Moving from Principle to Moving from Principle to ExecutionExecution

Applications of the Risk-Dosage Relationship

Kimberly Sperber, PhD

Support for the Risk Support for the Risk PrinciplePrinciple

• Hundreds of primary studies• 7 meta-analyses• Men, women, juveniles, violent offenders, sex

offenders

• Programs that target higher risk offenders are more effective

• Reductions in recidivism are greatest for higher risk offenders

• Intensive interventions can harm low risk offenders

2002 UC Ohio Study of HH2002 UC Ohio Study of HH’’s and CBCFs and CBCF’’ss

2002 UC Ohio Study of HH2002 UC Ohio Study of HH’’s and CBCFs and CBCF’’ssTreatment Effects For High Risk Offenders

-34

-18-15 -14

-6 -5-2 -2

2 3 3 35 6 7 8 8 9 10 10

12 12 12 13 13 1315

21 2224 25

2730

3234

River City

Fresh Start

Alternative Agency

Talbert House Cornerstone

Community Assessment Program (Men’s)

Monday

WORTH

Cincinnati VOA McM

ahon Hall

Talbert House Spring Grove

NEOCAP

Oriana House RIP

Alvis House Dunning Hall

Lorain/Medina

All CBCF Facilities

Canton Community Treatment Center

Lucas County

SRCCC

All Facilities

Licking/Muskingum

Summit County

Butler

SEPTA

Community Transitions

Franklin County

Small Programs

Oriana House TMRC

Cincinnati VOA Chemical Dependency Program

Alvis House Alum Creek

Talbert House Beekman

Comp Drug

Harbor Light Salvation Army

Community Corrections Association

Toledo VOA

Mahoning County

EOCC

0

10

20

30

40

-10

-20

-30

-40

P rob

abil

ity

o f R

einc

arc e

r ati

o n

Challenges for PractitionersChallenges for Practitioners

• We understand more services/supervision for high risk and less services/supervision for low risk

• Conceptual understanding of the risk principle versus operationalization of the risk principle in real world community settings to achieve maximum outcome

• “Can we quantify how much more service to provide high risk offenders?”

Limited GuidanceLimited Guidance

• Prior Literature:– Lipsey (1999)

• Meta-analysis of 200 studies• Serious juvenile offenders

– Bourgon and Armstrong (2005)• Prison study on adult males

• More Recent Literature:– Sperber, Makarios, and Latessa (2013)

• Community-based setting

Identifying Effective Dosage Levels in Identifying Effective Dosage Levels in a Community-Based Settinga Community-Based Setting

• Sperber, Latessa, & Makarios (2013):– 100-bed CBCF for adult male felons– Sample size = 689 clients– Clients successfully discharged between 8/30/06 and

8/30/09– Excluded sex offenders– Dosage defined as number of group hours per client– Recidivism defined as new sentence to prison– All offenders out of program minimum of 12 months

Unanswered QuestionsUnanswered Questions(Sperber, Makarios, & Latessa, 2013)(Sperber, Makarios, & Latessa, 2013)

1. Defining dosage2. What counts as dosage?3. Prioritization of criminogenic needs4. Counting dosage outside of

treatment environments

Unanswered QuestionsUnanswered Questions

5. Sequence of dosage6. Cumulative impact of dosage7. Impact of program setting8. Low risk but high risk for specific

criminogenic need

Unanswered QuestionsUnanswered Questions

9. Nature of dosage for special populations

10.Impact of skill acquisition11.Identifying moderators of risk-

dosage relationship12.Conditions under which dosage

produces minimal or no impact

Treatment Dosage and the Risk Principle: An Treatment Dosage and the Risk Principle: An Extension and RefinementExtension and Refinement

Makarios, Sperber, and Latessa(under review)Makarios, Sperber, and Latessa(under review)

• Methodology– 100-bed CBCF for adult male felons

• Sample size = 980 clients

– Clients successfully discharged between 8/30/06 and 12/31/10

– Excluded sex offenders– Dosage defined as number of group

hours per client– Recidivism defined as return to prison– All offenders out of program minimum

of 12 months

Table 1. Descriptive Statistics for the Table 1. Descriptive Statistics for the Study Sample (n = 941)Study Sample (n = 941)

Variables N %RaceCaucasian 840 89Minority 101 11

Risk LevelLow/Moderate 195 21Moderate 587 62High/Moderate 159 17

Dosage Categories0-99 149 16100-149 190 20150-199 245 26200-249 234 25250-299 90 10300+ 33 3

Return to PrisonYes 360 39No 581 61

Mean/SD RangeAge 31.6/9.2 18-61Time at Risk 1344.8/398.8 550-2027

Table 2. Cox Regression Predicting Table 2. Cox Regression Predicting Time to Return to Prison (N = 941)Time to Return to Prison (N = 941)

Variable Slope (b) SE Wald Exp(B)

Age -.015** .006 6.163 .985

Minority .283* .157 3.265 1.328

Risk Level -.102*** .044 5.283 .903

Dosage Categories .529** .100 28.285 1.696

Model Chi-Square = 38.760***

Dosage by Risk LevelDosage by Risk Level

Categories with less than 20 cases excluded

Summary of FindingsSummary of Findings

• Overall, increased dosage reduces recidivism– But not equally for all categories or risk levels

• Low / Moderate and Moderate– Curvilinear relationship

• Matters at the low ends of dosage, but effects taper off and eventually reverse as dosage increases

• High / Moderate– Increases in dosage consistently result in decreases

in recidivism, but• Saturation effect at high dosage levels

LimitationsLimitations

• Single study from a CBCF in Southwestern Ohio

• Male Sample• Does not consider other potential

moderators• Lack of “0” Dosage comparison

group

Treatment Dosage and Personality: Examining Treatment Dosage and Personality: Examining the Impact of the Risk-Dosage Relationship on the Impact of the Risk-Dosage Relationship on

Neurotic OffendersNeurotic OffendersSperber, Makarios, and LatessaSperber, Makarios, and Latessa

• Research on the risk principle confirms that correctional practitioners should differentiate services by offender risk.

• Research also confirms that these services should be based on a cognitive-behavioral modality.

• At the same time, there is some research to suggest that offenders with certain personality types (e.g. neurotics) are higher risk for re-offending and may not fare as well as other personality types within cognitive behavioral programs.

• If this is true, increasing cognitive behavioral dosage for high risk neurotic offenders may have a detrimental impact on recidivism for those offenders.

• Consequently, this study examines personality type as a moderator of the risk dosage relationship to determine the impact on recidivism.

MethodologyMethodology

– 100-bed CBCF for adult male felons– Clients successfully discharged

between 8/30/06 and 12/31/10• 980 offenders total• 257 neurotic offenders

– Excluded sex offenders– Dosage defined as number of group

hours per client– Recidivism defined as return to prison– All offenders out of program minimum

of 12 months

Personality TypesPersonality Types

• Jesness Inventory• 9 Types collapsed into 4:

– Aggressives– Neurotics– Dependents– Situationals

Table 1: Sample Characteristics

Characteristics N % Race White 236 91.8 Non-White 21 8.2 Age 18 – 30 111 43.2 31 – 40 93 36.2 41 – 50 46 17.9 51+ 7 2.7 Mean Age 33.4 Risk Level Low/Low Moderate 33 12.8 Moderate 155 60.3 High/Very High 69 26.8 Mean 29.8 Dosage Categories 0 – 99 39 15.2 100-199 107 41.6 200+ 111 43.2 Mean Dosage 186.9 Recidivism Yes 111 43.2 No 146 56.8

Table 2: Cox Regression Predicting Time to Return to Prison Variable Slope (b) SE Wald Exp(B)

Age -.023* .011 3.984 .978

Moderate Risk .837* .404 4.301 2.309

High Risk 1.354** .442 9.358 3.871

100-199 Hours -.195 .275 .503 .823

200+ Hours -.540 .298 3.283 .583

** p < 0.01 *p<.05 Model X2 = 16.10**

0-99 hrs 30 54 49

100-199 hrs 15 42 85 42

200+ hrs 40 45 42

0

10

20

30

40

50

60

70

80

90

low moderate high overall

Perc

ent R

etur

ned

to P

riso

n

Percentage Returned to Prison by Tx Dosage and Risk Level

0-99 tx hours

100-199 tx hours

200+ tx hours

SummarySummary

• Pattern for neurotics similar to the overall sample

• Increasing dosage reduces recidivism but not equally for all risk levels

• Largest decrease in recidivism was for the high risk/high dosage group

LimitationsLimitations

• Single study from a CBCF in Southwestern Ohio

• Limited number of cases in certain categories may have limited power of analysis

• Can’t address issues of service delivery content that may still be relevant for a neurotic population

Examining the Risk-Dosage Relationship in Examining the Risk-Dosage Relationship in Female OffendersFemale Offenders

Spiegel and SperberSpiegel and Sperber

• Studies on the number of treatment hours necessary to reduce recidivism for high risk offenders are few in number.

• Studies to date have relied on male samples. • Cannot assume that a standard number of

treatment hours necessary to reduce recidivism exists for both men and women.

• Present study examines the impact of varying levels of treatment dosage by risk for female offenders in a halfway house setting.

MethodologyMethodology

• Sample size = 314 clients• Clients successfully discharged between

10/1/07 and 2/28/10• Dosage defined as number of group hours per

client• Recidivism defined as re-arrest

– Checked Hamilton County and referral/home county websites

– All offenders out of program minimum of 12 months

Table 1: Sample Characteristics

Characteristics N % Race White 222 70.9 Non-White 91 29.1 Age 18 – 30 102 32.6 31 – 40 95 30.4 41 – 50 95 30.4 51+ 21 6.7 Mean Age 36.5 Risk Level Low/Moderate 169 54.0 Moderate 130 41.5 High/Moderate 14 4.5 Mean 22.8 Dosage Categories 0 – 50 174 55.6 51 – 100 96 30.7 101+ 43 13.7 Mean Dosage 60.0 Mental Health History Yes 165 52.7 No 148 47.3 Re-arrest Yes 69 22.0 No 244 78.0 Mean Range Time at Risk 1188.2 (SD= 442.0) 7 - 1802

Table 2: Cox Regression Predicting Time to Re-arrest

Variable Slope (b) SE Wald Exp(B)

Race (White=1) -.607** .246 6.084 .545

Mental Health History .604** .275 4.839 1.830

Risk Level .055** .021 6.829 1.056

Dosage Categories -.001 .003 .209 .999

** p < 0.05 Model X2 = 24.276***

19.3

34.1

27

11.316.3

13.518.2

30

20.9

05

10152025303540

Low-Moderate Risk Moderate + Risk Overall

Recidivism Rates by Dosage and Risk Level

0-50 Hours 51- 100 Hours 101+

SummarySummary

• Further evidence of the application of the risk principle to women– Over-treating lower risk women can result in

recidivism increase

• Findings suggest a non-linear relationship for both risk groups

• Initial increases in dosage have positive impact on recidivism

• Increasing dosage to 101+ hours appears to result in increases in recidivism

LimitationsLimitations

• Sample drawn from a single halfway house with limited geographical region

• Limited risk distribution• Limited dosage distribution• Inclusion of drug court clients in sample• Reliance on public websites for recidivism

checks• Limited geographical range for recidivism

– Doesn’t account for all Ohio counties– Doesn’t account for bordering counties of other

states

Forthcoming StudiesForthcoming Studies

• Under Construction:– Examining the Risk-Dosage

Relationship in Sex Offenders– The Relative Impact of Role-Play

versus Treatment Hours: Is There a Trade-Off?

– The Impact of Client Strengths on the Risk-Dosage Relationship

But What Do We Know?But What Do We Know?

• Research clearly demonstrates need to vary services and supervision by risk

• Currently have general evidence-based guidelines that suggest at least 100 hours for moderate risk and at least 200 hours for high risk

• Should not misinterpret to imply that 200 hours is required to have any impact on high risk offenders

• Not likely that there is a one-size-fits-all protocol for administering dosage

• Practitioners have a responsibility to tailor interventions to individual’s risk/need profile based on best available evidence

Practitioner Responsibilities for Practitioner Responsibilities for Effective Execution of the Risk PrincipleEffective Execution of the Risk Principle

• Process for assessing risk for all clients• Modified policies and curricula that allow for variation

in dosage by risk– Assess infrastructure and resources

• Definitions of what counts as dosage and mechanism to measure and track dosage– Unit of measurement– Quality versus quantity

• Formal CQI mechanism to:– Monitor whether clients get appropriate dosage by risk– Monitor quality of dosage– Monitor outcomes of clients receiving dosage outside of

evidence-based guidelines

ConclusionsConclusions

• Corrections has benefitted from a number of well-established Evidence-Based Guidelines and Evidence-Based Practices

• Next evolution will focus on bringing a more nuanced understanding and application of these EBG’s and EBP’s to the individual client level

• Practitioner-driven CQI/data needs to intersect with research to drive this process so that we continually move the field forward to maximize public safety outcomes