment or the Instrument-based Assessment of Change?

In forensic psychiatry, it is common practice to use an unstructured clinical judgment for treatment evaluation. From risk assessment studies, it is known that the unstructured clinical judgment is unreliable and the use of instruments is recommended. This paper aims to explore the clinical judgment of change compared to the calculated change using the Instrument for Forensic Treatment Evaluation (IFTE) in relation to changes in inpatient violence This study shows that the clinical judgment is much more positive about patient's behavioral changes than the calculated change. And that the calculated change is more in accordance with the change in the occurrence of inpatient violence, suggesting that the calculated change reflects reality closer than the unstructured clinical judgment. Therefore, it is advisable to use the IFTE as a base to make a structured professional judgment of the treatment evaluation of a forensic psychiatric patient.

A Systematic Literature Review of the Contribution Accumulation Makes to Psychological and Physical Trauma Sustained through Childhood Maltreatment

The pervasive effects of cumulative harm resulting from adverse childhood experiences influence all aspects of an individual’s life course. Research highlights a relationship between accumulation and trauma symptomology across all domains of harm and risk. A systematic literature review was conducted to explore and synthesize the current evidence base for the contribution accumulation makes to psychological and physical injury of childhood trauma. A search was conducted relevant to two areas of interest: (a) “cumulative harm” or “cumulative trauma” and (b) “consequences and outcomes”. Database searches and further manual searches yielded a total of 1199 articles, and 12 studies satisfied all the inclusion criteria. Only studies that were peer-reviewed and published between January 2011 and January 2022 were included. The evidence from the review indicated that multiplicity and polyvictimization, parental history and intergenerational transmission of trauma, systemic cumulative harm, and developmental lifespan outcomes were associated with the likelihood and impact of the accumulation of physical and psychological injury. The findings of this review contribute valuable knowledge to allow for a better understanding of the physical and psychological impact of accumulated and chronic childhood trauma. This knowledge will improve intervention, prevention, and management strategies for helping professionals working with traumatized or vulnerable children and adults.

Conducting Randomized Controlled Trials of Complex Interventions in Prisons: A Sisyphean Task?

Randomized Controlled Trials (RCT) are the "gold standard" for measuring the effectiveness of an intervention. However, they have their limitations and are especially complex in prison settings. Several systematic reviews have highlighted some of the issues, including, institutional constraints e.g., "lock-downs," follow-ups, contamination of allocation conditions and a reliance on self-report measures. In this article, we reflect on our experiences and will describe two RCTs. People in prison are a significantly disadvantaged and vulnerable group, ensuring equitable and effective interventions is key to reducing inequality and promoting positive outcomes. We ask are RCTs of complex interventions in prisons a sisyphean task? We certainly don't think so, but we propose that current accepted practice and research designs may be limiting our understanding and ability to test complex interventions in the real-world context of prisons. RCTs will always have their place, but designs need to be flexible and adaptive, with the development of other rigorous methods for evaluating impact of interventions e.g., non-randomized studies, including pre-post implementation studies. With robust research we can deliver quality evidence-based healthcare in prisons - after all the degree of civilization in a society is revealed by entering its prisons.

Pharmacotherapy of Primary Impulsive Aggression in Violent Criminal Offenders

Primary impulsive aggression (PIA) can be implicated as a common factor that results in an arrest, disciplinary, and restraint measures during confinement, and criminal recidivism after release. Evidence suggests that anti-impulsive aggression agents (AIAAs) can diminish or prevent impulsive aggression even when occurring with personality pathology such as borderline or antisocial personality disorder (ASPD), common conditions in offender populations. A previous review identified agents that have been subjected to controlled drug trials of sufficient quality, and subsequently, a decisional algorithm was developed for selecting an AIAA for individuals with IA. This selection process began with the five agents that showed efficacy in two or more quality studies from the earlier review. Today, 8 years after the quality review study, the present authors undertook this follow-up literature review. The aims of the present review were to survey the literature to identify and assess: (1) drug trials of comparable quality published since the 2013 review, including trials of the previously identified AIAAs as well as trials of agents not included in the earlier review; (2) severity of aggressive outbursts; (3) the materiality of risks or side-effects that are associated with individual AIAAs as well as antipsychotic agents commonly used to control clinical aggression; (4) efficacy of these agents in special populations (e.g., females); and (5) cost and convenience of each agent. Improved pharmacotherapy of PIA by addressing risks, side effects and practicality as well as the efficacy of AIAAs, should promote the rehabilitation and reintegration of some pathologically aggressive offenders back into the community.

Factors Affecting Treatment Regress and Progress in Forensic Psychiatry: A Thematic Analysis

International variability and shifting trends in forensic psychiatry lead to gaps in national service provision and needs for service development. This study explores these needs through the subjective narratives of those involved in Finnish forensic services, either as forensic psychiatric patients, their parents, or service providers. Data was gathered by means of thematic interview and subjected to thematic analysis. Three main themes emerged: (1) pre-treatment challenges, (2) institutional/treatment-related concerns about therapeutic security and (3) adapting and recovery. The research highlights the need to develop forensic psychiatric services at three levels. First, it calls for increased risk awareness and risk assessment skills at the general psychiatric level. Second, it emphasizes the need for increased therapeutic engagement throughout the rehabilitative process. Third, it calls for structured and meaningful post-discharge aftercare. At all three levels, gradated security-aware standardization and patient triage in forensic services would help to develop and maintain an intact care pathway. This would decrease offending, marginalization, and suffering. Only then can we begin to meet the requirements of the WHO European Mental Health Action Plan. These findings can contribute to the development of international, standardized treatment models for clinical forensic psychiatric practices.

The effects of judicial supervision on recidivism of offenders in Australia and New Zealand: a systematic review and meta-analysis

This meta-analysis compares recidivism reduction in problem-solving courts employing judicial supervision in Australia and New Zealand to traditional processes. Using a four-phased search strategy, 16 studies totalling a treatment sample of 6588 individuals and 32,147 comparison participants were identified from 7161 unique records. Meta-analyses indicate that the problem-solving courts significantly reduced both the odds and incidences of recidivism compared with standard justice processes but that the heterogeneity observed within the latter analysis plus reliance on weak methodologies limits the strength of these conclusions. Studies at risk of bias may have had an undue influence on the odds of recidivism analysis. Additionally, the benefits of treatment on the incidence of recidivism are closely linked to the overlap of measurement and treatment periods. The findings suggest a positive impact from judicial supervision but further rigorous research is needed that closely matches experimental samples, strictly measures participants post-intervention and meticulously reports pertinent information.

Effectiveness of psychological interventions in prison to reduce recidivism: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Repeat offending, also known as criminal recidivism, in people released from prison has remained high over many decades. To address this, psychological treatments have been increasingly used in criminal justice settings; however, there is little evidence about their effectiveness. We aimed to evaluate the effectiveness of interventions in prison to reduce recidivism after release.

METHODS

For this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, Embase, Global Health, MEDLINE, PsycINFO, and Google Scholar for articles published from database inception to Feb 17, 2021, without any language restrictions. We searched for randomised controlled trials (RCTs) that evaluated the effect of psychological interventions, delivered to adolescents and adults during incarceration, on recidivism outcomes after release. We excluded studies of solely pharmacological interventions and of participants in secure psychiatric hospitals or special residential units, or attending therapies mainly delivered outside of the prison setting. We extracted summary estimates from eligible RCTs. Data were extracted and appraised according to a prespecified protocol, with effect sizes converted to odds ratios. We used a standardised form to extract the effects of interventions on recidivism and estimated risk of bias for each RCT. Planned sensitivity analyses were done by removing studies with fewer than 50 participants. Our primary outcome was recidivism. Data from individual RCTs were combined in a random-effects meta-analysis as pooled odds ratios (ORs) and we explored sources of heterogeneity by comparing effect sizes by study size, control group, and intervention type. The protocol was pre-registered with PROSPERO, CRD42020167228.

FINDINGS

Of 6345 articles retrieved, 29 RCTs (9443 participants, 1104 [11·7%] females, 8111 [85·9%] males, and 228 [2·4%] unknown) met the inclusion criteria for the primary outcome. Mean ages were 31·4 years (SD 4·9, range 24·5-41·5) for adult participants and 17·5 years (SD 1·9; range 14·6-20·2) for adolescent participants. Race or ethnicity data were not sufficiently reported to be aggregated. If including all 29 RCTs, psychological interventions were associated with reduced reoffending outcomes (OR 0·72, 95% CI 0·56-0·92). However, after excluding smaller studies (<50 participants in the intervention group), there was no significant reduction in recidivism (OR 0.87, 95% CI 0·68-1·11). Based on two studies, therapeutic communities were associated with decreased rates of recidivism (OR 0·64, 95% CI 0·46-0·91). These risk estimates did not significantly differ by type of control group and other study characteristics.

INTERPRETATION

Widely implemented psychological interventions for people in prison to reduce offending after release need improvement. Publication bias and small-study effects appear to have overestimated the reported modest effects of such interventions, which were no longer present when only larger studies were included in analyses. Findings suggest that therapeutic communities and interventions that ensure continuity of care in community settings should be prioritised for future research. Developing new treatments should focus on addressing modifiable risk factors for reoffending.

FUNDING

Wellcome Trust, Fonds de recherche du Québec - Santé.

The association between adverse childhood experiences and mental health problems in young offenders

High rates of adverse childhood experiences (ACEs, e.g., abuse and neglect) have been found in young offenders. Furthermore, ACEs seem to increase the risk of developing relevant mental health problems, in non-offending juveniles and adults. However, this association has only seldomly been addressed in offending juveniles and young adults. The present study aimed at evaluating the prevalence of ACEs and mental health problems as well as their association within a sample of male and female young offenders. Altogether, 161 adolescent and young adult offenders (16.8% females) from the youth detention center Worms (Germany) filled out questionnaires concerning ACEs and mental health problems with a focus on attention-deficit/hyperactivity disorder and intermittent explosive disorder. Considerable rates of mental health problems were found, e.g., a prevalence of 35.9% was found for intermittent explosive disorder. Furthermore, a greater proportion of the female offenders fell into the clinically significant category for somatic complaints, anxiety/depression, and attention problems than the male offenders. Female young offenders also reported more frequently about all forms of ACEs compared to the male offenders. Latent class analysis defined three subtypes of young offenders depending on their individual ACE patterns: (1) low ACEs, (2) mainly neglectful ACEs, and (3) multiple ACEs. ACEs were significantly associated with the occurrence of both internalizing and externalizing mental health disturbances, with the multiple-ACE subtype being most likely to report about significant mental health problems. The results of the present study point towards the relevance to routinely assess ACEs in young offenders to identify possible precursors of mental health problems and of future criminal behaviors.

Self-report versus clinician-ratings in the assessment of aggression in violent offenders

BACKGROUND

The construct of aggression is central to work with violent offenders, but it is a broad construct that can be assessed by many different methods and instruments. Its measurement may, however, have profound implications for treatment planning. We need more knowledge about how different methods for assessing aggression relate to each other.

AIMS

Our aims were to investigate, first, the convergence and concordance of two methods of assessing aggression: self-report and clinical assessment and, second, to determine the degree to which aggression can be discriminated from neighbouring constructs, such as hostility, anger and criminal behaviour.

METHODS

A nationally representative Swedish cohort of 269 18-25-year-old incarcerated violent offenders was recruited. Data were collected through structured self-reports of aggression, anger and hostility traits (Aggression Questionnaire-Revised Swedish Version) and clinical assessments of lifetime prevalence of aggressive and antisocial behaviours (Life History of Aggression). Criminal records were retrieved from the Swedish National Crime Register.

RESULTS

Self-ratings and clinician-ratings of aggression were highly convergent and concordant, especially regarding physical aggression. Violent offence records were weakly, if at all, correlated, while self-reported hostility was weakly, or not at all, correlated with self-reported or with clinician-rated aggression. There was an inverse relationship between aggression and criminal records of sexual offences.

CONCLUSIONS AND IMPLICATIONS

Even though a combination of self-reports and clinician-ratings may provide a better overview of an individual's aggressive behaviours, our results indicate that they yield such similar information that either alone would be sensitive enough. Our results do not, however, support using one of these methods as a proxy for the other since choice of measure and accepted concordance between them depend on the context within which the assessment is conducted. We reconfirmed that official records of violent offending are unlikely to be adequate measures of outcome after interventions to reduce aggressive behaviours.

A Systematic Review of Non-pharmacological Strategies to Reduce the Risk of Violence in Patients With Schizophrenia Spectrum Disorders in Forensic Settings

Background: The purpose of this systematic review is to systematically investigate which non-pharmacological interventions are effective in reducing violence risk among patients with schizophrenia spectrum disorders (SSD) in forensic settings. Methods: Six electronic data bases were searched. Two researchers independently screened 6,003 abstracts resulting in 143 potential papers. These were analyzed in detail by two independent researchers yielding 10 articles that could be used. Results: Of the 10 articles, four were non-randomized controlled trials, three were pre-post studies without controls, and one was observational. Only two studies applied a randomized controlled trial design. Cognitive behavioral treatment programs were investigated in three studies. A broad range of other interventions were studied. Often outcome measures were specific to each study and sample sizes were small. Frequently, important methodological information was missing from the papers. It was not possible to carry out a meta-analysis due to the heterogeneity of the study designs and outcome measures. Conclusion: Because of methodological limitations it is difficult to draw firm conclusions about the effectiveness of non-pharmacological interventions to reduce the risk of violence in patents with SSD in forensic psychiatry settings. Studies applying better methods in terms of study design, sample sizes and outcome measures are urgently needed.

A Perspective on the Integration of eHealth in Treatment of Offenders: Combining Technology and the Risk-Need-Responsivity Model

While there are multiple ways in which eHealth interventions such as online modules, apps and virtual reality can improve forensic psychiatry, uptake in practice is low. To overcome this problem, better integration of eHealth in treatment is necessary. In this perspective paper, we describe how the possibilities of eHealth can be connected to the risk-need-responsivity (RNR) model. To account for the risk-principle, stand-alone eHealth interventions might be used to offer more intensive treatment to high-risk offenders. The need-principle can be addressed by connecting novel experience-based interventions such as VR and apps to stable and acute dynamic risk factors. Finally, using and combining personalized interventions is in line with the responsivity-principle. Based on research inside and outside of forensic psychiatry, we conclude that there are many possibilities for eHealth to improve treatment-not just based on RNR, but also on other models. However, there is a pressing need for more development, implementation and evaluation research.

Effectiveness of an Individual Cognitive-Behavioral Intervention for Serious, Young Male Violent Offenders: Randomized Controlled Study With Twenty-Four-Month Follow-Up

Background: Psychological recidivism-reducing interventions with serious, young violent offenders in residential care have unsatisfactory effects. We tested if a complementary individual cognitive behavioral therapy (iCBT) intervention focusing problem-solving, cognitive self-control, and relapse prevention reduces criminal recidivism beyond usual institutional care encompassing interventions such as social skills training and prosocial modeling (treatment-as-usual; TAU). Method: We consecutively approached 115 eligible serious, male violent crime offenders in five residential treatment homes run by the Swedish National Board of Institutional Care. Eighty-one (70%) 16 to 21-year-old youth at medium-high violent recidivism risk were included and randomized to an individualized 15 to 20-session CBT intervention plus TAU (n = 38) or to TAU-only (n = 43), 4-6 months before release to the community. Participants were assessed pre- and post-treatment, at 12 months (self-reported aggressive behavior, reconvictions) and 24 months (reconvictions) after release. Intent-to-treat analyses were applied. Results: The violent reconviction rate was slightly higher for iCBT+TAU vs. TAU-only youth at 12 months (34 vs. 23%, d = 0.30, 95% CI: -0.24 to 0.84) and 24 months following release (50 vs. 40%, d = 0.23, 95% CI: -0.25 to 0.72), but neither of these differences were significant. Cox regression modeling also suggested non-significantly, negligibly to slightly more violent, and any criminal recidivism in iCBT+TAU vs. TAU-only youth during the entire follow-up. Further, we found no significant between-group differences in conduct problems, aggression, and antisocial cognitions, although both iCBT+TAU and TAU-only participants reported small to large within-group reductions across outcome measures at post-treatment. Finally, the 12-month follow-up suggested marginally more DSM-5 Conduct Disorder (CD) symptoms of "aggression to people and animals" in iCBT+TAU vs. TAU-only youth (d = 0.10, 95% CI: -0.40 to 0.60) although this difference was not significant. Conclusion: We found no additive effect of individual CBT beyond group-based TAU in residential psychological treatment for serious, young male violent offenders. Limited sample size and substantial treatment dropout reduced the robustness of intent-to-treat effect estimates. We discuss the possible impact of treatment dose and integrity, participant retention, and TAU quality.

The Effect of Dietary Supplementation on Aggressive Behaviour in Australian Adult Male Prisoners: A Feasibility and Pilot Study for a Randomised, Double Blind Placebo Controlled Trial

This study aimed to assess the feasibility of conducting a nutrition trial in adult male prisoners. Adult male prisoners were recruited for a 16-week randomised control trial comparing the effect of ingestion of omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA) and multivitamin supplements versus placebo on aggressive behaviour. The baseline and post-intervention assessments from the participant blood samples were the erythrocyte n-3 LCPUFA levels as well as measures of aggressive behaviour determined through institutional records of misconduct (IRM), the Inmate Behaviour Observation Scale (IBOS), and questionnaires. A total of 136 adult male prisoners consented to the study with a retention rate of 60%, and 93% of blood samples were successfully collected. The IRM and IBOS scores were collected for 100% of participants, whilst 82–97% of participants completed the questionnaires. From the baseline data, the Odds Ratio shows that prisoners are 4.3 times more likely to have an IBOS >2 if they are below the 6% cut off on the omega-3 index. Both groups improved across all outcome measures and, at the current sample size, no significant differences were seen between them. A power calculation suggests a total sample size of 600 participants is required to detect the effects of this dietary supplementation, and that this supplementation study is feasible in a Correctional Centre. Important criteria for the exclusion and consideration of logistics and compliance are presented.

Virtual Reality Aggression Prevention Therapy (VRAPT) versus Waiting List Control for Forensic Psychiatric Inpatients: A Multicenter Randomized Controlled Trial

Many forensic psychiatric inpatients have difficulties regulating aggressive behavior. Evidence of effective aggression treatments is limited. We designed and investigated the effectiveness of a transdiagnostic application of a virtual reality aggression prevention training (VRAPT). In this randomized controlled trial at four Dutch forensic psychiatric centers, 128 inpatients with aggressive behavior were randomly assigned to VRAPT (N = 64) or waiting list control group (N = 64). VRAPT consisted of 16 one-hour individual treatment sessions twice a week. Assessments were done at baseline, post-treatment and at 3-month follow-up. Primary outcome measures were aggressive behavior observed by staff and self-reported aggressive behavior. Analysis was by intention to treat. This trial was registered in the Dutch Trial Register (NTR, TC = 6340). Participants were included between 1 March 2017, and 31 December 2018. Compared to waiting list, VRAPT did not significantly decrease in self-reported or observed aggressive behavior (primary outcomes). Hostility, anger control, and non-planning impulsiveness improved significantly in the VRAPT group compared to the control group at post-treatment. Improvements were not maintained at 3-month follow-up. Results suggest that VRAPT does not decrease aggressive behavior in forensic inpatients. However, there are indications that VRAPT temporarily influences anger control skills, impulsivity and hostility.

The Violent Behavior Vignette Questionnaire (VBVQ): A Measure of Violent Behavior for Research in Forensic and Non-Forensic Settings and Populations

The measurement of violent behavior presents serious challenges for research on violence. In the current article, we present initial tests of the construct validity of scores on the Violent Behavior Vignette Questionnaire (VBVQ), which consists of a series of interpersonal conflict vignettes with response options in a multiple-choice format designed to measure current violent behavior. Violent responses on the initial version of the VBVQ generally corresponded to independent indicators of physical aggressiveness and violent behavior among male university students, men in the community, and incarcerated male offenders. We then refined the VBVQ and again tested the validity of its scores in new samples of men in the community and incarcerated male offenders. In both samples, men who selected a violent response option on the VBVQ generally had much higher levels of physical aggressiveness and violent behavior than did men who selected non-violent response options. However, VBVQ responses were not associated with the number of violent offenses in offenders' official criminal records. Our findings provide some support for the use of the VBVQ in lab and correctional/forensic research, but further research is required to determine whether it offers advantages over other measures.

At a crossroads? Offender rehabilitation in Australian prisons

This article presents a commentary on the current status of offender rehabilitation in Australian prisons. Prompted by recent debates concerning the value of rehabilitation programs in reducing rates of re-imprisonment, it considers the current evidence to support the effectiveness of Australian correctional programs highlighting the importance of the prison social climate, the intensity and quality of treatment and the need for psychological treatment to be integrated within broader models of rehabilitation and reintegration.

Well-Being as a Precursor and Consequence of Micro-Processes in a Group Psychotherapy With Forensic Patients

Psychotherapy is an important approach for the treatment of psychiatric disorders. Apart from treating disorders as such, psychotherapy aims at increasing patients' well-being. The Therapeutic Cycles Model (TCM) is a process-oriented theoretical model that makes predictions about the psychotherapeutic progress based on verbatim content. The model helps to identify therapeutic factors on a language level. The present study aims at analyzing transcripts of group therapy sessions with forensic psychiatric patients using the rationale of the TCM. Furthermore, the relationship between linguistic features of psychotherapy sessions and patients' well-being before and after therapy are investigated. In order to identify therapeutic factors, a group psychotherapy with nine drug addicted forensic psychiatric patients was videotaped and transcripts of N = 16 sessions were analyzed. Process-oriented measures were rated by the patients, their therapists, and an external observer. Patients' self-reported well-being before therapy was negatively related to Connecting (indicating emotional insight), and the frequency of therapeutic cycles, which are both thought of as key moments in therapy. Well-being of forensic patients is not necessarily a helpful precursor for insightful and productive events in therapy to occur. The findings help to better understand psychotherapeutic micro-processes throughout forensic therapies, and their relationship with patients' well-being. Implications for research and the forensic practice are discussed.