Treatment Engagement From the Perspective of the Offender

"One a Day Keeps the Prison Away": Understanding the Experiences of Individuals Convicted of Sexual Offences Receiving Anti-Androgens for the Treatment of Problematic Sexual Arousal

Problematic sexual arousal (PSA) is an umbrella term to describe a range of clinical presentations related to excessive sexual thinking (e.g., sexual preoccupation) and sexual behavior (e.g., hypersexuality). Although such concepts are known to affect sexual recidivism among individuals convicted of sexual offences, PSA is not routinely or directly targeted in offending behavior programs in England and Wales. However, in recent years, there have been moves to incorporate pharmacological interventions for addressing this among people with sexual offence histories. Although some work to understand the experiences of those taking SSRI medication for this purpose has emerged, little is known about the experiences of service users taking anti-androgen medication. In this study, we interviewed all individuals in prison taking anti-androgens for the treatment of problematic sexual arousal following convictions for sexual offences in England at the time of data collection (N = 10). Using a phenomenologically oriented thematic analysis, we established themes pertaining to "Differing needs: Motivations for treatment," "Medication as a risk management strategy," and how the medication helped the men in their pursuit of "Discovering a 'new me'." This work contributes important knowledge to inform the development of ethical and effective prescribing of anti-androgen medication with this population and offer recommendations for both future research and the development of clinical practice.

Attachment Theory and Sexual Offending: Making the Connection

PURPOSE OF REVIEW

The purpose of this review is to discuss how attachment theory can be applied to explain sexual violence. Specifically, it discusses how the development of certain risk factors contributes to these behaviors and how attachment-based models can be used to address this issue through prevention and therapeutic interventions.

RECENT FINDINGS

Recent research demonstrates that individuals who commit sexual offenses have higher rates of insecure attachment styles and that these styles are associated with a number of criminogenic risk factors associated with sexual offending. Such risk factors include cognitive processing difficulties, affect dysregulation, and challenges in interpersonal relationships, among others. Fortunately, treatment interventions have been shown to foster more secure attachment styles and reduce these risk factors. Attachment theory is a viable theory to both understand and intervene with those who have committed sexual violence to reduce the risk factors associated with sexual violence.

Looping Disruption: A Relational Mechanism Enhancing Treatment Readiness among Individuals Convicted of Sexual Offending?

Many convicted individuals do not enter or complete treatment programs in prisons, which limits effective rehabilitation and prevention of recidivism. Treatment readiness is suggested to be an important construct when addressing this problem. Nevertheless, the underlying processes (e.g., how readiness factors interact) are not well studied, and even less is known regarding readiness in the sub-population of individuals convicted of sexual offenses. This paper aims to open up the "black box" and explore psychosocial and context-specific processes behind treatment readiness from the vantage point of the individuals' lived experiences. In-depth interviews were conducted with 19 adult men convicted of sexual offenses in Swedish prisons, treatment participants (N = 13) as well as non-participants (N = 6). The thematic analysis illustrates readiness obstacles in terms of unintended antagonistic forces in the correctional system operating in the opposite direction of rehabilitative objectives. Nonetheless, a hypothesized relational mechanism, looping disruption, initiated by a non-punitive and supportive response (from prison staff, therapists, close ones, or inmates) to the convicted individual's negative behaviors or emotions, appeared to reverse such negative, punitive loops, contributing to the mobilization of treatment readiness. Implications for theory, policy, and practice are discussed.

Implementing evidence-based supported employment within specialty mental health probation: A hybrid type I implementation-effectiveness trial protocol

BACKGROUND

People with serious mental illnesses who are involved in the criminal justice system face significant challenges in obtaining meaningful employment. Given the importance of employment in reducing recidivism, the field needs effective interventions to increase employment rates, address mental health needs, and reduce recidivism for justice-involved people with serious mental illnesses. Individual Placement and Support - Supported Employment (IPS-SE) improves employment outcomes among individuals with serious mental illnesses and has shown promising results when implemented with individuals with histories of justice involvement; however, IPS-SE has only been implemented in mental health service settings. Given lower levels of treatment engagement and completion among justice-involved populations, implementation of IPS-SE in specialty mental health probation (SMHP) is an opportunity to increase reach and engagement among justice-involved people with serious mental illnesses.

METHODS

This article describes a hybrid type 1 implementation-effectiveness study that aims to: (1) assess the implementation enablers and barriers, as well as the feasibility, appropriateness, and acceptability of IPS-SE embedded within SMHP; (2) identify the multi-level factors (i.e., implementation determinants) that influence IPS-SE implementation within the context of a probation setting; and (3) assess the impact of IPS-SE on employment - our primary endpoint - and the impact of IPS-SE on a number of secondary outcomes and potential treatment mechanisms. The efficacy arm of the study will be a randomized controlled trial of 130 adults on community supervision who will either receive treatment as usual or IPS-SE. The implementation arm of the study will examine implementation determinants and implementation outcomes using qualitative methods.

Changes in the Risk of Sexual Reoffending: The Role and Relevance of Perceived Self-Efficacy and Adult Attachment Styles in Correctional Treatment

According to the Risk-Need-Responsivity (RNR) model, treatment effectiveness increases when treatment addresses all three associated core principles. While researchers have focused on the risk and need principles, responsivity remains under-investigated. The theoretical foundation of the RNR model and former research indicates low perceived self-efficacy and inadequate adult attachment styles as potential responsivity factors that can impede treatment of the underlying risk factors. This study assesses firstly whether these factors predict treatment attrition, and secondly changes in the assessed risk of sexual reoffending. Participants were N = 146 men sentenced for sexual offenses in a German social-therapeutic correctional facility. Younger age, higher number of previous convictions, and higher scores on the interpersonal facet of the Psychopathy Checklist-Revised are associated with a higher risk of treatment attrition. Unemployment prior to incarceration was found to be an aggravating factor, whereas substance abuse emerged as a mitigating factor, according reducing the risk of reoffending. Neither pre-treatment self-efficacy nor attachment styles revealed as responsivity factors in this study. Future studies should examine if the consideration of these factors during treatment might impact treatment outcomes.

"I've Got the Energy to Change, But I Haven't Got the Energy for This Kinda Therapy": A Qualitative Analysis of the Motivations Behind Democratic Therapeutic Community Drop-Out for Men With Sexual Convictions

Prison-based democratic therapeutic communities (TCs) provide an alternative to mainstream prison, where prisoners can work on psychological difficulties and address offending behavior. Research demonstrates TCs are effective at reducing reoffending rates for residents who stay in therapy 18+ months, and those who drop out of TCs offend at a significantly higher rate than those who complete therapy. Thus, it is important to reduce attrition in TCs. No research has yet explored the explanations for TC drop out offered by those with sexual convictions. The present study uses Interpretive Phenomenological Analysis to qualitatively explore the accounts of men with sexual convictions (n = 7) who dropped out of a TC in a UK prison. Results highlight that issues surrounding external responsivity, therapeutic relationships, and treatment readiness were salient in the participants' accounts of drop out. This research has implications for TCs seeking to better understand and address attrition of people with sexual convictions.

Exploring Risk for Sexual Recidivism and Treatment Responsivity Through the Lens of Early Trauma

Adverse childhood experiences (ACE) are common in the histories of individuals who have sexually offended. Many risk factors for sexual recidivism resemble symptoms of early trauma, and early trauma may present a responsivity barrier to engagement in offense-focused treatment. Using the ACE scale, the current study aimed to (i) examine relationships between ACE scores and static and dynamic risk assessment scores, (ii) examine whether ACE scores differ between treatment completers versus noncompleters, and finally (iii) examine whether ACE scores predict treatment noncompletion. ACE scores were retrospectively coded from files of adult men receiving community-based assessment and/or treatment in New Zealand for sexual offenses against children (N = 491; n = 185-411 for individual analyses). Although effect sizes were generally small, static risk and general self-regulation dynamic risk factors correlated positively with ACE scores, ACE scores were higher for treatment noncompleters versus completers, and higher dynamic risk assessment scores and ACE scores increased the odds of treatment noncompletion. Implications for future research and enhancing treatment responsivity are discussed.

Client Retention in Community Treatment: Completer and Noncompleter Experiences of an Individualized, Needs-Based Partner Abuse Intervention Program

There has been increased interest in the subjective experiences of participants of community partner abuse intervention programs (PAIPs). In the context of high attrition rates, qualitative research is needed to understand the factors associated with sustained engagement and dropout. Using a community nonmandated PAIP, the current study is a rare investigation of the experiences of both completers and noncompleters. We explored the differences between completers' and noncompleters' perceptions of the treatment process, the reasons for sustained program engagement, and the perceived outcomes of treatment. Semi-structured interviews were completed with 14 participants: nine completers and five noncompleters. The majority of participants were referred by children's social care and were unemployed at the time of interview. The interviews were conducted by research staff independent from the treatment-providing organization. Three themes emerged from the data: (a) Treatment as Challenging Yet Enlightening, (b) the Importance of a Well-timed and Safe Therapeutic Environment, and (c) Improved Emotional Self-Management Due to Treatment. Results highlighted how structured individualized sessions, underpinned by a strong therapeutic alliance with facilitators, helped participants increase their interpersonal problem-solving and communication skills. The study reinforced the importance of developing a therapeutic alliance and providing structured individualized treatment characterized by flexibility and accessibility. Noncompletion was perceived as related to known risk factors and treatment readiness. Therefore, it may be beneficial to employ screening measures to monitor these factors. Future research should use larger, more diverse samples to further investigate subjective experiences of PAIP completers and, particularly, noncompleters to enhance the limited literature in this area.

“Hurt people hurt other people”: The link between past trauma and sexual offending

Background

A growing body of research documents the high rates of trauma among individuals who have sexually offended. Yet the relationship between prior victimization and subsequent sexual offending remained unclear. Objective: By including the voices and perspectives of individuals convicted of sexual offenses, we sought to strengthen professionals’ understanding of the connection between victimization and offending.

Method

This qualitative study used an online survey to collect data from individuals convicted of sexual offenses (n = 195) with the aims of understanding their perceptions of the link between trauma and offending and what they would like sex-offense treatment providers to know about this connection.

Results

Using grounded theory, five major themes emerged from the data analysis: Relationship between Trauma Offending (n = 91), Acknowledging the Connection (n = 57), Specific Effects of Trauma (n = 48), Individualized Treatment (n = 34), and Recognition of Humanity (n = 26).

Conclusions

The participants perceived a strong connection between one’s own victimization and subsequent sexual offending. In addition, they offered specific recommendations for treatment providers, including individualizing treatment with an emphasis on humanity and compassion. Implications for trauma-informed practice and policy are discussed.

Early Treatment Change in Perpetrators of Sexual Versus Non-Sexual Violence

The purpose of this study is to assess treatment change at both a group and individual level in a sample of 81 Dutch male patients who received mandated care for either violent (non-sexual) behavior or sexual violent behavior. Psychiatric nurses rated patients' social skills, insight, hostility, physical violence with the BEST-Index every 6 months over the course of 2 years after patients were admitted to hospital. Mixed analysis of covariances and the reliable change index indicated that patients, irrespective of offense type, showed treatment change over time with exception of physical violence. This study shows that general treatment may be useful in the first 18 month for risk factors common to different types of offenses, but that specialized treatment is needed to establish further change.

Life on "the List" is a Life Lived in Fear: Post-Conviction Traumatic Stress in Men Convicted of Sexual Offenses

In recent years, there has been a rapid expansion of increasingly restrictive laws managing the post release behavior and movement of individuals convicted of sexual offenses. In the US, this legislation has led to many barriers for people returning to their community as "registered sex offenders." We consider the often ignored but undeniable traumagenic impact of life on "the list" and conceptualize this experience as Post-Conviction Traumatic Stress. We present a qualitative content analysis of secondary data collected from interviews with over 70 men. Emergent themes were first organized according to the human needs identified in Maslow's hierarchy, and then by the established symptoms of PTSD, and finally in terms of resilient coping versus traumatic coping when basic human needs were unmet. We discuss the unexplored impact of traumatic instability on risk for recidivism and present recommendations for trauma-informed policies and practices with individuals required to register as "sex offenders."

Longitudinal Network Structure and Changes of Clinical Risk and Protective Factors in a Nationwide Sample of Forensic Psychiatric Patients

In this study, we investigated network configurations of 14 Clinical risk and protective factors in a sample of 317 male forensic psychiatric patients across two time points: at the time of admission to the forensic psychiatric centers (T1) and at the time of unconditional release (T2). In terms of network structure, the strongest risk edge was between "hostility-violation of terms" at T1, and between "hostility-impulsivity" at T2. "Problem insight-crime responsibility" was the strongest protective edge, and "impulsivity-coping skills" was the strongest between-cluster edge, at both time points, respectively. In terms of strength centrality, "cooperation with treatment" had the highest strength centrality at both measurement occasions. This study expands the risk assessment field toward a better understanding of dynamic relationships between individual clinical risk and protective factors and points to the highly central risk and protective factors, which would be the best for future treatment targets.

Perceptions of procedural justice and coercion among forensic psychiatric patients: a study protocol for a prospective, mixed-methods investigation

BACKGROUND

The risk and recovery paradigms are the dominant frameworks informing forensic mental health services and have been the focus of increasing research interest. Despite this, there are significant gaps in our understanding of the nature of mental health recovery in forensic settings (i.e., 'secure recovery'), and specifically, the key elements of recovery as perceived by forensic patients and their treatment providers. Importantly, we know little about how patients perceive the forensic mental health system, to what extent they see it as fair and legitimate, and how these perceptions impact upon treatment engagement, risk for adversity, and progress in recovery.

METHODS

In this prospective, mixed-methods study, we investigate patient perceptions of procedural justice and coercion within the context of the forensic mental health system in Ontario, Canada (final N = 120 forensic patients and their primary care providers). We elicit patient self-assessments of risk and progress in recovery, and assess the degree of concordance with clinician-rated estimates of these constructs. Both qualitative and quantitative methods are used to assess the degree to which patient perceptions of coercion, fairness and legitimacy impact upon their level of treatment engagement, risk for adversity and progress in recovery. A prospective, two-year follow-up will investigate the impact of patient and clinician perspectives on outcomes in the domains of forensic hospital readmission, criminal reoffending, and rate of progress through the forensic system.

DISCUSSION

Results from this mixed-methods study will yield a rich and detailed account of patient perceptions of the forensic mental health system, and specifically whether perceptions of procedural fairness, justice and legitimacy, as well as perceived coercion, systematically influence patients' risk for adversity, their ability to progress in their recovery, and ultimately, advance through the forensic system towards successful community living. Findings will provide conceptual clarity to the key elements of secure recovery, and illuminate areas of similarity and divergence with respect to how patients and clinicians assess risk and recovery needs. In doing so, knowledge from this study will provide a deep understanding of factors that promote patient safety and recovery, and provide a foundation for optimizing the forensic mental health system to improve patient outcomes.

Predicting Attrition and Engagement in the Treatment of Young Offenders

Premature treatment termination in offender treatment is linked to negative consequences for clients, practitioners, and the criminal justice system. Therefore, identifying predictors of treatment attrition is a crucial issue in offender rehabilitation. Most studies on this topic focus on adult offenders; less is known about adolescent offenders. In our study, therapy attrition and engagement were predicted via logistic and linear regression to examine the link between pretreatment variables, engagement, and treatment failure in 161 young offenders treated in a social-therapeutic unit in Germany. Engagement could be predicted by motivation, disruptive childhood behavior, low aggressiveness, and higher age. In turn, low motivation, substance abuse, and young age predicted attrition, but their impact diminished when engagement was added to the model with only substance abuse remaining significant. The effect of substance abuse on attrition disappeared, when the offender's initial motivation was high. Implications for assessment and treatment planning are discussed.

Using Theory to Understand the Barriers to Engagement in Group Offending Behavior Programs

Noncompletion of group offending behavior programs is a common problem, indicating barriers to engagement. While existing theoretical models have accounted for determinants of motivation, little focus has been directed towards barriers to engagement. The authors developed the program engagement theory (PET) which not only accounts for the determinants of engagement and the engagement process, it also considers the barriers to engagement. Interviews and session observations were used to collect data from 23 program facilitators and 28 offenders, which were analyzed using grounded theory. The barriers to engagement were classified as program and referral factors (uninformative referrals, offense-focused programs, rigid and abstract content, didactic delivery, and homework), facilitator characteristics (lack of control: contentious and nonassertive), and group member characteristics (unmotivated, pre-contemplative, and blaming others and young, chaotic, and disruptive). Suggestions as to the design and facilitation of group offending behavior programs, and facilitator training and supervision to overcome barriers to engagement are proposed.

Can Completers, Non-Completers, and Non-Starters of Community-Based Offending Behavior Programs be Differentiated by Internal Treatment Readiness Factors?

This research aimed to determine whether completers, non-completers, and non-starters of community-based offending behavior programs could be differentiated by their levels of internal "treatment readiness." The Corrections Victoria Treatment Readiness Questionnaire (CVTRQ) measures offenders' Attitudes and Motivation, Emotional Reactions, Offending Beliefs, and Efficacy which, according to the Multifactor Offender Readiness Model (MORM), are internal dimensions of an offender's readiness to engage with treatment. Participants were offenders who had been court-mandated to attend a community-based cognitive skills offending behavior program. There were no significant differences between groups in respect of the CVTRQ total score. After controlling for risk of reconviction, however, the Self Efficacy construct differentiated program non-starters from program completers, while the Emotional Reactions construct differentiated program non-completers from program completers. In conclusion, the CVTRQ failed to differentiate program completion groups with the same success as elsewhere.

Are guilt and shame in male forensic patients associated with treatment motivation and readiness?

BACKGROUND

Motivation and readiness to change are important drives for forensic patients accessing interventions. It is thought that guilt and shame influence these drives, but to date, their relationship has not been empirically tested.

AIMS AND HYPOTHESES

The aim of this study is to investigate associations between guilt, shame, and treatment motivation and readiness in a sample of men in a secure hospital. It was hypothesised that guilt would be positively correlated, and shame negatively correlated, with treatment motivation and readiness.

METHODS

Sixty-six adult male patients detained in a secure hospital completed the assessments of experiences of guilt, shame, motivation, and readiness for treatment. Clinician-rated readiness ratings were also collected.

RESULTS

Shame proneness showed no significant association with motivation for change or treatment readiness. Guilt proneness and offence-related shame were positively correlated with treatment readiness. Offence-related guilt was positively correlated with both motivation and readiness. Regression modelling indicated offence-related guilt had a significant level of explanatory power.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This first study of the impact of guilt and shame on motivation and readiness for change among offender hospital inpatients found that offence-related guilt may be helpful but did not replicate the potential disadvantage of shame. Further research would be warranted into whether the "newness" or the extent of shame may be more important than shame more generally. Given the probable importance of offence-related guilt, we recommend that guilt attribution is assessed in offender patients to optimise nature and timing of treatment.

Support for the predictive validity of the multifactor offender readiness model (MORM): forensic patients' readiness and engagement with therapeutic groups

BACKGROUND

Treatment non-engagement in forensic health settings has ethical and economic implications. The multifactor offender readiness model (MORM) provides a framework for assessing treatment readiness across person, programme and contexts.

AIMS

To answer the following question: Are the internal factors of the MORM associated with likelihood of engagement in groups by patients in forensic mental health services?

METHOD

In a retrospective design, associations were investigated between internal factors of the MORM, measured as part of assessment for group participation, and the outcomes of treatment refusal, treatment dropout and treatment completion.

RESULTS

One hundred and eighteen male patients in a high security hospital consecutively referred for group treatment agreed to participate. Internal factors of the MORM associated with treatment refusals included: psychopathic cognition, negative self-evaluation/affect and effective goal-seeking strategies. Those associated with dropouts included emotional dysregulation, low competencies to engage and low levels of general distress. MORM factors associated with completion included: low motivation, ineffective goal-seeking strategies, absence of psychopathic cognition, high levels of general distress and competency to engage.

CONCLUSIONS

Internal factors of the MORM could be useful contributors to decisions about treatment readiness for hospitalised male offender-patients. Up to one in three programmes offered were refused, so clinical use of the MORM to aid referral decisions could optimise the most constructive use of resources for every individual. Copyright © 2016 John Wiley & Sons, Ltd.