Forensic CBT

A Handbook for Clinical Practice

Raymond Chip Tafrate, Damon Mitchell, Raymond Chip Tafrate, Damon Mitchell

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118589892
• Edition: 1
• Topic: Psychologie
• Subtopic: Kognitive Verhaltenstherapie (CBT)

Forensic CBT: A Handbook for Clinical Practice is an edited collection that represents the first authoritative resource on the utilization of CBT strategies and techniques for offender clients.

• Features contributions from leaders of the major schools of CBT on the treatment of antisocial personality patterns as well as anger, interpersonal violence, substance abuse, and sexual aggression
• Addresses modified CBT approaches for female, juvenile, and culturally diverse forensic populations
• Covers emerging areas of forensic practices, including the integration of motivational interviewing and strength-based approaches
• Includes an assortment of worksheets, handouts, and exercises for practitioners to use with their clients

1

Introduction

Critical Issues and Challenges Facing Forensic CBT Practitioners

Damon Mitchell, David J. Simourd, and Raymond Chip Tafrate

Although the scientific conundrums of one generation are often made obsolete by the technological advances of the next, the area of forensic treatment may be an exception. The problem is not a lack of knowledge regarding the components of effective treatment: Instead, the problem is one of their dissemination into practice. Scholars have noted that quackery marks the correctional treatment landscape (Gendreau, Smith, & Theriault, 2009; Latessa, Cullen, & Gendreau, 2002) with nonscientific and “commonsense” theories of criminal behavior (e.g., offenders lack discipline; offenders need to get back to nature) leading to subsequent programs (e.g., boot camps; wilderness adventure) that do not reduce recidivism. Perhaps worse, a variety of bizarre forensic “interventions” that escape scientific evaluation altogether pop up (e.g., dog sled racing; aura focus therapy; see Gendreau et al., 2009, for a list) and make forensic treatment appear similar to the patent medicines of the nineteenth century that claimed to cure a variety of ills but were often no more than opium dissolved in alcohol.

What makes correctional quackery a serious matter of concern rather than a source of comic relief is the sheer size of the criminal justice population and the scope of the financial and human costs. In the United States alone, there are over 2 million people in jail or prison, and an additional 4.8 million on probation or parole (Bureau of Justice Statistics, 2012) at an annual cost of approximately $70 billion (Pew Center on the States, 2009), and incalculable human suffering on the part of victims. In order to make an impact on such a large and significant social problem, there is a correspondingly large need for competent forensic professionals utilizing sound assessment and treatment practices.

The Complexities of Clinical Work in Forensic Contexts

Effecting change through clinical intervention is not an easy endeavor in the best of settings. There are at least two specific aspects of clinical work with justice-involved clients that make it particularly challenging. The first is the behavior of the clients themselves. By definition, a forensic client is a person who has committed a criminal act and this, by extension, means they have caused harm to someone else. This makes forensic clinical work a perpetrator-based enterprise. It is a normal human condition to have personal reactions to human tragedy, and forensic practitioners are no different. The degree to which this occurs depends on the practitioner and can range from negligible to extreme. At the low end of the reaction continuum, practitioners can remain relatively unaffected regarding a client’s character or behavior and can be clear-headed in formulating a clinical opinion. At the other end of the continuum, clinicians can have excessively negative reactions to the nature or behavior of the client and possibly fall prey to such clinical events as compassion fatigue (Joinson, 1992), which can significantly compromise clinical judgment.

A second professional challenge in working with justice-involved clients relates to the goals of treatment and the consequences of treatment failure. In general psychotherapy, the clinical goal is often symptom relief. For example, depressed clients seek relief from low mood in order to have better and more enjoyable life functioning. The consequences of failing to effect change may be disappointing to such clients and clinicians, but less than optimal outcomes result in relatively limited harm to others. In contrast, clinical tasks with justice-involved clients may not be geared toward symptom relief but rather to a broad class of rule-violating behaviors (Bonta, 2002). Practitioners identify and attempt to therapeutically modify the factors responsible for antisociality such that risk potential for future rule violation behavior is reduced. Practitioners working with justice-involved clients often have a realization, typically based on historical behavior, that clients have the potential to commit future antisocial acts. It may be determined, for example, that criminality is linked to criminal thinking. Thus, the goal is to modify antisocial thoughts with the understanding that future criminal conduct is less likely to occur. Unlike in general psychotherapy, suboptimal treatment performance with forensic populations can result in an unchanged criminal risk profile, the consequences of which are future criminality and victimization. The fact that justice-involved clients are notorious for being resistant to treatment and chronically fail to complete interventions offered to them (Olver, Stockdale, & Wormith, 2011; Wormith & Olver, 2002) only adds to the professional challenges.

Effective forensic practitioners are not born – they develop certain competencies that set them apart from less capable practitioners. There is no clear information articulating the essential features of a good forensic practitioner; however, information exists on generic clinicians that can serve as a guide for forensic clinical work. Welfel (1998) identifies three areas of competence linked to the degree of clinical effectiveness with clients:

1. Knowledge – expertise in understanding the theory, research, and application of information in the field of practice.

2. Skill – understanding of therapeutic procedures and the application of those procedures to clients.

3. Diligence – attentiveness to the clients’ needs.

The knowledge competency may be unique in that it will shift from clinical specialty to specialty (e.g., the specific knowledge base for effective forensic practice will be different from that of health or neuropsychology) while the skill and diligence competencies are more likely to cut across clinical specialties. Below we focus on the unique knowledge competencies that are relevant to forensic practice.

Knowledge in three specific areas may serve as the foundation for effective clinical practice with forensic clients. The three areas concern an awareness of: (i) criminal risk variables; (ii) the Risk-Need-Responsivity (RNR) model of offender assessment and rehabilitation; and (iii) the offender treatment effectiveness literature. Practitioners fluent in these areas will be better equipped to provide effective treatment to justice-involved clients, which hopefully translate to better clinical outcomes.

Criminal risk variables

The first core forensic knowledge area relates to the primary factors responsible for antisocial conduct, often referred to as criminal risk variables. Justice-involved clients have multiple problem areas and it can be difficult to determine what problem assumes clinical priority. Information on the relative importance of certain risk factors can assist in the treatment planning process. Although there is extensive literature available on general criminal risk factors, research evidence from meta-analytic literature reviews exists on the predictors of criminal behavior among adult male (Gendreau, Little, & Goggin, 1996), juvenile male (Cottle, Lee, & Heilbrun, 2001), juvenile female (Simourd & Andrews, 1994), adult sex (Hanson & Bussiere, 1998), and mentally-disordered (Bonta, Law, & Hanson, 1998) offenders. Andrews, Bonta, and Wormith (2006) have identified those risk factors most closely linked to recidivism, and have referred to them as the Central Eight (see Box 1.1).

The Risk-Need-Responsivity (RNR) model

The second area of core knowledge concerns the RNR model of offender assessment and rehabilitation developed by Andrews, Bonta, and Hoge (1990). While the RNR model may be unfamiliar to practitioners who come from traditional mental health backgrounds, it has come to be important in the practice and research literature around correctional assessment and treatment. We recommend that practitioners unfamiliar with the model start with Andrews and Bonta’s The Psychology of Criminal Conduct (2010) before jumping into the large base of conceptual and empirical work on RNR that appears in scholarly journals. Each component of the model is briefly described below.

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Box 1.1 The ‘Central Eight’ Criminal Risk Variables

1. History of antisocial behavior (early and continuing involvement in antisocial acts).

2. Antisocial personality (adventurous, pleasure seeking, poor self-control).

3. Antisocial cognition (attitudes, values, beliefs supportive of crime).

4. Antisocial associates (close association with criminal peers and relative isolation from prosocial others).

5. Family/marital (lack of nurturing relationship; poor monitoring of behavior).

6. School/work (low levels of performance and satisfaction in school or work).

7. Leisure/recreation (low levels of involvement and satisfaction in prosocial pursuits).

8. Substance abuse (abuse of alcohol or drugs).

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The Risk component concerns the dosage of clinical services and contends that services be titrated to the degree of presenting problem; with the presenting problem defined as risk to reoffend. Specifically, higher risk cases should receive proportionally more services than lower risk cases. The Need component relates to the targets of clinical services and suggests that clinical attention be placed on the specific factors giving rise to the client’s antisocial behavior. Moreover, the Need component distinguishes between criminogenic (those more strongly related to criminality – attitudes, companions, etc.) and noncriminogenic (those weakly related to criminality – self-esteem, social status, etc.) and suggests clinical attention focus on criminogenic needs. The Responsivity component relates to providing clinical services that are tailored as best as possible to the unique learning styles of the client. Research on the RNR model has revealed that adherence to RNR principles is linked to better clinical outcomes for justice-involved clients in terms of lower recidivism (Andrews & Bonta, 2010; Andrews & Dowden, 2005; Latessa, 2004).

Mental health symptoms are classified less criminogenic in the RNR model. They are related to recidivism, but not as strongly as the Central Eight. Therefore, practitioners must not assume that addressing their client’s depression, anxiety, or low self-esteem will have an appreciable impact on the client’s likelihood to recidivate. In fact, a recent study found that for forensic clients with both significant mental health symptoms and criminogenic risks/needs, focusing solely on the mental health components produced limited effects on recidivism (Guzzo, Cadeau, Hogg, & Brown, 2012). Forensic clients high on both mental health problems and criminogenic risks/needs will require good mental health treatment and interventions that directly address criminal risk factors. This suggests that like co-occurring mental health and substance use disorders, treatment for mentally disordered justice-involved clients should target both problem areas. In cases in which the mental health symptoms are particularly severe, alleviating psychological distress is important so that justice-involved clients can later work on criminogenic needs, but alleviating distress does not replace the importance of intervention around criminogenic needs.

Treatment effectiveness with offenders

Familiarity with the “what works” literature on forensic treatment is the third area of core knowledge. Energetic debates about the effectiveness of offender treatment have raged for years in the forensic literature. The lightening rod of interest in this area can be attributed to Robert Martinson (1974), who after reviewing the correctional treatment literature concluded “nothing works.” As was pointed out previously, the clinical outcomes of interest in forensic settings are most often focused on rule-breaking conduct and thus the determination of treatment benefit is focused on a very specific criterion, namely future criminality (i.e., recidivism).

After Martinson’s (1974) report, the field of forensic rehabilitation saw the development of a generation of manualized cognitive-behavioral therapy (CBT)-based programs as well as the first meta-analyses of offender rehabilitation programs. Both of these developments supported the potential for CBT to be effective with justice-involved clients. In a little over a decade after the Martinson report several manualized group treatments based on CBT principles were introduced, including: Aggression Replacement Training (Goldstein, Glick, & Gibbs, 1998), Moral Reconation Therapy (Little & Robinson, 1986), and Reasoning and Rehabilitation (Ross, Fabiano, & Ross, 1986). The three programs have different foci but were all specifically developed for offenders, can be delivered by trained facilitators rather than psychologists, and have been found to reduce recidivism (Milkman & Wanberg, 2007; Wilson, Bouffard, & MacKenzie, 2005). The first meta-analysis of offender rehabilitation programs found a moderate effect on reducing recidivism – e.g., well-run treatment programs decreased reoffending by 30%, while simple custody (in the absence of treatment) results in an increase of recidivism by 7% (Andrews, Zinger, Hoge, Bonta, Gendreau, & Cullen, 1990). Subsequent meta-analytic reviews of the offender treatment l...