Assessing Efficacy of Sex Offender Treatment Programs: Why This is Important Anthony Beech 1

Assessing Efficacy of Sex Offender Treatment Programs: Why This is Important 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 knowledge Given the limited resources to run programs, all work clearly has to be evidence-based We 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 20092

Aims of the talk Give a background to how research-based treatment evolved Examination of meta-analyses that have attempted to demonstrate what treatment works And further, what type of treatment Describe how the What Works approach has grown out of this work, that addresses: ◦ Risk ◦ Need ◦ Responsivity in treatment 3

Background The issue of offender rehabilitation has been a controversial and contested one The 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 Works4

Background 2 However, 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 Works5

Background 3 For 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 Works6

What 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 Works7

Effective treatment delivery in the UK In June 1998 the UK Home Office started what is known as the ‘What Works’ Initiative While earlier Dr. David Thornton had done the same thing in UK prisons This 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 8

Meta-analytic approaches Meta-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 treatment using a wider range of designs 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 , p < ) indicating that the likelihood of individuals being reconvicted after treatment was around half that of those who had not undertaken treatment 10

Treatment designs 11

Meta-analytic evidence base for CBT 12 Kenworthy et al. (2004) (N = 500+) CBT and behavioural treatment ↓ sexual recidivism psychodynamicn.s Alexander (1999) recidivism rates (N = ????) Untreated25.8% (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 psychodynamicn.s

The What Works (RNR) Principles (Andrews & Bonta, 2003; 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 13

Targeting risk Overall risk management approach to treatment Key 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) 14

Why target high risk 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 15

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 16

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 17

Evidence supporting treatment that adheres to RNR principles (Andrews & Bonta, 2003) If no treatment is offered or if none of the principles are 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 observed Therefore treatment programs that adhere to all three principles of RNR show greatest reductions in sexual recidivism (Hanson et al., 2009) 18

Evidence supporting RNR sex offender work (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. 19

Overview of treatment process The 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 20

Critique of the ‘What Works’ approach 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 21

Some 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, 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, Harkins, L., & Beech, A.R. (2007a). Measurement of the effectiveness of sex offender treatment. Aggression and Violent Behavior, 12, 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, Lösel, F., & Schmucker, M. (2005). The effectiveness of treatment for sexual offenders: A comprehensive meta-analysis. Journal of Experimental Criminology, 1,