Interventions That Target Criminogenic Needs for Justice-Involved Persons With Serious Mental Illnesses: A Targeted Service Delivery Approach

Criminogenic Risk and Justice-Involved Persons With SMI

Research comparing the presence of criminogenic risk factors among offenders with and without SMI has found that justice-involved people with SMI face higher levels of criminogenic risk factors than offenders without mental illness (Girard & Wormith, 2004; Skeem, Eno Louden, Manchak, Vidal, & Haddad, 2008). Several recent studies have examined the extent to which specific types of criminogenic risks are present among justice-involved people with SMI, finding that people with SMI had elevated levels of criminal thinking and attitudes as compared with their justice-involved counterparts without SMI (Morgan, Fisher, Duan, Mandracchia, & Murray, 2010; Wilson et al., 2014; Wolff et al., 2013; Wolff et al., 2011).

Addressing the presence of elevated levels of criminal thinking and attitudes among justice-involved people with SMI is important when developing interventions for this population because antisocial cognitions are one of the criminogenic risk factors that have the greatest effect on offending behaviors and are both dynamic (i.e., changeable) and amenable to intervention (Andrews, Bonta, & Wormith, 2006; Friendship, Blud, Erikson, Travers, & Thornton, 2003; Walters, Trgovac, Rychlec, Di Fazio, & Olson, 2002). However, traditional mental health services focus on the treatment of symptoms associated with mental illness (e.g., depression, mania, and psychosis) rather than on antisocial cognitions or other criminogenic risk factors. Therefore, to effect criminal justice involvement among justice-involved people with SMI, the scope of intervention needs to be expanded to address the dynamic, malleable criminogenic risk factors associated with this involvement, which are commonly referred to as criminogenic needs (Calsyn et al., 2005; Epperson et al., 2014; Skeem et al., 2011; Wilson et al., 2014).

Interventions That Target Criminogenic Needs for Justice-Involved Persons With SMI

One promising approach to addressing criminogenic needs among justice-involved people with SMI involves modifying existing correctional interventions for use with this population (Skeem et al., 2011). Some of the best-known interventions that target criminogenic needs include reasoning & rehabilitation (R&R; Ross & Fabiano, 1985) which has several versions (see http://www.cognitivecentre.ca/RRProgram for more information), moral reconation therapy (MRT; Little, Robinson, & Burnette, 1991), and Thinking for a change (T4C; Bush, Glick, & Taymans, & Guevara, 2011). Each of these interventions adheres to the central principles of effective correctional interventions (Andrews & Bonta, 2010) by using group-based cognitive behavioral therapy (CBT) interventions that target one or more criminogenic needs (i.e., antisocial behavior, personality, cognition, and associates) with the strongest associated with criminal offending. All three interventions provide a structured, manualized, time-limited group-based intervention that engages some combination of cognitive restructuring, cognitive skills training, problem-solving therapies, and structured learning experiences (Landenberger & Lipsey, 2005; Milkman & Wanberg, 2007). Meta-analyses have established that these interventions reduce recidivism by 20% to 55% (Landenberger & Lipsey, 2005; Pearson, Lipton, Cleland, & Yee, 2002; Wilson, Bouffard, & MacKenzie, 2005). However, there is little evidence to support these interventions’ effectiveness with people with SMI (Milkman & Wanberg, 2007).

The lack of support for the effectiveness of interventions that target criminogenic needs among people with SMI is important to note because the responsivity principle from the Risk-Need-Responsivity (RNR) model posits that the delivery of interventions that target criminogenic needs must to be tailored to the specific learning styles and treatment needs of particular client populations (Andrews & Bonta, 2010). The neurocognitive and social impairments associated with SMI have led to individuals with these disorders being identified as a group of participants who have specific learning and treatment needs that require further consideration during the delivery of interventions that target criminogenic needs (Bonta, Law, & Hanson, 1998; Young & Ross, 2007).

Reasoning & rehabilitation has been adapted for use with people with mental illness (Young & Ross, 2007; see http://www.cognitivecentre.ca/RRProgram). The preliminary outcomes related to the acceptability of the adapted intervention have been positive (Young, Chick, & Gudjonsson, 2010). Moreover, these outcomes support the need to modify interventions that target criminogenic needs to meet the specific learning and treatment needs of people with SMI. However, the proprietary nature of the R&R intervention limits the information available regarding the adaptation process or strategies used to develop the modified intervention.

Given these constraints, the field needs more accessible interventions that target criminogenic needs among justice-involved people with SMI. To fill this gap, we present a targeted service delivery approach (TSDA) that is designed to make existing evidence-based interventions that address criminogenic needs in justice-involved populations responsive to the specific learning and treatment needs of people with SMI. In this article, we describe the development and use of a newly developed TSDA.

The TSDA presented in this article represents an important step forward in the development of interventions for justice-involved people with SMI because it is designed to increase the chances that people with SMI will be able to participate fully in and benefit from interventions that address criminogenic needs. This advancement comes at a critical time in this field of research because interventions with the potential to address criminogenic needs are a critical component of the next generation of services currently being developed for people with SMI involved in the criminal justice system (Epperson et al., 2014).

Method

Results

TSDA

The TSDA illustrated in Table 1 presents the five service delivery strategies that were developed through the research process described above. These strategies do not supplant or replace any of the content of the criminogenic intervention, rather they are designed to be used during the delivery of the intervention to make it more responsive to the needs of people with SMI. The content of the intervention itself remains intact.

OPEN IN VIEWER

Table 1.

Targeted Service Delivery Approach.

Targeted delivery strategy	Defined	Examples of in-session application
1. Repetition and frequent summarizing	What it means: Repetition: Maximize knowledge acquisition by increasing participants’ exposure to key concepts and information. Summarizing: Maximize knowledge acquisition and skill development by regularly restating and recapping key points throughout the session.	Reinforce key lessons by identifying natural transition points in a session and briefly summarizing content in each segment before proceeding. Use the cognitive-behavioral SCEP (summarize, check-in, empathize, proceed) strategy as needed to focus and clarify participants’ contributions to group discussions. Provide at least two to three examples of concepts and information that participants must understand to successfully perform the skill being taught in each session. Include additional review sessions at the end of each intervention module that recaps the newly learned skill set. Briefly review skill steps from earlier sessions that are components of the skill being taught in the current session.
	When to use: Use through all aspects of a session.
2. Amplification techniques	What it means: Knowledge acquisition and skill development is maximized by breaking down abstract information into concrete examples by using verbal and visual examples of what the concept means and how to apply the concept to the skill being developed.	Use visual aids such as PowerPoint slides, handouts, white boards, flip charts, and live demonstrations when presenting and discussing abstract information. Verbally explain unwritten rules of social interactions that a participant has to understand to successfully engage the skill being taught. Engage facilitator-led demonstrations of a social skill where one or more unwritten rules of social interaction, such as amount of eye contact or social space, is broken. During the demonstration, facilitators use guided discovery techniques to lead the group through the reasoning process required to identify what “was wrong” with the initial demonstration and to identify the additional behavior(s) needed to successfully engage the skill being demonstrated. Identify abstract concepts being used in a skill step such as being “objective” or “nonthreatening.” Then break each one down into concrete examples during the discussion of that skill step.
	When to use: When teaching skill steps and when engaging role-plays and other forms of practice that involve abstract concepts or situations
3. Active coaching	What it means: Skill development is maximized through the provision of individualized instruction and supports during activities where participants are attempting to apply or practice what they are learning in session	Have two facilitators work in tandem to provide one-on-one coaching and present in small group settings during role-plays and other structured activities. Help participants to develop ideas for their scenarios by providing examples of the types of situations that could be used to practice the skill being role-played. Provide individualized instruction (i.e., a one-on-one coaching session) prior to the group role-play to help the participant practice each skill step for the scenario. Use behavior-modeling techniques such as reverse role-plays, mirroring, and shadowing to help participants successfully engage the skill being practiced. Use behavior-shaping techniques such as positive acknowledgement, clapping, praise, and group recognition to reward positive approximations of the behaviors being practiced. Use guided discovery techniques to help participants identify and resolve key decisions they have to make to successfully use of the skill they are practicing.
	When to use: Use in active learning situations such as one-on-one coaching sessions, group role-plays, group discussions, and discussion of between-session skill practice.
4. Low-demand practice	What it means: Maximize skill development by providing opportunities to practice skills during and between sessions in a setting that minimizes behavioral expectations related to what constitutes “successful” practice and positively reinforces for all approximations of desired behavioral changes.	Make participation in between-session practice voluntary. Minimize rules or expectations surrounding what constitutes successful practice. Provide positive reinforcement such as facilitator lead acknowledgement and group recognition for all attempts to practice skills. Utilize naturally occurring opportunities in session to engage additional practice of a skill as a group. Provide individually tailored feedback and positive reinforcement for aspect(s) of practice that demonstrates improvement in a participant’s ability to engage a practice generally and/or as it relates to a specific skill.
	When to use: Use in situations in which participants are involved in active learning activities such as role-plays, group discussions, and impromptu in-session practice and reviews of in-between session practice.
5. Maximize participation	What it means: Knowledge acquisition and skill development are maximized by using techniques designed to increase individuals’ motivation to attend and actively take part in group, and enhance their sense of self-efficacy related to their ability to successfully carry out newly learned skills.	Incorporate group activities such as opening and closing activities in each session to foster the development of group identity and group cohesion. During screening sessions, work individually with group members to identify life goals they want to achieve through participation in this group, and then, at the beginning of the intervention, provide each group member with a written list of their top three goals. To facilitate attendance and increase participation, provide incentives such as transportation or snacks. Collaborate with group members to identify potential roadblocks to participation and develop solutions. Use flexible engagement techniques to provide participants with some autonomy in determining their level of participation in each intervention session. Limit session length to a maximum of 90 min. Limit group size to a maximum of 10 members.
	When to use: Use through all aspects of a session.

The goal of the TSDA is to compensate for the neurocognitive and social impairments that impede participant’s ability to fully engage and understand the intervention materials. The targeted delivery strategies developed through this research process include repetition and frequent summarizing, amplification, active coaching, low-demand practice, and maximizing participation. Table 1 also indicates points in the intervention where facilitators should use each targeted service delivery strategy to facilitate the delivery of the intervention’s content and provides examples of how each of these five strategies can be used during the delivery of a group-based CBT intervention to address criminogenic needs for justice-involved people with SMI.

The first four targeted service delivery strategies listed in Table 1—repetition and frequent summarizing, amplification, active coaching, and low-demand practice—engage therapeutic techniques that target different aspects of intervention activities that focus on knowledge development and skill acquisition activities. Although each strategy has a distinct therapeutic target listed in the second column of the table, these four strategies also work together in a session to maximize participants’ learning opportunities while engaging techniques that limit participants’ errors or incorrect responses during the learning process. Most of the targeted service delivery strategies developed in this research focus on knowledge development and skill acquisition in interventions that target criminogenic needs because these components of the intervention are especially vulnerable to the effects of neurocognitive and social impairments associated with SMI (Bartholomeusz & Allott, 2012; Bellack et al., 1999; Hogarty & Flesher, 1999; Kopelowicz et al., 2006; Wexler & Bell, 2005).

The primary target of the first four targeted service delivery strategies was maximizing participants’ learning opportunities (knowledge and skill based). However, by minimizing the mistakes participants make in the learning process, these service strategies also supported the goal of the fifth targeted service delivery strategy, maximizing participation. This service delivery strategy is designed to support participants’ ability to engage the intervention materials by maximizing the amount of time individuals are physically present and active in the group (e.g., incentives, collaborative inquiry techniques, limiting session length), and incorporates techniques to optimize individual participants’ involvement in group activities when they are physically present (e.g., opening and closing exercises, snacks, limiting group size).

Discussion

This article presents a TSDA that provides a new way to deliver interventions that target criminogenic needs to people with SMI. The central component of this new TSDA are five targeted service delivery strategies that explicitly address the specific learning and treatment needs of people with SMI during the delivery of these interventions. This TSDA represents a step forward in the development of interventions that target criminogenic needs for justice-involved people with SMI because these five service delivery strategies are designed to increase the likelihood that people with SMI will be able to fully engage in and benefit from interventions that target criminogenic needs. The description of this TSDA and how it was developed makes a contribution to the literature because it can inform other efforts to use group-based CBT interventions that target criminogenic needs with justice-involved people with SMI, thereby increasing the accessibility of these interventions for this population.

When considering how to deliver interventions that target criminogenic needs to people with SMI, we found that pacing the delivery of intervention content was a key issue. Controlling the pace of content was of such importance during the delivery of the intervention that four of the five targeted service delivery strategies included in our approach either directly adjusted the pacing of intervention content (repetition and summarizing, low-demand practice) or provided additional supports that compensate for the pacing (amplification, active coaching). The issue of optimal pacing of interventions that target criminogenic needs remains open and warrants further investigation. However, given that people with SMI present with various combinations and degrees of neurocognitive and social impairments, it is unlikely that one level of pacing will be optimal for all participants; therefore, flexible service delivery strategies, such as the ones presented here will be needed.

The study team also found that participants’ engagement in the intervention was highest when facilitators remained focused on the therapeutic targets of the intervention (i.e., developing new thinking and learning skills for dealing with situations that are likely to increase an individual’s risk of involvement with the criminal justice system). Implicit in this focus is the study team’s purposeful decision not to incorporate additional treatment goals (e.g., medication compliance, symptom reduction) as a focus of the intervention. This decision is consistent with the recommendations of Andrews and Bonta (2010), who cautioned against targeting noncriminogenic needs within interventions that target criminogenic needs. However, this focus on criminogenic needs differs from the approach and focus of traditional mental health services which typically target symptoms associated with mental illnesses.

The use of two facilitators for each intervention session in our TSDA also has implications for the delivery of interventions that target criminogenic needs to people with SMI. Initially, the role of the second facilitator focused on helping to provide one-on-one coaching during the role-play activities. However, the intervention team found having two facilitators present for each session optimized facilitators’ ability to engage all of the different targeted service delivery strategies that are needed to support the target population’s comprehension of intervention materials during the session. A second facilitator was also useful to deal with the differing skill levels among group members and to attend to group members who required additional active coaching and amplification of content. Thus, the second facilitator was recognized as a critical component of the successful implementation of the TSDA.

Conclusion

This article presents a TSDA designed to address the specific learning and treatment needs of people with SMI during the delivery of group-based CBT interventions that target criminogenic needs such as T4C. This TSDA adds to the literature on the development of effective interventions for justice-involved people with SMI by providing service strategies that support the use of interventions that target criminogenic needs with this population. This TSDA represents an important step forward in the development of interventions that target criminogenic needs for this population because it increases the chances that justice-involved people with SMI will be able to participate fully in and benefit from these interventions. The development of this TSDA builds on the increased attention that researchers, practitioners, and policy makers are giving to the RNR framework and its applicability to the development of treatment services for justice-involved people with SMI. The development of this framework comes at a critical time in the field in that it can inform efforts to incorporate interventions that target criminogenic needs into the continuum of services available to justice-involved people with SMI.