Treatment of Offenders (Edexcel A-Level Psychology): Revision Notes
Treatment of Offenders
Introduction to treating offenders
The criminal justice system commonly uses punishment for convicted offenders, including prison sentences, fines, or community punishments. Over the past two decades, there has been an increasing focus on including treatment programmes alongside punishment.
Forensic psychologist: A psychologist who specialises in working with offenders. They apply psychological theory to criminal investigation, understanding psychological problems associated with criminal behaviour, and treating those who have committed offences.
Treatment programmes predominantly focus on psychological techniques and behavioural interventions, though biological treatments have also been developed. The effectiveness of these treatments varies depending on the specific approach used.
Treatment is typically delivered by forensic psychologists or staff trained in the required skills under psychologist supervision. Offenders may receive treatment in community settings or prisons. The principles remain consistent regardless of location, though the extent of treatment may differ based on offence severity and reoffending risk.
Why treat offenders?
Punishment teaches offenders that their behaviour has consequences and acts as a deterrent by restricting their activities. If imprisoned, it removes them from the community. However, punishment alone does not directly teach offenders how to act differently. Offenders may lack the skills to deal with challenging situations or may have learned to associate offending with positive outcomes. Consequently, punishment cannot be the sole solution to reducing reoffending.
Treatment programmes aim to identify problem behaviours and their underlying causes, then teach offenders non-offending ways to manage their problems. Treatment predominantly focuses on developing these skills. If staff delivering treatment are not psychologists, they are usually supervised by psychologists.
Treatment categories
Offence-related treatment falls into three distinct groups:
- Cognitive-behavioural therapy (CBT)
- Behavioural treatments
- Biological approaches
Cognitive-behavioural therapy
Cognitive-behavioural therapy (CBT) is a treatment that helps offenders develop insight into their thoughts and feelings and how these influence their behaviour. CBT operates on the principle that for every situation we experience, we have thoughts about that situation (the cognitive element). We also have emotional reactions to the same experience. These thoughts influence our feelings and how we react to the situation (the behavioural element).
CBT seeks to change an offender's reactions to situations by developing their awareness of their own thoughts and modifying these thoughts to ensure their reaction is more prosocial (behaviour that considers others' welfare and deliberately avoids harming them). The approach also encourages offenders to consider alternative ways they could act in non-criminal situations. Offenders may undertake CBT individually with a therapist, in group settings with other offenders and a therapist, or both.
Theoretical basis
CBT has a sound theoretical foundation for treating offenders because criminal thinking patterns have been firmly linked to offending behaviour (Beck, 1999). Criminals display distorted thinking, including:
- Displacing blame for their crime onto the victim or another source external to themselves
- Misinterpreting offending behaviour
- Interpreting social cues as potential threats
- Having schema related to self-dominance and personal entitlement
These distorted thinking patterns are assumed to be learned. Therefore, CBT aims to help offenders identify and restructure these faulty thinking patterns, develop victim empathy, and challenge their tendency to self-justify their offending.
Evaluation of CBT
CBT is not counselling and does not focus on overcoming emotional reactions to past difficulties, as counselling often does. The focus remains on the present thinking of offenders at the time they receive treatment. CBT acknowledges past thoughts and experiences but does not work immediately. It requires commitment from the offender for effectiveness. As a talking therapy, it requires offenders to discuss their thoughts and experiences with therapists so they can help them understand their reactions to different situations and consider alternative thoughts and behaviours.
CBT Effectiveness: Research has demonstrated CBT's effectiveness in treating many emotional difficulties in both offenders and non-offenders. In a meta-analysis of 20 group-oriented CBT research studies, CBT reduced recidivism by up to 30% compared to control groups that did not receive CBT (Wilson, Bouffard and MacKenzie, 2005). Other meta-analyses have also found CBT more effective than behavioural techniques in reducing reoffending (Pearson et al., 2002).
However, some studies within meta-analyses show greater effects than others. Certain studies suggest there may be variables moderating whether CBT's effect on reoffending rates is small or large in bringing about changes in criminal thinking. A review of 58 CBT studies with careful scrutiny of possible moderator variables (such as offender type in the programme, study methodology, and intervention nature) revealed that only the amount and quality of the CBT programme affected the likelihood of success (Lipsey, Landenberger and Wilson, 2007).
Anger management
A common CBT application for offenders is anger management, endorsed by Raymond Novaco since the 1970s. Novaco describes anger as a strong emotion impacting a person's physiology, behaviour and cognition. Anger management teaches relaxation techniques to address the physiological response to anger (such as increased heart rate), cognitive restructuring to retrain thought patterns, and time out or assertiveness training to address the behavioural element of anger. The process involves three steps.
1. Cognitive preparation
Offenders identify situations that provoke anger so they can recognise when an aggressive outburst is likely to occur. Thought patterns are challenged. For example, if they become angry when laughed at, they might work through alternative conclusions, such as that people are laughing at the behaviour and not at them. They also consider the negative consequences of their anger on others.
2. Skill acquisition
New coping skills are learned to help deal with anger-provoking situations, such as relaxation, avoidance, or social skills like assertiveness and conflict resolution. Since anger is a normal emotion experienced by everyone, offenders are not taught to be fearful of becoming angry. Instead, the emphasis is on giving offenders skills so they can control their anger.
3. Application practice
Offenders role-play various scenarios to practise new skills to control anger. These are conducted in controlled environments so offenders feel safe and untrained individuals are not exposed to risk of harm.
Anger management programmes can be used in prisons or with offenders serving a probationary period in the community. Courses are usually conducted in small groups and last for approximately ten sessions, although some can last for several months.
Use of anger diaries
Offenders may be asked to complete anger diaries regularly. They complete these every time they feel angry. With support from the therapist, they start to recognise their triggers for anger and be in a position to evaluate which anger management techniques work best for them in specific situations. The anger diaries may have additional columns added as they become more insightful throughout their treatment. This adopts a scaffolding approach to learning, avoiding giving the offender too many expectations at the start of therapy when they are likely to need to develop their understanding before they can use these skills.
Example of an Anger Diary
The table below shows how an offender might record their anger experiences to help identify triggers and patterns:
| Date | What happened when I started to feel angry (Trigger) | What physiological symptoms did I have? | On a scale of 1-10, how angry did I feel (10 being very angry) | What did I think about the situation? | How did I deal with the situation? |
|---|---|---|---|---|---|
| Tues 1st July | Someone bumped into me and I spilt my cup of tea | Heart racing, Fast breathing | 5/10 | 'How dare he', 'He did that on purpose' | I shouted at him and told him to make me another cup of tea |
As treatment progresses, additional columns can be added to track coping strategies used and their effectiveness.
Evaluation of anger management
Critical Limitation: Anger management is only effective for offenders who have problems with anger control. Not all offences, even violent ones, are committed because the offender was unable to control their anger. Before attending anger management treatment, offenders are interviewed to assess if this would be suitable for them. It has also been shown to be effective only for those motivated to change their behaviour, who are committed to the programme (Howells et al., 2005).
Ireland (2004) assessed 50 young male prisoners on an anger management course and 37 control prisoners. It found that 92% of prisoners showed an improvement in their management of anger, suggesting such programmes are effective. However, it is possible that offenders may be dishonest on psychometric assessments measuring anger and may try to show that they have either improved their anger management skills or minimised the anger they experienced initially. This remains a difficulty with any intervention that relies on self-reporting data, and is not exclusive to the treatment of offenders. For offenders, however, there may be a greater incentive to lie, including looking good for parole (if in prison) or trying to have their restrictions reduced by demonstrating they are no longer a risk to the public.
Behavioural treatments
Social skills training
Evidence suggests that the way an offender interacts with others can increase the potential for a situation to become hostile and therefore result in offending. Additionally, developing positive social skills provides offenders with skills that can be used proactively in the community in different situations, including trying to obtain employment and dealing with future problems.
CBT typically incorporates aspects of social skills training, problem-solving skills, and assertiveness training. CBT as a treatment package is used to encourage offenders to consider their existing social skills and to develop these and other social skills.
Assertiveness Training: One social skill focused on is assertiveness. This involves communicating in a confident, non-confrontational way to minimise conflict and increase the likelihood the offender will be responded to positively. This encourages an offender who may usually interact with others in an aggressive way (by communicating in a forceful, threatening or intimating way) to consider how to do so in a more assertive way instead. They are encouraged to practise the techniques introduced within such treatments and reflect on how successfully they used the skills.
Such treatment provides a supported approach to developing skills that, by giving greater guidance, is more effective than simply telling the offender what they should do. The offender learns from personal experience how beneficial it may be to be polite in a situation. It also helps them to feel more confident in being able to use the skills. The offender is then more likely to continue to use the skills in the future.
Offenders can be trained on general thinking skills and decision making, such as getting them to stop and think before they respond, considering other ways of responding to situations, and helping them to reflect on the consequences of their decision making. They can also receive problem-solving training to help them deal with conflict that they may experience.
Evaluation of social skills training
Pearson et al. (2002) reviewed the impact of social skills training on reoffending rates. They found that CBT programmes in general had a positive effect on reducing reoffending. However, it is difficult to assess the effectiveness of specific CBT techniques, such as social skills training, problem-solving and assertiveness training, because they are often used alongside other techniques. In a careful analysis of the techniques used within 58 CBT programmes, cognitive skills training and interpersonal problem solving were found to have a modest positive effect (respective effect sizes 0.2, 0.4) on reducing recidivism.
Mixed Findings for Juvenile Offenders: Specific treatment packages focusing on problem-solving skills in juvenile offenders have produced mixed findings. The Enhanced Thinking Skills programme (McGuire, 1995) helps juvenile offenders to learn critical reasoning skills, problem solving and self-control. It is a 20-session programme specifically focused on the cognitive skills that younger people may not have developed, which may have contributed to offending behaviour.
Initial research findings suggested the programme lowered juvenile recidivism in low-, medium- and high-risk offenders (Friendship et al., 2002). However, a reanalysis of the data did not show any effect in reducing reoffending (Falshaw et al., 2003). A later study found that effects were only shown after one year, but reoffending rates after two years were not improved by the programme (Cann et al., 2003), suggesting that cognitive training may only have short-term effects.
Biological treatments
Diet
A less-used approach to treating offenders relates to biological interventions. The reason for such interventions being used less is due to the limited research evidence to support them. Diet is one consideration for a biological treatment for aggression. This suggests that minerals, vitamins or essential fatty acids play a role in human behaviour, with a deficit in any of these areas increasing the potential for an individual to act in a violent manner.
Low blood sugar levels have been noted to result in increased irritability, although the evidence is often confounded by other variables, such as drug-taking behaviours or a lack of clarity as to the type of antisocial behaviours researchers are observing to determine any correlation between sugar levels and aggression.
Evaluation of diet
Blood Sugar and Irritability: Benton (1996) looked at Peruvian children aged 6-7 years old and monitored their irritability while playing a deliberately frustrating computer game. After monitoring their blood sugar levels, he reported there was an increase in irritability when there were moderate falls in levels. However, he concluded that the likelihood of this irritability translating into aggressive behaviour depended on other factors such as provocation and their own social skills, suggesting diet was not the only influencing factor.
When looking at the effect of diet on behaviour, it is necessary to consider how diet can affect hormones within the body, which in turn influence behaviour, rather than the diet having a direct effect. There are many other variables that may contribute to violence, which are not accounted for by diet. Benton identified provocation and social skills as two factors excluded from consideration in this treatment approach. Others include the influence of others, previous experience and the individual's interpretation of the situation.
Worked Example: Gesch et al. (2002) Prison Study
Study Design: A total of 231 male prisoners in a young offender's institution signed a consent form, supported by a prison officer, to receive either a daily vitamin, mineral and essential fatty acid supplementation (active group) or placebo (an inactive substance used as a control in a study to see the effect of a drug).
Key Features:
- Participants were not told if they were receiving placebo medication or the vitamin trial
- Participation varied from a minimum period of two weeks to nine months
- Average time spent on supplementation was 142 days for the placebo group and 142.62 for the active group
- No individuals were withdrawn as a result of ill effects from supplementation
Measurements:
- Disciplinary records (serious incidents of violence and minor non-compliance)
- Dietary intake recorded
- Baseline measure of anger, anxiety and depression obtained for all participants
Key Findings:
- Average number of disciplinary incidents per 1,000 person-days dropped from 16 to 10.4 in the active group (), which is a 35% reduction, whereas the placebo group only dropped by 6.7%
- Violent incidents in the active group dropped by 37%, and in the placebo group only 10.1%
- No difference in self-reported levels of anger, anxiety and depression between groups
Conclusion: Antisocial behaviour in prisons, including violence, are reduced by vitamins, minerals and essential fatty acids with similar implications for those eating poor diets in the community.
Diet can be easily changed by including multi-vitamins in a person's diet. This is a form of treatment that can be easily implemented with minimal cost. However, it is necessary to understand the person's dietary levels prior to starting them on any such treatment, and this requires the skills of medical professionals, which can be costly.
Hormone and drug treatments
Individuals may be placed on hormone treatments or be given other drugs as a means of treating aggression. There are a number of key treatments provided that aim to address the hormone imbalances identified as contributing to aggression.
Dopamine
High levels of dopamine have been found to increase aggression and, among adolescents, Conduct Disorder. Dopamine affects the reward systems in the brain, which results in aggressive behaviour. Aggression activates the release of dopamine and generates rewarding feelings in the individual. The individual then continues to act in an aggressive way as it makes them feel good. The role of dopamine in aggression has been demonstrated in studies using amphetamines, a chemical that when consumed increases levels of dopamine. Studies have found that when participants are given amphetamines, there is a corresponding increase in their levels of aggression.
In order to reduce dopamine-related aggression, it is necessary to reduce the level of dopamine in the brain. This can be achieved via the use of dopamine antagonists. These are chemicals that reduce dopamine activity in the brain, which in turn reduces aggressive behaviour. Evidence supporting the importance of dopamine in aggression comes from studies using antipsychotics, such as risperidone, which reduce dopamine levels in the brain. Risperidone is typically used to treat schizophrenia, and also works to reduce irritability. It works by blocking the receptors in the brain on which dopamine acts. This prevents excess dopamine activity, which then has a positive effect in reducing aggression.
LeBlanc et al. (2005) Study: A randomised controlled trial investigated the effect of risperidone on aggression among 163 adolescent boys diagnosed with either Conduct Disorder or Oppositional Defiant Disorder. Both conditions result in aggressive behaviour. All participants had below average levels of IQ.
The boys were allocated to either a placebo drug or a dose of risperidone (taken orally). The study found that after six weeks, those who were treated with risperidone displayed a 56.4% reduction in aggressive behaviour when compared to the placebo group. A reduction in aggression was also noted in the placebo group (21.7%). There was a clinically significant reduction () in the aggression score among the risperidone group at the end of the six weeks compared to the control group. They concluded that risperidone is effective in reducing symptoms of aggression among boys with disruptive behaviour disorders.
A study by Couppis and Kennedy (2008), however, found that dopamine might be a consequence of aggressive behaviour rather than a cause (see Neurotransmitters page 372). As such, to treat aggression with a treatment method that addresses the consequence of aggression may not address the underlying reason for the aggression.
Serotonin
Serotonin is responsible for maintaining mood balance.
Serotonin levels can be increased by the drug treatment selective serotonin reuptake inhibitors (SSRIs). SSRIs are a form of antidepressant medication. After carrying a message in the brain, serotonin is usually reabsorbed by the nerve cells. This is known as 'reuptake'. SSRIs work by blocking (inhibiting) this reuptake. This results in more serotonin being available to pass further messages between neurons.
Fluoxetine (an SSRI): Coccaro and Kavoussi (1997) investigated the influence of fluoxetine on impulsive aggressive behaviour among a sample of personality-disordered individuals with a history of aggression but who did not have major depression, bipolar or schizophrenia.
A number of behavioural rating scales, including the Overt Aggression Scale-Modified for Outpatients (a rating scale used to identify the level of aggression presented by an individual within the past week, completed by people who know the individual well), were used to monitor the level of aggression displayed by the participants over a three-month period. A placebo group was used as a comparison group.
The study found that fluoxetine resulted in a sustained reduction in scores on irritability at the two-month stage and depression at the third month of treatment. This was not observed in the placebo group. This suggested that fluoxetine, as an SSRI, had a positive effect in reducing aggression among impulsive aggressive individuals with personality disorder.
In a recent review of 62 sexual offenders in Whatton prison (Hocken and Winder, 2012), the 32 offenders taking fluoxetine reported reduced frequency of sexual thoughts and excitability. However, the side effects of drowsiness, constipation and nausea were reported (Lievesley et al., 2012).
Testosterone
Testosterone is a hormone found in both men and women, but in greater levels in men. It plays a key role in the development of male reproductive tissue and is required to maintain muscle strength and bone density. Elevated testosterone has been documented among individuals with a history of aggression.
The administration of the female hormone medroxyprogesterone acetate (MPA), which decreases the functioning of testosterone, has been investigated as a way of reducing testosterone levels in males. This chemical agent, referred to as an anti-androgen, acts by breaking down and eliminating testosterone and inhibiting the production of luteinising hormone through the pituitary gland, which in turn inhibits or prevents the production of testosterone. It also produces side effects, including breast enlargement, osteoporosis and depression. This makes it more likely an individual will decline such treatments or result in higher rates of non-compliance following initial agreement to treatment.
Evaluation of hormone and drug treatments
Medication Limitations: Much of the guidance for the use of hormone treatment, specifically in relation to risperidone use, provides guidance that medication alone should not be the treatment plan. The use of drug treatments should form part of a wider intervention that also teaches individuals to recognise and manage their aggression. This suggests that drug treatment on its own is insufficient to treat aggression.
It is often necessary for prolonged drug treatment before an effect on behaviour can be observed. For example, it can take up to four weeks for SSRIs to have any noticeable effect on the individual. This can affect medication compliance, with the potential for people to not take the medication consistently if they do not see any effect. This then reduces the effectiveness of drug treatment. There can also be physical side effects of hormone treatment. This means the treatment might not be suitable for everyone displaying aggression, due to ongoing medical conditions or because the side effects are too severe to warrant the continued use of the medication.
Research studies investigating the effect of drug treatments on aggression often use placebo-controlled trials, in which the participants do not know which group they have been allocated to. This reduces the likelihood of demand characteristics, making the data more reliable.
Individual differences
Side Effects and Ethical Concerns: Risperidone is associated with a number of adverse side effects, such as a rash, vomiting, anxiety, sleep disturbance and hyperprolactinaemia (abnormal blood levels of prolactin, associated with spontaneous lactation, menstruation, infertility and erectile dysfunction), among many others.
It is therefore questionable whether risperidone should be used to treat aggression, particularly in young offenders. Pharmacological interventions, such as risperidone, should only be used after careful diagnosis, in conjunction with psychological therapy, and where aggression seems to be the most pervasive symptom. Because individuals with serious aggressive behaviour are often involved in other treatment programmes in addition to receiving medication, it is often difficult to establish whether the medication alone is effective in reducing symptoms.
Wider issues and debates
Reductionism
Avoiding Oversimplification: When understanding the individual as a whole person, it is important not to be reductionist, that is, oversimplifying or fragmenting what is important to an individual to the extent that it does not accurately represent the person.
It is easy for one factor to influence a person's behaviour without giving consideration to all the other influences that may have contributed. For example, we may spend so long thinking about how a person's background or family life has modelled antisocial behaviour that we fail to think about other influences, such as financial motivation or biological factors contributing to the behaviour. Psychological formulations can be criticised for being reductionist because they can overly simplify or compartmentalise factors that may have contributed to the person's behaviour, and perhaps miss out important factors or underplay the interconnection between each factor.
Gender
Male vs. Female Offenders: There is a prevalence of data regarding male offenders, as these represent the highest proportion of convicted criminals within the UK. Explanations for offending, such as elevated testosterone levels or XYY syndrome, help to explain male offending, but do not explain why females commit offences.
Similarly, structured treatment programmes have been designed with men in mind, and therefore may not reflect the needs of female offenders, thereby making them less effective for female offenders completing such treatments. Consequently, less is known about the factors influencing women and how to address their treatment needs.
Issues of social control
Social Control Concerns: The treatment of aggression via the use of drug treatments has been argued to be a form of social control. In prescribing hormone or drug treatments this can change the behaviour of the individual, to more closely match the expectations of those of the general population.
The use of psychological knowledge within society
Chemical Restraint Concerns: Medroxyprogesterone acetate (MPA) has typically been applied to male sexual offenders as a means of reducing sexual aggression thought to be the result of elevated testosterone levels. The use of anti-androgen medications to reduce sexual drive and consequently sexual behaviour could be classified as a form of chemical restraint, a practice of using specific hormonal agents to restrict sexual freedoms and behaviours.
The use of such chemical interventions, particularly involuntarily, as forms of restraint carry a negative ethical connotation. This form of hormone has limited effectiveness in reducing sexual aggression and its application as a treatment of sexual aggression within the UK is now limited.
Loosen, Purdon and Pavlou (1997) found that the administration of MPA resulted in marked reductions in outwardly directed anger among all eight participants within their study. However, the participants were non-aggressive men so their findings have limited application to aggressive individuals.
Ethics
Ethical Considerations: Drug treatments used for aggression and sexual deviancy have been used in forensic-psychiatric institutions to treat offenders with mental health issues. Improvements in behaviour or reductions in symptoms are often assessed by clinical experts or through self-reports.
Pharmacological treatments are voluntary in this country, so are only prescribed with the consent of the patient. However, there is concern over the nature of such consent within forensic-psychiatric institutions, and in other countries voluntary consent is not required.
Remember!
Key Points to Remember:
Treatment Approaches:
- Treatment of offenders includes three main approaches: cognitive-behavioural therapy (CBT), behavioural treatments, and biological approaches
CBT Effectiveness:
- CBT focuses on changing distorted thinking patterns that lead to offending behaviour
- Meta-analyses show it can reduce recidivism by up to 30%
- Only the amount and quality of the CBT programme affects the likelihood of success
Anger Management:
- Uses a three-step process: cognitive preparation, skill acquisition, and application practice
- Only effective for those motivated to change who have genuine anger control problems
- 92% of prisoners showed improvement in anger management in Ireland (2004) study
Social Skills Training:
- Particularly assertiveness, shows modest positive effects (effect sizes 0.2-0.4) on reducing reoffending
- Most effective when combined with other CBT techniques
- Enhanced Thinking Skills programme shows only short-term effects (effective after one year but not two years)
Biological Treatments:
- Include dietary interventions (vitamins, minerals, essential fatty acids) and hormone/drug treatments
- Diet can lead to a 35% reduction in disciplinary incidents (Gesch et al., 2002)
- Dopamine antagonists like risperidone show 56.4% reduction in aggressive behaviour
- SSRIs like fluoxetine reduce irritability and sexual thoughts
- Medication alone should not be the treatment plan - must be combined with psychological interventions
- Side effects and ethical concerns about social control affect compliance and voluntary consent