Best practices in corrections: using literature to guide interventions.
Best practices in intervention with, and the treatment of, offenders include the use of evidenced-based practices (EBPs) and empirically supported treatments (ESTs). EBPs are a comparatively more global set of principles that incorporate the characteristics and therapeutic needs of offenders into the design of an intervention program that is focused on recidivism prevention. EBPs are what is traditionally associated with the idea of best practices in corrections. ESTs, on the other hand, can work as a facet of an EBP model when designed specifically to affect recidivism risk, (3) or can be used outside of the recidivism prevention model to address the goal of symptom amelioration for mental health disorders in offender populations. (4) The use of ESTs in the treatment of psychological disorders is an extension of the traditional concept of best practices, in that it does not focus on recidivism prevention. However, the incorporation of ESTs into the notion of best practices is responsive to the role of many clinicians in corrections who spend the majority of their time focusing on the treatment of psychological disorders in offenders.
The use of EBPs for recidivism prevention and ESTs for symptom amelioration in corrections are two components of best practices that are complementary to one another, with both emphasizing the use of treatment/intervention models derived from scientific research that are focused on measurable outcomes.
Evidenced-Based Practice For Recidivism Prevention
Over the years, there has been a lot of focus on what does not work in corrections, with some researchers claiming that nothing works in rehabilitating offenders to avoid recidivism. (5) However, an increase in controlled research indicating a positive effect of correctional treatment has been seen in recent decades. (6) Studies examining the common features of successful programs have discovered principles to follow in developing effective interventions that will significantly affect the likelihood of criminal recidivism. (7) EBP entails the use of these principles in the development of a recidivism prevention program.
How Does EBP Work In A Correctional Setting?
According to the Crime and Justice Institute report Implementing Evidence-Based Practice in Community Corrections: The Principle of Effective Intervention, one of the first principles of EBP is to assess the risk (likelihood of reoffending) and needs of offenders using actuarial means. Risk is assessed to determine treatment candidates, with the higher-risk cases being prioritized for treatment. Next, a needs assessment should ascertain the dynamic factors that are related to an offender's criminal behavior and recidivism (i.e., criminogenic factors) such as criminal thinking, antisocial beliefs and antisocial associates. The Crime and Justice Institute indicates that an appropriate intervention model should be selected based on the findings of empirical literature and implemented with sensitivity to "temperament, learning style, motivation, gender and culture," and this treatment should focus on altering relevant criminogenic factors. (8) More often than not, the type of intervention selected is one that is behavioral or cognitive-behavioral in nature, as programs using techniques from these modalities have been shown to work in reducing recidivism. (9)
In addition to the risk, needs and responsivity principles. EBP interventions address barriers to treatment such as inadequate offender motivation with, for example, motivational interviewing, (10) which is a client-focused, directive approach to increase patient motivation by "exploring and resolving ambivalence." Effective interventions also use an intermittent schedule of positive reinforcement for successive approximations to desired changes, incorporate the arrangement of supportive networks outside of prison, are intensive in nature (40 percent to 70 percent of offender time should be structured for three to nine months) and necessitate the measurement of treatment progress and outcomes. (11)
Finally, for any intervention program to be successful, it must have credentialed, trained and supervised staff who implement it correctly. Craig Dowden and D.A. Andrews (12) found that core correctional practice helps to enhance treatment effectiveness. Core correctional practice entails maintaining a "firm but fair" interaction style marked by warmth, respect and open communication, modeling appropriate behavior and directly reinforcing appropriate and pro-social behaviors displayed by offenders, teaching appropriate skills focused on solving problems that are interfering with positive desired outcomes, and helping offenders secure resources that will help with the transition to the community such as job training.
Although it is known that EBP is effective in reducing recidivism, unfortunately, there is some indication that an EBP approach is not universally applied in correctional settings. (13) Barriers to EBP include a lack of time and/or resources to assess offenders, use of antiquated or invalid assessment measures, and a failure to use generated assessment information to guide intervention. (14) Of course, correctional psychologists are aware of the systemic limitations to providing services to their charges. Any systemic change in a correctional setting takes much work and innovation, especially when psychological services are seen as secondary in importance to corrections in a prison. Therefore, it is incumbent on treatment professionals to educate themselves and appropriate others about the benefits of using science to dictate practice, emphasizing extant evidence supporting the effect of EBPs on recidivism, and to ensure that systemic changes are implemented effectively.
Empirically Supported Therapies For Symptom Amelioration
While literature regarding correctional treatments espoused that nothing worked, outcome research about extant therapies for the treatment of psychological disorders indicated that while various psychotherapies appeared to work, they did not significantly differ from one another in their treatment effectiveness in the alleviation of symptomatology. (15) Known as the "dodo bird" verdict, this equality of effectiveness among therapies has been replicated in subsequent and more statistically sophisticated studies. (16) However, despite such results, other researchers adopted the view that there are substantive differences among the therapies that result in disparate degrees of effectiveness in the treatment of various disorders. (17) As a result of this debate and the concomitant pressure on clinicians for accountability in practice, efficacy (randomized controlled trials) and effectiveness (real-life treatment setting) studies of various psychotherapies were conducted. Results, in many cases, supported the contention that the various psychotherapies had different treatment outcomes within a given diagnostic group. For example, dialectical behavior therapy was found to be superior to community treatment for parasuicidal border personality disordered patients in controlling the number of patient hospitalizations and self-injurious behaviors over a period of one year. (18)
The debate about the effectiveness of various psychotherapies and the resultant increase in treatment outcome research helped give rise to a movement aimed at disseminating important treatment outcome research findings to professionals in the field. Lists of therapies found to be effective for various disorders were compiled and recommended, along with their respective treatment manuals, for use in clinical practice. (19) These recommended treatments were referred to as empirically validated treatments, and later empirically supported treatments. (20) The result of this dissemination effort was the start of a bridge between researchers and clinicians as the field strived for the integration of science and practice. The emphasis on the use of ESTs is not without controversy. (21) For example, the applicability of results generated from the research setting to real-life clinical settings is frequently challenged as an impediment to the development of an EST list. (22) Nevertheless, more and more clinicians are using ESTs as a front-line approach to treating their patients, and their patients are experiencing improved treatment outcomes. (23) In fact, the use of ESTs has been touted as the most ethically defensible approach to treatment that a clinician can take. (24)
How Do ESTs Work in a Prison Setting?
Inmates suspected of having a diagnosable mental health condition by previous history, current behavior or staff referral should be carefully assessed. After reaching a valid diagnosis, treatment literature can be consulted regarding what is empirically supported for use with that diagnosis or constellation of symptoms. When there are no available ESTs for a given disorder, clinicians would be well-advised to extrapolate from the clinical trials that are available in their development of a treatment plan.
Best practices calls for clinicians to also act as scientists in the evaluation of treatment effects. Symptom inventories and assessment measures should be used to track symptom presentation over time. Simple behavioral monitoring may be used if no standardized assessment tools are available. If a treatment has not demonstrated effectiveness after a reasonable period of time, assuming adherence to the manual and proper motivation, and alternative treatment approach should be considered.
It should be noted that most ESTs were not designed specifically for, or tested with, a correctional population. Therefore, there may be a number of problems associated with implementing ESTs "by the book" in a correctional setting. For example, an institution may not have enough willing offenders with borderline personality disorders at a given time to arrange a group treatment modality, as recommended for dialectical behavior therapy. (25) Or, more generally, offender security or disciplinary issues may interfere with the therapy process. Other issues common to a prison setting, such as language/culture barriers and illiteracy, can affect adherence to a particular treatment manual. Clinicians may be flexible and innovative in their handling of such treatment barriers, but should strive for the maintenance of maximum loyalty to a given treatment. Consultation with other correctional clinicians who have experience with individual and group ESTs may yield additional useful information.
EBP and ESTs: Tying Them Together
Clinicians working in correctional settings have a dual mandate to treat the psychological disorders of offenders that are common to the population at large and to address the psychological factors associated with incarcerated offenders that put them at risk to re-offend. As an offender's diagnosable psychological disorders may interfere with his or her ability to benefit from interventions aimed broadly at recidivism prevention, best practices dictate that the offender should be treated for those disorders. Once they are addressed and symptoms have improved, the focus and goals of treatment can change toward interventions aimed at recidivism prevention developed within an EBP framework.
It is incumbent for psychologists to provide treatment that works--treatment that is supported by research--whether they are addressing recidivism prevention or treating an Axis I disorder. In both tasks, the use of scientific principles and findings to guide psychologists' work is consistent with professional ethical guidelines that charge them with providing effective treatment. The time has come for best practices in corrections to shift from the status quo to the marriage of science and practice in the provision of treatment to offenders. In order to help facilitate this change, correctional clinicians must become familiar with the extant literature, use it to guide the provision of treatment, and echo scientific principles in their treatment by becoming regular evaluators of treatment outcome. Correctional researchers must continue to strive to publish effectiveness studies of EST use with offenders and note how ESTs were adapted for use with this population. Researchers can also endeavor to develop and evaluate treatments that merge the principles of change stipulated in correctional EBP into extant ESTs for the treatment of mental health disorders with dual goals of symptom amelioration and recidivism prevention.
Staying in the Loop
Both veteran clinicians and novice practitioners may have limited knowledge of what techniques are considered empirically supported for various diagnoses and/or what assessment measures are available and applicable for use in their particular correctional setting. In fact, the dissemination of research findings on empirically supported therapies has not been without problems, even on the graduate training level, (26) where one might expect the highest level of exposure and training. Additionally, burgeoning caseloads in need of attention and limited budgets for academic journal subscriptions are familiar to most correctional clinicians and may limit access to available treatment resources. Although searching for relevant research literature may be cumbersome, there are a few resources that the practicing clinician in search of more information might consider in order to "stay in the loop" about current research findings.
For those interested in obtaining information regarding ESTs for a variety of Axis I and Axis II disorders, a recommended resource is Peter Nathan and Jack Gorman's second edition of A Guide to Treatments That Work. This comprehensive book details what is known about the efficacy of various psychosocial and psychopharmacological treatments from outcome data provided by controlled clinical trials. Less research-savvy clinicians will likely find that this resource takes the guesswork out of having to evaluate the quality of individual studies, as the authors succinctly summarize and categorize treatments according to their scientific rigor and resultant degree of treatment efficacy.
Another resource for those interested in ESTs is the Internet. For example, the Division 12 section of the American Psychological Association's Web site is ripe with information about ESTs and treatment manuals (see www.apa.org/divisions/div12/journals.html and associated links). Robert DeRubeis and Paul Crits-Christoph's article (27) is another recommended resource for learning about ESTs for group and individual treatment. Additionally, clinicians interested in learning more information about EBP and ESTs specific to corrections could begin by getting references located in the Criminal Justice Institute's report (28) and by consulting Preventing Crime: What Works, What Doesn't, What is Promising. (29)
The Internet can also provide connection to various correctional organizations such as the National Institute of Corrections (www.nicic.org), the American Correctional Association (www.aca.org) and the National Commission on Correctional Health Care (www.ncchc.org). In some cases, entire treatment manuals are available for download. (30)
Those interested in research about a broad range of correctional topics may want to consult "Where to Find Corrections Research: An Assessment of Research Published in Corrections Specialty Journals," (31) which examines a number of correctional publications to evaluate trends in research topics over time, within and between journals. For example, the authors found that of the journals examined, The Prison Journal had the most information about gangs in prison and HIV/AIDS-related issues. On the other hand, journals such as the Journal of Offender Rehabilitation and International Journal of Offender Therapy and Comparative Criminology had the most information (relatively) on mental health programming and assessment. In addition to the journals reviewed in "Where to Find Corrections Research," other prominent specialty journals such as Criminal Justice and Behavior and Law and Human Behavior regularly feature articles about correctional assessment instruments and other topics relevant to clinical work in prison.
Finally, membership in relevant professional associations such as the American Psychological Association (www.apa.org) Division 12 (Society of Clinical Psychology) or Division 41 (American Psychology-Law Society), as well as specialty professional associations such as the American Association for Correctional and Forensic Psychology (www.aa4cfp.org) and the Association for the Treatment of Sexual Abusers (www.atsa.com) can expose clinicians to advances in the field through associated journals and newsletters as well as continuing education opportunities through annual conferences. Members, associates and affiliates of APA can also upgrade their membership to include electronic access to full-text APA journal articles, which can be easily accessed via computer download. This upgraded membership also includes the use of PsycINFO, an article-searching database that provides the user with abstracts of articles from a broad range of journals. Additionally, many professional organizations have listservs through which members can communicate about a variety of topics, putting professionals in the field in contact with one another in order to promote knowledge. Together, these various resources help today's busy clinician stay in touch with the research literature without the hassle of having to track down information in a local library.
(1) Crime and Justice Institute. 2004. Implementing evidence-based practice in community corrections: The principle of effective intervention. Washington, D.C.: Department of Justice, National Institute of Corrections.
(2) MacKenzie, D.L. 2000. Evidence-based corrections: Identifying what works. Crime and Delinquency, 46(4):457-471.
(3) Bush, J., B. Glick and J. Taymans. 1997. Thinking for a change: Integrated cognitive behavior change program. Washington, D.C.: U.S. Department of Justice, National Institute of Corrections. Available at www.nicic.org/downloads/pdf/2001/t4c-files/t4c.pdf.
(4) Linehan, M. 1993. Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.
(5) Martinson, R. 1974. What works? Questions and answers about prison reform. The Public Interest, 35:22-54.
(6) Losel, F. 1995. The efficacy of correctional treatment: A review and synthesis of meta-evaluations. In What works: Reducing reoffending, ed. J. McGuire, 79-111. New York: John Wiley and Sons.
(7) Andrews, D.A., I. Zinger, R.D. Hoge, J. Bonta, P. Gendreau and F.T. Cullen. 1990. Does correctional treatment work? A clinically relevant and psychologically informed meta-analysis. Criminology, 28(3):369-404.
(8) Andrews, D.A. et al. 1990.
(9) MacKenzie, D.L. 2000.
(10) Miller, W.R. and S. Rollnick (Eds.). 2002. Motivational interviewing: Preparing people for change, second edition. New York: The Guilford Press.
Also see www.motivationalinterview.org.
(11) Crime and Justice Institute. 2004.
(12) Dowden, C. and D.A. Andrews. 2004. The importance of staff practice in delivering effective correctional treatment: A meta-analytic review of core correctional practice. International Journal of Offender Therapy and Comparative Criminology, 48(2):203-214.
(13) Latessa, E.J., F.T. Cullen and P. Gendreau. 2002. Beyond correctional quackery--professionalism and the possibility of effective treatment. Federal Probation, 66(2):43-49.
(14) Latessa et al. 2002.
(15) Luborsky, L., B. Singer and L. Luborsky. 1975. Comparative studies of psychotherapies: Is it true that "everyone has won and all must have prizes"? Archives of General Psychiatry, 32(8):995-1008.
(16) Wampold, B.E., G.W. Mondin, M. Moody, F. Stich, K. Benson and A. Hyunnie. 1997. A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "all must have prizes." Psychological Bulletin, 122(3):203-215.
(17) Chambless, D.L. 2002. Beware the dodo bird: The dangers of over-generalization. Clinical Psychology: Science and Practice, 9(1):13-16.
(18) Linehan, M.M., H.E. Armstrong, A. Suarez, D. Allmon and H.L. Heard. 1991. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12):1060-1064.
(19) Nathan, P. and J. Gorman. 1998. A guide to treatments that work. New York: Oxford University Press.
(20) The terminology of empirically "supported" is generally preferred to empirically "validated" as the former reflects the dynamic nature of treatment outcome research.
(21) Kendall, P.C. 1998. Empirically supported psychological therapies. Journal of Consulting and Clinical Psychology, 66(1):3-6.
(22) Persons, J.B. and G. Silberschatz. 1998. Are results of randomized controlled trials useful to psychotherapists? Journal of Consulting and Clinical Psychology, 66(1):126-135.
(23) Cukrowicz, K.C., B. White, L.R. Reitzel, A.B. Burns, K. Driscoll, T. Kemper and T.E. Joiner. (in press). Improved treatment outcome: Associated with the shift to empirically validated treatments in a graduate training clinic. Professional Psychology: Research and Practice.
(24) Persons, J.B. and G. Silberschatz. 1998.
(25) Linehan, M. 1993.
(26) Crits-Christoph, P., E. Frank, D.L. Chambless, C. Brody and J.F. Karp. 1995. Training in empirically validated treatments: What are clinical psychology students learning? Professional Psychology: Research and Practice, 26(5):514-522.
(27) DeRubeis, R.J. and P. Crits-Cristoph. 1998. Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66(1):37-52.
(28) Crime and Justice Institute. 2004.
(29) Sherman, L.W., D. Gottfredson, D.L. MacKenzie, J. Eck, P. Reuter and S. Bushway. 1997. Preventing crime: What works, what doesn't, what is promising. Washington, D.C.: National Institute of Justice.
(30) See, for example, Bush et al. 1997.
(31) Tewksbury, R. and E.E. Mustaine. 2001. Where to find corrections research: An assessment of research published in corrections specialty journals, 1990-1999. The Prison Journal, 81(4):419-435.
Lorraine R. Reitzel is a clinical psychology doctoral candidate at Florida State University.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||CT FEATURE|
|Author:||Reitzel, Lorraine R.|
|Date:||Feb 1, 2005|
|Previous Article:||Meeting the needs of mentally ill offenders: inmate service utilization.|
|Next Article:||Deconstructing criminal networks: intervening to break down patterns of criminal associations.|