Cognitive-Behavioural Therapy - Ministry Of Justice

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Cognitive-Behavioural TherapyEVIDENCE BRIEFCognitive-Behavioural Therapy (CBT) is a core form of psychological treatment foroffenders. CBT has been well researched and shown to reliably reducereoffending among many groups of offenders. There is substantial potential toincrease its provision for young offenders.OVERVIEW Cognitive-Behavioural Therapy is thecornerstone of modern approaches torehabilitate offenders. CBT has been extensively implemented inCorrections for adult offenders. There isstrong international and New Zealandevidence that this reduces reoffending. There is also strong international evidencethat CBT reduces reoffending by youngoffenders. The scope of investment in CBT for youngoffenders is currently modest, at just over10% of the level of investment for adultoffenders. There is strong evidence that expandedinvestment in CBT for young offenders wouldreduce crime. The health sector also needs trainedpsychologists and reports there is currently ashortage. As a result, expansion would requireincreasing the number of trainedpsychologists and other professionals in NewZealand who can deliver CBT. In expanding the workforce, appropriatetraining would be vital as to be effective, CBTneeds to be delivered by people with therelevant skills.INVESTMENT CLASS SUMMARYEvidence rating:StrongUnit cost: 5,000- 20,000 perperson given treatmentEffect size (numberneeded to treat):Current spend:For every 5-15offenders receivingtreatment, one less willreoffendc. 25m (Corrections)c. 3m (MSD)Unknown (Health)High (young offenders)Unmet demand:Low (adults)

DOES COGNITIVEBEHAVIOURAL THERAPYREDUCE CRIME?Cognitive-Behavioural Therapy (CBT) is a broadclass of interventions that attempt to restructurethoughts and beliefs that lead to problembehaviours.i Among offenders, CBT is used tochallenge and restructure antisocial cognitions,beliefs and attitudes that contribute to theiroffending.International evidenceIt has been known for at least 25 years that CBTfor offenders reliably reduces reoffending.ii Alarge number of meta-analyses repeat this basicconclusion. CBT reduces reoffending among: adult offendersiii young offendersiv men and womenv general offendersvi, violent offendersvii andsexual offendersviii alcohol and drug using offendersix offenders of various ethnicities (in a Canadiancontext).xProgrammePercentagepoint reductionin reconvictionin 12 months(RQ)Offenders needing tocomplete programmeto prevent one frombeing reconvictedwithin 12 monthsSpecialtreatmentunit ison)6.715Kowhiritanga(prison)6.4*16Mauri TuPae mIntensityProgramme(prison)4.2*24* statistically significant at a 90% threshold** statistically significant at a 95% thresholdNew Zealand EvidenceMost correctional rehabilitation programmes inNew Zealand are based on CBT. Theseprogrammes are evaluated each year andtypically demonstrate statistically significantreductions in reconviction. The latest resultsfrom Corrections (for the 2014/15 financial year)are summarised in the following table.Internal Corrections research has separatelyexamined the effect of these programmes forMāori prisoners and has found them to be justas effective for Māori as for non-Māori.Some of these results have also been publishedin peer-reviewed journals and other publicforums.xiThe CBT programmes provided or funded by theMinistry of Social Develpment and the Healthsector in New Zealand have not been evaluated.COGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 2 of 11

WHEN IS COGNITIVEBEHAVIOURAL THERAPY MOSTEFFECTIVE?Programme typeVarious types of CBT are each effective atreducing reoffending, including: Moral Reconation Therapyxii Reasoning and Rehabilitationxiii Aggression Replacement Trainingxiv Relapse preventionxv Dialectical behaviour therapyxvi CBT-informed anger managementxviithe distortions and errors that characterisecriminogenic thinking.xxiv For school-based CBT, the intervention isprovided across the whole school orclassroom rather than to targetedindividuals.xxvProgramme integrity is also very important.Factors such as clinical supervision of treatmentdelivery are associated with greatereffectiveness.xxvi Tools such as the CorrectionalProgram Assessment Inventory have beendeveloped to help people involved in deliveringCBT ensure they are considering issues suchas: the quality of the training given to thosedelivering the programmeThe evidence for the various types of CBT isequally strong.xviii The only exception is thatthere is not yet sufficient evidence to concludethat Rational Emotive Behaviour Therapy iseffective.xix the programme goals and objectivesProgramme design and implementationThe evidence is mixed about whether CBTprogrammes are more effective in thecommunity or in institutions. There are metaanalyses that conclude that services are moreeffective in the community, xxviii more effective ininstitutions, xxix and equally effective in A reasonable conclusion from thisevidence is that CBT can be made to work inany context so long as it is delivered inaccordance with principles of programmeintegrity.Meta-analyses report that CBT is more effectiveat reducing reoffending when: Higher intensity programmes are offered tohigher risk offenders.xx Programmes target factors such assubstance abuse that are related tooffending, and interventions are modified tomeet the learning style of the offendersinvolved.xxi The treatment involves individualised one-onone treatment in addition to groupsessions.xxii The treatment involves training in techniquesfor maintaining self-control and identifyingtriggers that arouse anger.xxiii The treatment involves activities andexercises aimed at recognising and modifying the approach to matching the programmewith the learning style of the participants.xxviiProgramme locationProgramme participantsCBT has been extensively studied for youngoffenders in particular and has been shown tobe very effective for this group. In hiscomprehensive meta-analysis, Mark Lipseyfound that Cognitive-Behavioural Treatment hada larger effect on reoffending than any otherintervention type for young offenders, althoughmentoring was not far behind.xxxiCOGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 3 of 11

Participant motivationCBT is more effective when offenders aremotivated to participate, and less effective whenoffenders are mandated into treatment.xxxii Foroffenders who are unmotivated, a separatepreliminary intervention called MotivationalInterviewing can be used. There is goodinternationalxxxiii and New Zealand evidencexxxivthat Motivational Interviewing increasesoffenders’ willingness to participate in CBT.What makes cognitive-behaviouraltherapy effective?Compared to many other crime preventioninvestments, a reasonable amount is knownabout what make CBT effective.WHAT OTHER BENEFITS DOESCOGNITIVE-BEHAVIOURALTHERAPY HAVE?Health and behavioural outcomesCBT has been successfully used to address to awide range of problem behaviours and healthconditions. A 2012 review by the NationalInstitutes of Health in the United Statessummarised the results of 269 meta-analysesexamining the effect of CBT on variousoutcomes.xxxviiiAccording to this review, CBT has beendemonstrated to: reduce substance abuse support smoking cessationCBT is based on social learning theory, which isone of the explanations about the causes ofcrime that has the strongest empiricalsupport.xxxv Social learning theory describes aprocess whereby people can adopt anti-socialattitudes and beliefs and have these beliefsreinforced by association with peers and otherswho share these beliefs. reduce problem gambling reduce the impact of chronic pain mitigate the symptoms of schizophrenia,bipolar disorder, PTSD, OCD, bulimia,insomnia, depression, anxiety and generalstress reduce anger and aggression.These antisocial beliefs and attitudes can lead tocriminal behaviour. For example, offenders oftenare quick to perceive harmless situations asthreats, and to believe that violence is necessaryto maintain social status.xxxviCBT aims to reverse this learning process byengaging offenders in a process to change theway they think about themselves and the world.CBT programmes seek to teach offenders toself-monitor their own thinking, and to correctbiased, risky or deficient thinking patterns.xxxviiOther outcomes such as employment,earnings and benefit receiptWe were unable to find any evidenceinvestigating a link between CBT and otheroutcomes such as employment, earnings andbenefit receipt.In CBT, offenders are also taught thinking andbehavioural skills to help them manageproblematic emotional states such as anger, andincrease their capacity for self-control.COGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 4 of 11

CURRENT INVESTMENT IN NEWZEALANDneeds. It targets the attitudes and behavioursthat contributed to their offending and teachesskills and new ways of thinking.Department of CorrectionsMauri Tu Pae: A group-based programme MauriTu Pae (formerly known as the Maoritherapeutic programme) is delivered in Maorifocus units nationally. It’s for male prisoners witha range of offending needs and teachesprisoners skills to alter the thoughts, attitudesand behaviours that led to their offending.The Department of Corrections provides a rangeof different treatments based on CBT, both inprison and the community. Total investment isabout 25m per year. These treatment optionsare listed below.Special treatment units: High intensitytreatment programmes are provided bypsychologists for people who are at highest riskof violence or sexual re-offending. These prisonbased, therapeutic community environments areoffered in six special treatment units. Theseprogrammes include intensive reintegration andsafety planning for release. Two of the unitsprovide treatment for child sex offenders, whilethe other four provide treatments for violent andadult sex offenders.Psychological treatment: This one-on-oneintervention primarily deals with high risk sexualand violent offenders. Psychologists providespecialist advice, assessment, and treatment toreduce an offender’s risk of re-offending.Medium intensity rehabilitation programme:The medium intensity rehabilitation programmeis for male offenders with a medium risk of reoffending. It teaches participants new skillsabout how to alter the thoughts, attitudes andbehaviour that led to their offending, and assiststhem to develop strategies for maintaining theirpositive changes.MSD provides CBT as part of its residentialprogramme for young offenders sentenced to ayouth justice facility for a serious crime. Fewerthan 100 young offenders per year receive thisservice, and the cost is not separately reportedfrom the total cost of the residential placement.Motivational programmes: The shortmotivational programme is designed to improveoffenders’ motivation to understand theiroffending and increase their interest in engagingwith other interventions that will reduce theirlikelihood of re-offending.Young offenders programme: The youngoffenders programme is a rehabilitativeprogramme for prisoners under the age of 20. Itteaches skills about how to change attitudes andbehaviours.Kowhiritanga (for female offenders):Kowhiritanga is a group-based programme forfemale offenders with identified rehabilitationMinistry of Social DevelopmentThere is substantial room to expand the use ofCBT for young offenders, as it is currently usedonly for a small number each year.MSD also funds CBT for about 300 youngpeople per year who have committed sexualoffences or who are at risk of sexual offending.These programmes are provided by specialistproviders such as SAFE, at a total cost of 2.7m, or between 5,000 and 20,000 peryoung person.CBT is also part of treatments such as MultiSystemic Therapy. For more information onthese, see the evidence brief on family-basedinterventions for adolescents.Health sectorCBT is extensively provided in the Health sector,though not typically for offenders. At a nationallevel, statistics about the use of CBT are notCOGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 5 of 11

available as decisions about what type oftherapy to offer are made at a local level.The Ministry of Health advises that mentalhealth services are under significant demandpressure so there would be very limited scope toshift their focus towards reducing offending.There is also a rather limited CBT-trainedworkforce so expanding it would take time.EVIDENCE RATING ANDRECOMMENDATIONSEach evidence brief provides an evidence ratingbetween Poor and Very Strong.PoorRobust evidence that investmentdoes not reduce crime or increasescrimeSpeculativeLittle or conflicting evidence thatinvestment can reduce crimeFairSome evidence that investment canreduce crimeVeryPromisingRobust international or local evidencethat investment tends to reduce crimeStrongRobust international and localevidence that investment tends toreduce crimeVery StrongVery robust international and localevidence that investment tends toreduce crime there is robust international and localevidence that the investment tends to reducecrime the investment is likely to generate a return ifimplemented well this investment type could benefit fromadditional evaluation to confirm investment isdelivering a positive return and to supportfine-tuning of the investment design.A successful high-quality randomised controlledtrial of treatment on crime outcomes in NewZealand would raise the evidence rating to VeryStrong.The evidence base for CBT for young offendersis particularly strong.xxxix Given that offendingpeaks in the teenage years and that manyyoung offenders go on to have extensivecriminal careers, there is a clear strategic andeconomic case for further investment in CBT foryoung offenders.First edition completed: May 2016Primary author: Tim HughesAccording to the standard criteria for allevidence briefs1, the appropriate evidence ratingfor Cognitive-Behavioural Therapy is Strong.This rating reflects that the internationalresearch base shows consistent positive results,supported by reliable local evidence that wehave been able to deliver reductions inrecidivism in a New Zealand setting.As per the standard definitions of evidencestrength outlined in our methodology, theinterpretation of this evidence rating is that:1Available at orks-to-reduce-crime/COGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 6 of 11

xUsher and Stewart 2012Bakker and Riley 1993, Bakker and Riley 1996,Polaschek et al 2005, Polaschek 2011xiiAllen et al 2001, Little 2005, MacKenzie 2006,Fergusson and Wormith 2012xiiiAllen et al 2001, MacKenzie 2006 Tong andFarrington 2008xivLee et al 2012xvDowden et al 2003xviFrazier and Vela 2014xviiHenwood et al 2015xviiiLandenberger and Lipsey 2005xixDebidin and Dryden 2011xxAndrews and Bonta 1990, Landenberger andLipsey 2005, Andrews and Dowden 2006, Gendreauet al 2006, Lipsey et al 2007, Lipsey 2009xxiAndrews et al 1990, Dowden et al 2003, Gendreauet al 2006xxiiLandenberger and Lipsey 2005xxiiiLandenberger and Lipsey 2005xxivLandenberger and Lipsey 2005xxvBarnes et al 2014xxvieg Dowden and Andrews 2004, Andrews andDowden 2005xxviiMiceli 2009xxviiiIzzo and Ross 1990xxixFergusson and Wormith 2012xxxTong and Farrington 2008, Lipsey 2009xxxiLipsey 2009xxxiiParhar et al 2008xxxiiiMcMurran 2009xxxivAustin et al 2011xxxvPratt et al 2010xxxviLipsey et al 2007xxxviiLipsey et al 2007xxxviiiHofmann et al 2012xxxixLipsey and Cullen 2007xiFIND OUT d readingAndrews, D. & Bonta, J. (2010). The Psychologyof Criminal Conduct (fifth edition). Cincinatti, OH:Anderson.Hoffman, S., Asnaani, A., Vonk, I., Sawyer, A. &Fang, A. (2012). The efficacy of cognitivebehavioral therapy: a review of meta-analysis.Cognitive Therapy and Research, 36(5).Lipsey, M, Landenberger, N, & Wilson, S.(2007). Effects of cognitive-behavioral programsfor criminal offenders. Campbell SystematicReviews 2007:6CitationsiGendreau et al 2006Izzo and Ross 1990iiiAllen et al 2001, Landenberger and Lipsey 2005,Lipsey et al 2007ivIzzo and Ross 1990, Dowden and Andrews 1999a,McCart et al 2006, Armelius and Andreasson 2007,Garrido et al 2007, Lipsey 2009, Koehler et al 2013,although Kim et al 2013 is alone is finding no effectvDowden and Andrews 1999b, Gobeil et al 2016viSupra notes ii-vviiDowden and Andrews 2000, Garrido et al 2007viiiSee the evidence brief on sex offender treatmentfor more detailixSee the evidence brief on AOD treatment for moredetailiiCOGNITIVE-BEHAVIOURAL THERAPY: EVIDENCE BRIEF – APR 2016. PAGE 7 of 11

REFERENCESFerguson, L. & Wormith, J. (2013). A meta-analysis of moralreconation therapy. International Journal of Offender Therapy andComparative Criminology, 57(9).Advisory Group on Conduct Problems (2013). EffectiveProgrammes for Adolescents by the Advisory Group on ConductProblems. Wellington: Ministry of Social scents.htmlFrazier, S. & Vela, J. (2014). Dialectical behaviour therapy for thetreatment of anger and aggressive behaviour: a review.Aggression and Violent Behavior, 19(2).Allen, L., Mackenzie, D. & Hickman, L. (2001). The effectivenessof cognitive-behavioral treatment for adult offenders: Amethodological, quality-based review. International Journal ofOffender Therapy and Comparative Criminology, 45(4).Andrews, D. & Bonta, J. (2010). The Psychology of CriminalConduct (fifth edition). Cincinatti, OH: Anderson.Andrews, D. & Dowden, C. (2006). Risk principle of caseclassification in correctional treatment: a meta-analyticinvestigation. International Journal of Offender Therapy andComparative Criminology, 50.Andrews, D. A. & Dowden, C. (2005). Managing correctionaltreatment for reduced recidivism: a meta-analytic review ofprogramme integrity. Legal and Criminological Psychology. 10,173–187.Andrews, D., Zinger, I., Hoge, R., Bonta, J., Gendreau, P., &Cullen, F. (1990). Does correctional treatment work? A clinicallyrelevant and psychologically informed meta-analysis. Criminology,28(3), 369–404Armelius, B & Andresassen, T. (2007). Cognitive-behavioraltreatment for antisocial behavior in youth in residential treatment.Campbell Systematic Reviews 2007:8Austin, K., Williams, M. & Kilgour, G. (2011). The effectiveness ofmotivational interviewing with offenders: an outcome evaluation.New Zealand Journal of Psychology, 40(1).Bakker, L. & Riley, D. (1993). The re-conviction study 1990/91.Psychological Service Report, Department of Justice. Wellington,New Zealand.Garrido, V. & Morales, L. (2007). Serious (violent or chronic)juvenile offenders: A systematic review of treatment effectivenessin secure corrections. Campbell Systematic Reviews 2007:7Gendreau, P., Smith, P. & French, S. (2006). The theory ofeffective correctional intervention: empirical status and futuredirections. In F. Cullen, J. Wright & K. Blevins (eds.) Taking Stock:The Status of Criminological Theory. New Brunswick, NJ:Transaction.Gobeil, R., Blanchette, K. & Stewart, L. (2016). A meta-analyticreview of correctional interventions for women offenders: genderneutral versus gender-informed approaches. Criminal Justice andBehavior, 43(3).Henwood, K., Chou, S. & Browne, K. (2015). A systematic reviewand meta-analysis on the effectiveness of CBT informed angermanagement. Aggression and Violent Behavior, 25(B).Hoffman, S., Asnaani, A., Vonk, I., Sawyer, A. & Fang, A. (2012).The efficacy of cognitive behavioral therapy: a review o

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