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					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 2009     2
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 Works                 4
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 Works                  5
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 Works            6
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 Works                   7
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 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
                                                                      10
Treatment designs




                    11
         Meta-analytic evidence base for CBT
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
                                                                                 12
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, 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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