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					   Developments in Psychological Assessment &
Treatment and Management for Adult Offenders with
            Developmental Disabilities


  4th International Conference on the Care and Treatment of
              Offenders with a Learning Disability
           University of Central Lancashire, Preston
                  Wednesday, 6th April 2005


                Professor John L Taylor
                Northumbria University and
              Northgate & Prudhoe NHS Trust



                  john2.taylor@unn.ac.uk
   Developments in Psychological Assessment &
Treatment and Management for Adult Offenders with
            Developmental Disabilities
 – Definitions
 – Prevalence
 – Recidivism
 – Risk
           psychometric
           actuarial
           clinical
 – (Sex offending)
 – (Fire-setting)
 – Anger and aggression
 – Process issues
 – Conclusions
    Acknowledgements


•    Dr Bruce Gillmer, Northgate & Prudhoe NHS Trust

•    Professor Gregory O‟Brien, Northgate & Prudhoe NHS Trust

•    Alison Robertson, Northgate & Prudhoe NHS Trust

•    Ian Thorne, Northgate & Prudhoe NHS Trust

•    Professor Ray Novaco, University of California, Irvine, USA

•    Professor Bill Lindsay, NHS Tayside and The State Hospital

•    Dr Todd Hogue, Rampton Hospital

•    Dr Sue Johnston, Rampton Hospital
    Key References

•    Frankish, P. (Ed.). (2001). [Special issue on people with learning
     disabilities who offend]. British Journal of Forensic Practice, 3.

•    Fraser, W.I. & Taylor, J.L. (Eds.). (2002). Forensic learning
     disabilities: The evidence base. [Supplement 1]. Journal of
     Intellectual Disability Research, 46.

•    Lindsay, W.R. (Ed.). (2002). Offenders with intellectual disability.
     [Special issue]. Journal of Applied Research in Intellectual
     Disabilities, 15.

•    Lindsay, W.R., Taylor, J.L. & Sturmey, P. (Eds.). (2004). Offenders
     with developmental disabilities. Chichester: Wiley.

•    Lindsay, W.R. & Taylor, J.L. (in press). A selective review of research
     on offenders with developmental disabilities: Assessment and
     treatment. Clinical Psychology & Psychotherapy.
Prevalence of Offending and People with DD

Prevalence studies of offending amongst people with DD report
large variations in rates depending on:

   • Inclusion criteria used - particularly whether those with
     „borderline intelligence‟ are included or not

   • The type of assessment instrument used to detect DD (e.g. file
     review vs. standardised IQ assessment)

   • Location of the sample - community vs. courts vs. prisons vs.
     secure hospital settings

   • Study design and methodology (e.g. case note review vs. clinical
     evaluation vs. informant survey; sampling method)

   • Changes/differences in criminal justice, social & health care
     policies affect apparent incidence, visibility and reporting (e.g.
     de-institutionalisation; Lund, 1990).
Prevalence of Offending and People with DD /contd.

•   Prevalence of offending among people with DD is difficult to estimate
    with any degree of accuracy
    (Lindsay, Taylor & Sturmey, 2004)


•   The evidence base is poor with regard to epidemiological studies - in
    particular there is dearth of well-controlled studies including
    comparison reference groups.
     (Lindsay & Taylor, in press)


•   It is not clear, therefore, whether people with DD are over- or under-
    represented in the offender population, and whether offending is
    more prevalent among people with ID than the general population
    (Day, 1993; Holland et al., 2002; Simpson & Hogg, 2001)
Recidivism Amongst Offenders with DD

•   Studies of recidivism amongst offenders with DD have reported rates
    between 39% (Walker & McCabe, 1973) and 72% (Lund, 1990)

•   There are major problems in interpreting the findings of recidivism
    studies (Lindsay & Taylor, in press)

•   Recidivism rates for DD offenders subject to probation orders are
    high, but no higher than for offenders in general (Linhorst et al.,
    2003)

•   Voluntary clients have markedly higher recidivism rates than those
    mandated to community case management programmes by the
    courts (Linhorst et al., 2003)

•   Longer-term treatment and supervision under probation orders
    reduces recidivism of SXO (Lindsay et al., 1998)

•   Treated sex offenders followed up over 4 years showed re-offending
    rates of 4%, 12%, 13% and 21% over this period (Lindsay et al., 2002)
Risk Assessment in Offenders with DD

•   2 recent reviews focusing on risk assessment in offenders with ID:
     – Johnston (2002); Quinsey (2004)
• A special issue of JARID on risk assessment in forensic DD (Eds.
  Lindsay & Beail, 2004)

                     Psychometric Risk Assessment

     – Staff-rated risk using the Short Dynamic Risk Scale (SDRS) is
       predictive of community offending-type behaviour, including violence
       (Quinsey, 2004)

     – Fire-setting is closely associated with antecedents of anger, low
       „social attention‟ and low mood as measured on the FSAS (Murphy &
       Clare, 1996; Taylor et al., 2002)

     – Self- and staff-rated anger using the NAS and WARS is predictive of
       inpatient violence (Novaco & Taylor, 2004)
Hierarchical Regression of Violence Risk and Anger
Predictors of Patient Assaultiveness in Hospital
Ref: Novaco & Taylor (2004) in Psychological Assessment


Predictors             beta        t           R2        R2 Change      F change           p

Step 1

Age                    -.148       1.47
WAIS-R (Full Scale)    -.214       2.12
Violence Offence       .143        1.45
                                               .081        .081         2.77 (3,95)       .046
Step 2
NAS Total              .369        3.95
                                               .211        .131         15.59 (1,91)      .000
Step 3
Extraversion (EPQ)     .224        2.43
                                               .258        .047         5.90 (1,93)       .017

Note: The dependent measure is the number of assaults since hospital admission (square root
transformed). At Step 3, STAXI Trait Anger and Anger Expression, and the EPQ-Lie scale were
statistically excluded in the stepwise procedure. For the final model including the covariates, NAS Total,
and EPQ-E, R = .508, F (5,93) = 6.48, p = .000
Risk Assessment in Offenders with DD – Actuarial
Assessment


          “The Applicability of Personality Disorder and Risk
            Assessment (DSPD) Measures in a Sample of
                  Intellectual Disability Offenders”

                   Study funded by the Home Office
                        Grant No. RDS/01/247



•   Dr Todd Hogue – Rampton Hospital
•   Dr Sue Johnston – Rampton Hospital
•   Professor John Taylor – Northgate & Prudhoe NHS Trust
•   Professor Greg O‟Brien – Northgate & Prudhoe NHS Trust
•   Professor Bill Lindsay – NHS Tayside
•   Dr Anne Smith – NHS Tayside
Study Participants and Sites

212 men with ID/developmental disabilities and offending and
  offending-type histories from 3 sites:

•   Rampton Hospital (High Security) N = 73

•   Northgate & Prudhoe Hospitals (Medium & Low Security) N = 70

•   Tayside (Community Forensic Service) N = 69

•   Mean Age = 37.5 years (SD = 11.4; Range 18 – 69 years)

•   Mean Full Scale IQ = 65.8 (SD = 8.6; Range 43 – 89)

•   Mean Length of Stay = 8.1 years (SD = 7.5; Range 1 – 26 years)
    Risk Instruments


•   Violence Risk Appraisal Guide (VRAG; Harris, Rice & Quinsey, 1993) -
    actuarial

•   Static 99 (Hanson & Thornton, 2000) - actuarial

•   Risk Matrix 2000 (Thornton, 2000) - actuarial


•   Individual Psychological Risk Factor (IPRF; Hogue, 2003) - clinical

•   Short Dynamic Risk Scale (SDRS; Quinsey, 2003) – clinical


•   HCR-20 (Webster, Eaves, Douglas & Wintrup, 1995) – actuarial and
    clinical
Results: HCR-20 by Site


Rampton & Northgate mean scores were significantly higher
than Tayside on the „Historical‟ scale (F = 42.95, df = 3, p < .001)


Rampton mean scores were significantly higher than Northgate
& Tayside on the „Risk Management‟ scale (F = 3.19, df = 3, p <
.05)


There were no differences in mean scores on the „Clinical‟
scale across sites (F = 1.56, df = 3, p = .20)
Correlations between HCR-20, other Risk Measures and
Violent/Aggressive Incidents


                                                           HCR-20
                                           Historical       Clinical     Risk Managt.


VRAG                                          .65*            .23*            .22*

Short Dynamic Risk Scale                      .39*            .42*            .27*


Total Incidents                               .28*            .28*           .20*


Note. * p < .01. All correlations are Spearman Rho, two-tailed tests. N = 151 – 203.
Correlations between HCR-20 and EPS Scales

                                                           HCR-20
                                            Historical      Clinical      Risk Managt.

EPS Scales

Physical Aggression                             .32*           .35*            .23*

Verbal Aggression                              .30*            .37*           .19

Anxiety                                         .12            .18            .15

Withdrawal                                      .17            .13            .03


Note. * p < .01. All correlations are Spearman Rho, two-tailed tests. N = 154 – 171.
Mean HCR-20 Scores, Grouped According to Conviction for
Violent Offences



                                  Convictions for Violence
                              No Conviction       Conviction
                                (n = 127)          (n = 77)         t      p


HCR-20 Historical               10.7 (4.4)        14.3 (3.4)      -6.23   .000


HCR-20 Clinical                  4.3 (2.3)            4.5 (2.6)   -0.68   ns


HCR-20 Risk Managt.              2.9 (1.7)            3.2 (1.8)   -1.51   ns

Note: Standard deviations are given in parentheses.
Mean HCR-20 Scores, Grouped According to
Violent/Aggressive Incidents During Previous 12 Months



                                       Violent Incidents
                               No Incident            Incident
                                (n = 139)              (n = 65)     t      p


HCR-20 Historical               11.2 (4.6)         13.9 (3.4)     -4.01   .000


HCR-20 Clinical                  3.9 (2.5)            5.3 (1.9)   -3.8    .000


HCR-20 Risk Managt.              2.8 (1.8)            3.5 (1.7)   -2.4    .017

Note: Standard deviations are given in parentheses.
Conclusions – HCR-20 for Offenders with DD


• HCR-20 scales show good concurrent validity with
  conceptually relevant clinical and actuarial risk measures

• The scales have good levels of discriminant validity, as
  measured against EPS clinical and aggressive behaviour
  indices

• HCR-20 scales correlate significantly with proximal violent
  incident data

• HCR-20 differentiates between clients with convictions for
  violence (and those who have been violent recently) and
  non-violent clients in a logically consistent manner
Risk Assessment in Offenders with DD – Treatment Planning
Ref: Taylor, J.L. & Halstead, S. (2001). Br. J. of Forensic Practice

                              Case Study - Mr L.
   •     27 years old
   •     Admitted from prison under s.47 of the MHA 1983
   •     Convicted of Indecent Assault – reduced from Attempted
         Rape
   •     Victim – sister-in-law, 13 years old
   •     Sentence – 6 months imprisonment ) reduced on appeal
         from 18 months)
   •     Married for 3 years
            •    Wife, 19 years old
            •    1 son, 2 years old
            •    1 daughter, 1 year old

   •     Full Scale IQ = 67; Level 2 Social Reasoning
    Some Conclusions about „Forensic-Clinical‟ Risk
    Assessment
    Ref: Taylor, J.L. & Halstead, S. (2001). Br. J. of Forensic Practice


•       Clinicians tend to avoid systematic risk assessment
•       There is a gap between practice and the science of risk
        assessment
•       This results in clients being denied effective assessments
        and targeted interventions to reduce their risks
•       Use of shared clinical models that allow for risk analysis is
        one way forward
•       This approach could enable the development of “clinically
        defensible judgements” concerning patients‟ risks
•       More research and evaluation is required concerning the
        implementation of this approach and its predictive validity
    Sex Offenders and Fire-Setters with DD - Key References
                                      Sex Offenders
•    Lindsay, W.R. (2002). Research and literature on sex offenders with intellectual
     and developmental disabilities. J. of Intell. Disability Research, 46 (Suppl. 1), 74-
     85.

•    Lindsay, W.R. (2004). Sex offenders: conceptualisation of the issues, services,
     treatment and management. In Lindsay, Taylor & Sturmey (Eds.), Offenders with
     developmental disabilities. Chichester: Wiley.

•    Courtney, J. & Rose, J. (2004). The effectiveness of treatment for male sex
     offenders with learning disabilities: A review of the literature. Journal of Sexual
     Aggression, 10, 215-236.

                                        Fire-Setters
•    Taylor, J.L., Thorne, I., Robertson, A. & Avery, G. (2002). Evaluation of a group
     intervention for convicted arsonists with mild and borderline intellectual
     disabilities. Crim. Behaviour and Mental Health, 12, 282-293.

•    Taylor, J.L., Thorne, I. & Slavkin, M.L (2004). Treatment of fire-setting behaviour. In
     Lindsay, Taylor & Sturmey (Eds.), Offenders with developmental disabilities.
     Chichester: Wiley.
Anger & Aggression in People with DD

•   Aggression is a common feature of populations of people with DD
    (Deb et al., 2001; Hill & Bruininks, 1984; Sigafoos et al., 1994;
    Smith et al., 1996; Taylor et al., 2004)

•   Prevalence in the UK DD population is 12-22% (est. 144,000 –
    240,000 individuals)

•   Physical violence is a significant clinical/management problem in
    people with DD and forensic histories in institutional settings
    (Novaco & Taylor, 2004)

•   Aggressive behaviour presents significant problems for staff in
    DD services (Bromley & Emerson, 1995; Jenkins et al., 1997; Kiely
    & Pankhurst, 1998).

•   Anger is a significant activator of, and is predictive of violence in
    psychiatric, forensic and DD populations (Novaco, 1994; Novaco &
    Renwick, 2002; Novaco & Taylor, 2004)
Northgate Anger Treatment Project

  Stage 1
  – diagnostic/screening assessment of a group of 129 detained DD men
    with offending histories to examine the nature and scope of anger
    problems in this population and to investigate the psychometric
    properties of several criterion measures of anger and aggression


  Stage 2
  – development of an anger treatment protocol designed specifically for
    people with DD and histories of aggression and offending behaviour


  Stage 3
  – evaluation of a cognitive-behavioural anger treatment by comparison of
    post-treatment measures in the treatment group with pre-treatment
    measures in the waiting list control group
Cognitive-Behavioural Treatment of Anger for
People with DD

• Research on anger treatment for people with DD is limited,
  but there is some evidence of successful CBT-based
  interventions (see Taylor, 2002; Whitaker, 2001 for reviews)


• There are 7 small anger CBT outcome studies with DD
  clients that involved comparison groups (Benson et al., 1986;
   Lindsay et al., 2004; Rose et al., 2000, Taylor et al., 2002, 2004, in
   press; Willner et al., 2002)


• There are some reports in the literature of CBT for anger in
  offenders with DD (Allen et al., 2001; Lindsay et al., 2003, 2004;
   Taylor et al., 2002, 2004a, in press)
Three Concatenated Anger Treatment Outcome
Studies - Research Design & Analysis



• Wait-list controlled design (as considered unethical to
  withhold a potentially effective treatment from those who
  might benefit from it)


• Both groups continued to receive ‘treatment as usual’



• Patients meeting inclusion criteria allocated to the Anger
  Treatment (AT) group or Routine Care (RC) conditions
Anger Treatment for ID Offenders I

• Modification of Novaco’s (1975, 1993) treatment protocol

• Treatment is delivered individually by a qualified psychologist
  over 18 sessions (twice weekly)
    6 session preparatory phase (psycho-educational)
    12 sessions of treatment ‘proper’ (cognitive re-structuring,
     arousal reduction & skills training)

• Emphasises collaboration, personal responsibility, self-
  control & the legitimacy of anger

• Utilises a range of assessment, educational & training
  materials adapted to help patients with LD engage in the
  treatment process
Anger Treatment for ID Offenders II


Key components of the treatment:

   – Analysis and formulation of individual patients particular
     anger problems
   – Cognitive re-structuring
   – Self-monitoring of anger frequency, intensity and triggers
   – Construction of a personal provocation hierarchy
   – Arousal reduction techniques
   – Training behavioural coping skills
   – Development of personalised self-instructions to prompt
     coping
   – Stress inoculation to practice coping in imagination
Mean Novaco Anger Scale (NAS) Total scores over Time
ANCOVA (WAIS-R IQ as covariate) F(1,33) = 4.74. p < .05, r = .35

Ref: Taylor et al. (in press). Brit. J. of Clinical Psychology

     110                                                         Anger treatment (AT)

                                                                 Routine care (RC)
     105



     100



      95



      90
                     Screen       Pre-Treatment       Post-           Follow-Up
                                                    Treatment
Mean Provocation Inventory Total Scores over Time
ANOVA, F (1,17), = 13.56, p < .005, r = .66

Ref: Taylor et al. (2002). J. of Applied Research in Intell. Dis., Vol. 15



90                                                       Anger Treatment (AT)

                                                         Routine Care (RC)
80


70


60


50


40
                       Time 1                   Time 2
Mean IPT Anger Composite Scores over Time
ANCOVA (Time 1 score as covariate) F(1,14) = 11.20. p < .01, r = .67
Ref: Taylor et al. (2004). Clinical Psychol. & Psychotherapy, Vol. 11


30                                                     Anger treatment (AT)

                                                       Routine care (RC)


25




20




15
                   Time1            Time2            Time3
Mean WARS Anger Index scores over Time
ANCOVA (WAIS-R IQ as covariate) F(1, 33) = 1.49, p < .23

Ref: Taylor et al. (in press). Brit. J. of Clinical Psychology
   10
                                                            Anger treatment (AT)

    9                                                       Routine care (RC)


    8


    7


    6


    5


    4
                   Screen      Pre-Treatment      Post-          Follow-Up
                                                Treatment
Process Issues Related to Psychotherapy for
People with DD

1.   Can people with DD reliably engage in the collaborative,
     shared formulation approach of CBT?
Treatment Completers’ (n = 18) Evaluations of Preparatory and
Treatment Phases of Anger Treatment (PEAT Questionnaire
Responses)

                                                                                   % Responses

                             Item                                    Post-Preparatory         Post-Treatment
                   (Question and Response)                                Phase                   Phase

 1   Q. Overall, was it worthwhile for you to attend the
        sessions?
                                                                           89%                      78%
     R. Yes, most of the sessions

 2   Q. Have you enjoyed the sessions?
     R. Yes, most of the sessions                                          94%                      83%

 3   Q. Have the sessions been helpful to you?
     R. Yes, in lots of ways                                               78%                      83%

 4   Q. Do you think you have changed since you started
        your anger treatment?
     R. Yes, a lot for the better                                          22%                      67%

 5   Q.   Are you a more or less angry person now compared
          to before you started your anger treatment?
     R.   Less angry                                                         -                      83%

 Note. For each item, administered in a semi-structured interview format, three levels of response are
 available where, for item 2 for example „Have you enjoyed the sessions?‟, 1 = „no, not at all‟, 2 = „some of
 them‟, and 3 = „yes, most of them‟.
Patient G - Background Information

•   Age 27 years

•   Full Scale IQ = 68

•   Psychiatric Diagnosis = Mild Learning Disability

•   MHA Section = 37 Hospital Order

•   Length of stay in hospital = 8.5 years

•   Index Offence(s) = Indecent assaults against young boys

•   Rehabilitation Status = „Longer-stay‟ low secure (slow-track rehabilitation)

•   Previous Psychological Intervention = 1) Positive response to an
    individual behavioral programme to reduce interpersonal conflict; 2)
    Completion of group-based sex offender treatment programme with mixed
    outcomes
Process Issues Related to Psychotherapy for
People with DD

1.   Can people with DD reliably engage in the collaborative,
     shared formulation approach of CBT?

2.   Can people with DD do the cognitive component of CBT?
Cognitive-Behavioural Model of Emotion – Simple Linear


       A                  B                C



     Events           Thoughts           Feelings




                      Behaviour
Process Issues Related to Psychotherapy for
People with DD


1.   Can people with DD reliably engage in the collaborative,
     shared formulation approach of CBT?

2.   Can people with DD do the cognitive component of CBT?

3.   What is the effect of IQ on treatment outcome?

4.   Can treatment effects be achieved and sustained in
     routine practice settings?
  Mean NAS Total scores for AT (n = 16) and RC (n = 20) groups
  over time.



110                                                          AT group

                                                             RC group

105




100




95




90
        Screen     Pre-Treatment   Post-Treatment   4 Month Follow-up
Do you think you have learned anything about anger treatment
from your involvement in the project?
(Nurses’ Responses n = 14, Mean = 3.7)


9
8
7
6
5
4
3
2
1
0
    Nothing At   Probably   Maybe   To Some   A Great Deal
        All      Nothing             Extent
Has your involvement (in the treatment) had an effect on the
way you deal with other patients’ anger problems?
(Nurses’ Responses n = 14, Mean = 3.1 )


10
 9
 8
 7
 6
 5
 4
 3
 2
 1
 0
     Not at All   Probably Not   Maybe   To Some   A Great Deal
                                          Extent
Process Issues Related to Psychotherapy for
People with DD

1.   Can people with DD reliably engage in the collaborative,
     shared formulation approach of CBT?

2.   Can people with DD do the cognitive component of CBT?

3.   What is the effect of IQ on treatment outcome?

4.   Can treatment effects be achieved and sustained in
     routine practice settings?

5.   Can treatment effects be maintained over time and across
     settings?
Summary
•   It is not clear whether people with DD are over- or under-represented
    in the offender population, and whether offending is more prevalent
    among people with ID than the general population

•   There are major problems in interpreting the findings of recidivism
    studies – but mandated and longer-term treatments produce better
    outcomes

•   Good progress is being made in developing psychometric, actuarial
    and clinical assessments of forensic risk

•   The evidence for the effectiveness of interventions for sexually
    aggressive and fire-setting behaviour is building but lacks
    methodological rigour

•   The evidence for anger treatment is best developed and continues to
    build – the sustainability and impact on aggression is not clear

•   Offenders with DD appear to be able to engage in and benefit from
    CBT approaches
Future Research Directions for Offenders with DD

1)   More research concerning reliable and valid assessments is required to
     facilitate risk assessment and management, treatment planning, and
     evaluation of effectiveness


2)   Larger, more powerful and better designed controlled trials are required to
     show if the effects obtained to date are stable phenomena


3)   The mechanisms underlying treatment gains are not clear - component
     analysis and longer-term follow-up is required to evaluate these issues


4)   Process issues relating to optimum length of treatment, mode of delivery of
     treatment (group vs. individual), systematic involvement of carers and
     relative costs need more enquiry


5)   The sustainability and generalisability of treatment gains are not proven –
     research into optimum maintenance schedules is indicated
          Contact Details

         Professor John L Taylor
Head of Psychological Therapies & Research
      Northgate & Prudhoe NHS Trust
            Northgate Hospital
                 Morpeth
             Northumberland
                NE61 3BP
            Tel: 01670 394228


         john2.taylor@unn.ac.uk