Assessing Efficacy of Sex Assessing Efficacy of Sex Offender Treatment Offender Treatment Programs: Why This is Programs: Why This is ImportantImportant

Anthony Beech

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Assessing Efficacy of Sex Offender Assessing Efficacy of Sex Offender Treatment Programs: Why This is Treatment Programs: Why This is ImportantImportant

Decisions about public policy should be informed by the best available research evidence

Practitioners and decision-makers should be encouraged to make use of the latest research and information about best practice, and to ensure that decisions are demonstrably rooted in this knowledgeGiven the limited resources to run programs, all work

clearly has to be evidence-basedWe also need to know what works best for whom

Such work can give us a better idea of how to improve programs once they are in operation

Systematic reviews 2009 2

Aims of the talkAims of the talkGive a background to how research-

based treatment evolvedExamination of meta-analyses that

have attempted to demonstrate what treatment works

And further, what type of treatmentDescribe how the What Works

approach has grown out of this work, that addresses:◦Risk◦Need◦Responsivity in treatment

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BackgroundBackgroundThe issue of offender rehabilitation has been

a controversial and contested oneThe flashpoints include debate over the

effectiveness of rehabilitation and claims that even if treatment does reduce reoffending offenders do not deserve the opportunity to learn new skills and ultimately a chance at better lives (Ward, Collie & Bourke, 2009)

Instead, the argument goes, they should be humanely contained and the focus of sentencing on retribution rather than treatment (Ward, Collie & Bourke, 2009)

What Works 4

Background 2Background 2However, what is increasingly clear is that it

is possible to reduce reoffending rates by treating or rehabilitating offenders as opposed to simply incarcerating them (Andrews & Bonta, 2007)

Furthermore, treatment can be cost-effective as well as harm reducing

Most recent comprehensive reviews of what works in the correctional domain agree that some types of rehabilitation programmes are extremely effective in reducing reoffending rates (e.g., Andrews & Dowden, 2005, 2006).

What Works 5

Background 3Background 3For example, Lipsey’s (1992)

examination of almost 400 studies of juvenile delinquency treatment programmes led to the conclusion that cognitive behavioural interventions that were delivered in a rigorous and appropriate manner resulted in considerable reductions in reoffending (i.e., by at least 10%)

Thus active attempts to change the characteristics of offenders associated with crime can reduce future risk

What Works 6

What does not workWhat does not work On the other hand, deterrence based approaches

and diversion do not appear to provide any kind of significant treatment effect

The evidence suggests that deterrent type approaches which includes intensive supervision programming, boot camps, scared straight, drug testing, electronic monitoring, and increased prison sentences are ineffective in reducing recidivism (e.g., Gendreau, Goggin, Cullen, & Andrews, 2000; MacKenzie, Wilson & Kider, 2001)

In fact, a review of RCTs of scared straight programmes, Petrosino, Turpin-Petrosino and Fincknaeuer (2000) concluded that most actually increased recidivism (by up to 30%).

What Works 7

Effective treatment delivery in Effective treatment delivery in the UKthe UK In June 1998 the UK Home Office started what is

known as the ‘What Works’ InitiativeWhile earlier Dr. David Thornton had done the same

thing in UK prisonsThis has led to the development and

implementation of a demonstrably ‘effective core set of programs of supervision for offenders’ which:

Are research-based (typically from large meta-analytic studies)

Are based on a cognitive-behavioral treatment (CBT) approach

Run to a clear model that is used in for all groups Provide supervised treatment to ensure program integrity

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Meta-analytic approachesMeta-analytic approachesMeta-analysis is becoming increasingly recognized as

a useful tool as it is the process by which a number of study results are combined in order to yield an overall weighted average statistic (Egger et al., 2005)

In the sex offender field, Kenworthy, Adams, Bilby, Brooks-Gordon, and Fenton (2004), conducted a meta-analysis of nine identified RCTs, with over 500 offenders. Their results ranged from one study demonstrating no benefit of psychodynamic treatmen ; to another indicating that a cognitive-behavioral treatment (CBT) approach resulted in reduced re-offending

Using the same nine studies, by Brooks-Gordon, Bilby and Wells (2006), concluded that CBT reduced re-offense at one year but increased re-arrest at 10 years

Hence, merely relying on RCTs suggests somewhat inconclusive evidence for treatment

Therefore, it would seem necessary to look for the effectiveness of treatment using other treatment designs 9

Meta-analytic studies of sex offender Meta-analytic studies of sex offender treatment using a wider range of treatment using a wider range of designs than just RCTsdesigns than just RCTs

Hanson et al. (2002) (N = 9,534) sexual recidivism rate for the treated groups was lower than that of the comparison groups (12.3% versus 16.8% respectively;)

Lösel & Schmucker, 2005 (N = 22,181) treated offenders showed 37% less sexual recidivism that untreated controls

Beech, Robertson and Freemantle (in preparation) (N = 14694) A positive effect of treatment in sexual reconviction reduction (9.39% in the treated group versus 15.61% in untreated controls)

The Beech et al. study has an odds ratio of 0.54, CI 0.43 - 0.69, p < 0.0001) indicating that the likelihood of individuals being reconvicted after treatment was around half that of those who had not undertaken treatment

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Treatment designsTreatment designs

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Meta-analytic evidence base for Meta-analytic evidence base for CBTCBT

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Kenworthy et al. (2004) (N = 500+)CBT and behavioural treatment ↓ sexual recidivism psychodynamic n.s

Alexander (1999) recidivism rates (N = ????)Untreated 25.8% (119/461)Group/ behavioural 18.3% (96/254)Unspecified 13.6% (127/931)RP-CBT 8.1% (18/221

Lösel and Schmucker (2005) (N = 22,181 ) CBT and behavioural treatment ↓ sexual recidivism Insight oriented, therapeutic community, n.s.

other psychosocial

Robertson, Beech, & Freemantle (in preparation) (N = 14,694 ) CBT and behavioural treatment ↓ sexual recidivism psychodynamic n.s

The What Works (RNR) The What Works (RNR) PrinciplesPrinciples(Andrews & Bonta, 2003; (Andrews & Bonta, 2003; Harkins & Beech 2007b for a review)Harkins & Beech 2007b for a review)

RISK: Providing the treatment intensity proportional to risk level

NEED: Targeting problematic behaviours or criminogenic need (dynamic risk factors)

RESPONSIVITY: tailoring treatment in such a way that the individual will gain the most benefit from it

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Targeting riskTargeting riskOverall risk management approach to

treatmentKey assumption that criminal behaviour is

explained by an individual’s profile of risk factors which are acquired and maintained through conditioning, observational learning, and personality dispositions (Andrews & Bonta, 2006; Ward, Polaschek, & Beech, 2006)

Treatment then needs to target an individual’s specific risk factors to reduce the likelihood of future offending (Andrews & Bonta, 2006)

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Why target high risk Why target high risk individuals?individuals?When risk cases reported separately in

studies then larger effects found for higher risk cases (Andrews et al., 1990)

Might be expected as these are the people who untreated are much more likely to recidivate

It makes sense to target resources at those most likely to reoffend

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Why target criminogenic need?Why target criminogenic need? Targeting ‘more promising targets’ reduced

recidivism more than ‘less promising targets’ (Dowden, 1998)

‘More promising’◦ Changing antisocial attitudes/ feelings◦ Reducing antisocial peer associations◦ Promoting identification/ association with anticriminal role models◦ Increasing self-control, self- management, and problems solving

skills ‘Less promising’

◦ Increasing self-esteem without simultaneous reductions in anti-social thinking, feeling and peer associations

◦ Focusing on vague emotional complaints that have not been linked with criminal conduct

◦ Attempting to turn the client into a better person when standards of being a better person do not link with recidivism

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Why address ‘Responsivity’?Why address ‘Responsivity’?

Offender characteristics such as◦Motivation◦Learning style◦Psychopathy◦Cognitive maturity

By identifying personality and cognitive styles, treatment can be better matched to the client

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Evidence supporting treatment Evidence supporting treatment that adheres to RNR principles that adheres to RNR principles (Andrews & Bonta, 2003)(Andrews & Bonta, 2003)

If no treatment is offered or if none of the principlesare followed, an effect size (r) of -.02 was observed in

Andrews and Bonta’s study, demonstrating an increase in criminal recidivism

However, if treatment is delivered in a manner that adheres to:– only one of the above principles an effect size (r) of .02 is

observed– two of the principles effect size (r) is 0.18– all three principles an effect size (r) .26 is observedTherefore treatment programs that adhere to all three

principles of RNR show greatest reductions in sexual recidivism (Hanson et al., 2009)

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Evidence supporting RNR sex Evidence supporting RNR sex offender work offender work ((Hanson, Bourgon, Helmus, & Hodgson (2009) Hanson, Bourgon, Helmus, & Hodgson (2009) ))

• Hanson, Bourgon, Helmus and Hodgson (2009) report the most recent examination of effects of treatment examining 23 studies (n=6746) that met the basic criteria for quality of design

• All studies were rated on the extent to which they adhered to the risk, need, and responsivity (RNR) principles of the ‘What Works’ approach

• Hanson et al. found that the sexual recidivism rate in untreated samples was 19%, compared to 11% in treated samples

• Studies that adhered to all three RNR principles were found to produce recidivism rates that were less than half of the recidivism rates of comparison groups

• While studies that followed none of the RNR principles had little effect in reducing recidivism levels.

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Overview of treatment processOverview of treatment processThe RNR approach (a type of ‘What works’

approach) tells us:◦ who should be allocated to which programmes (e.g.,

higher RISK individuals should be allocated to highest intensity and lowest risk to lowest intensity or no treatment)

◦ what should be targeted in treatment (i.e., NEED principle says criminogenic need should be targeted in treatment- usually these need areas are deviant sexual interest, offense-supportive attitudes, socio-affective functioning, and self-management in sex offenders)

◦ and how treatment should be delivered (i.e., the RESPONSIVITY factor says treatment should be offered in a way so that the individual will gain the most benefit)

 Then a specific model to guide the treatment of sex offenders is used

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Critique of the ‘What Works’ Critique of the ‘What Works’ approachapproach Premier correctional rehabilitative theory Provides a clear direction for treatment Strong empirical base But it does not focus on the overall well-being of

the individual Avoidance-goals (e.g., avoiding reoffending) are

much less motivating than approach- goals (e.g., pursuing a better life that is not compatible with offending; Mann, Webster, Schofield, & Marshall, 2004)

There are problems with too much reliance on meta-analyses ◦ Are only as good as what you put in◦ Can be like comparing ‘apples and oranges’◦ File drawer effect

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Some key referencesSome key references Andrews, D. A., & Bonta, J. ( 2007). The psychology of criminal

conduct, 4th edition. Cincinnati, OH: Anderson. Andrews, D.A., Zinger, I., Hoge, R.D., Bonta, J., Gendreau, P., &

Cullen, F.T. (1990). Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology, 28, 369-404.

Beech, A.R., Robertson, C., & Freemantle, N. (submitted). A meta-analysis of treatment outcome studies: Comparisons of treatment designs and treatment delivery.

Hanson, R.K., Gordon, A., Harris, A.J.R., Marques, J.K., Murphy, W., Quinsey, V.L., & Seto, M.C. (2002). First report of the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sexual Abuse: A Journal of Research and Treatment, 14, 169-194.

Harkins, L., & Beech, A.R. (2007a). Measurement of the effectiveness of sex offender treatment. Aggression and Violent Behavior, 12, 36-44.

Harkins, L., & Beech, A.R. (2007b). A review of the factors that can influence the effectiveness of sexual offender treatment: Risk, need, responsivity, and process issues. Aggression and Violent Behavior, 12, 615-627.

Lösel, F., & Schmucker, M. (2005). The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis. Journal of Experimental Criminology, 1, 117-146.

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