Implementation of a Treatment Program for Individuals Imprisoned for Sex Offenses in Uruguay: Achievements,Problems and Challenges

Abstract

Treatment for individuals convicted of sex offenses has substantially improved in developed countries in recent decades, providing practitioners with an extensive literature to guide the implementation of effective programs to reduce sexual reoffending. Nevertheless, sexual offending rehabilitation is still in its infancy in Latin American countries such as Uruguay, so little is known about the transference and implementation of evidence-based programs. The current study examines the strengths, barriers, and challenges of implementing a sex offenses treatment program in Uruguay. The findings suggest some achievements of the program, but also several problems with implementation. Some problems are universal among different countries (e.g., scarce resources and facilities, insufficiently trained staff, and unexpected changes in the organization), but others were particularly relevant in the Uruguayan context (e.g., government policy alien to a rehabilitation approach, lack of appropriate prison facilities, lack of training for therapists from a cognitive-behavioral perspective). All these difficulties must be anticipated and solved for successful generalizability of rehabilitation programs to different correctional systems.

Keywords

sex offenses program implementation program fidelity prison Latin America

Sex crimes result in serious harms for victims and significant social rejection, especially when victims are children (Levenson et al., 2007). However, different strategies are in place to protect the public. Among these strategies is the implementation of programs for individuals convicted of sexual offenses (ICSO), to reduce the likelihood of reoffending. Since the 1990s, treatment programs for ICSO have been developed in various Western countries including Australia, Canada, New Zealand, the United States, and some European countries (Harrison et al., 2020).

In the context of what is internationally known as the What Works agenda, several meta-analyses have supported the effectiveness of these programs in reducing sexual reoffending (Hanson et al., 2004; Harrison et al., 2020; Schmucker & Lösel, 2015). In particular, programs that adhere to the theoretical principles of the risk-needs-responsivity model (RNR; Bonta & Andrews, 2017; Hanson et al., 2009) may reduce sexual recidivism by 32.6% (Gannon et al., 2019; see also, Farringer et al., 2009; Marshall & Marshall, 2014). The risk principle posits that the program intensity should be tailored to the level of risk of the treated individuals; the needs principle prescribes that the program should mainly address those dynamic risk factors associated with reoffending; and the responsivity principle establishes that the intervention should be tailored to the characteristics of the treated subjects such as their age, gender, motivation, substance use, and capacities (Bonta & Andrews, 2017).

Latin American Context

In Latin American countries, including Uruguay, financial and technical resources are more limited than in Western countries, and the research on sexual offending and evidence-programs are practically non-existent (Bergman & Andershed, 2009; Bergman & Fondevila, 2021). Conversely, transferring evidence-based interventions from developed countries to Latin-American correctional contexts could be a difficult challenge for reasons such as organizational ethos, staff and financial constraints, overcrowded prisons, and work overload (Blagden & Wilson, 2019; Bourgon & Armstrong, 2005; Corrective Services New South Wales, 2017; Dean et al., 2017; Duriez et al., 2017). Hence, to effectively apply evidence-based programs in Latin American prisons, it is critical to pre-emptively identify the possible strengths and barriers of such transference using a process evaluation (Farringer et al., 2019; Howard, 2020; Schmucker & Lösel, 2015).

The Uruguayan Context

Uruguay, with a population of nearly 3.5 million people, is considered a high-income country, with low levels of poverty and inequality (World Bank, 2019); yet crime trends have been rising since 1985 (Galain Palermo et al., 2019). Moreover, Uruguay yielded the fourth highest homicide rate per 100,000 inhabitants in South America (12.1%; UNODC, 2019), the highest imprisonment rate in the Southern Cone (337 per 100,000 inhabitants), and 16th in the world (International Centre for Prison Studies, 2021). In 2019, nearly 1% of all detected offenses were sexual offenses (73% first-time offenses), whereby 21% of them involved a prison sentence (Instituto Nacional de Estadística de Uruguay [Uruguayan National Institute of Statistics], 2020). The most common sexual offense (228 cases) involved contact and non-contact sexual offenses (e.g., exhibitionism, fondling minors, adults and sending indecent images), whereas 72 cases were rape (Instituto Nacional de Estadística de Uruguay [Uruguayan National Institute of Statistics], 2020), defined in the penal code (Art. 272) as “whoever compels someone with violence or threats to suffer carnal conjunction, even if the act was not consummated”.

Unlike other developed countries, Uruguay has no legal policy in place for the rehabilitation of individuals convicted of criminal offenses, which might encourage the implementation of evidence-based programs. Traditionally, Uruguay (and Latin American countries in general) have used exclusively punitive criminal policies (Hathazy & Müller, 2015; Palermo et al., 2018). For instance, the National Registry of Sex Offenders and Rapists has been recently approved in Uruguay, (Ley de Urgente Consideración [Law of Urgent Consideration], 2020) despite evidence showing that the registry does not have a significant impact on reducing recidivism (Zgoba & Mitchell, 2021). Within this context of inexistent rehabilitative policies, the Uruguayan correctional system faces a number of difficulties: prison violence, violation of human rights, overcrowding, inadequate prison management and infrastructure, poor sanitary conditions, insufficient and underpaid staff, unreliable information systems, and a lack of risk assessment and other assessment tools (Bergman & Andershed, 2009; Comisionado Parlamentario para el Sistema Penitenciario [Parliamentary Commissioner for the Penitentiary System], 2016; Darke & Karam, 2016).

In an attempt to overcome these challenges, in 2010 Uruguay established the National Institute of Rehabilitation (18.719 Act), which is managed by the Ministry of Interior. Its main purpose is to promote inmates’ rehabilitation by replacing police officers (who were in charge of the correctional institutions) with prison officers. Yet, the training of these new prison officers focuses mainly on prison security, promotion of health, penitentiary management, socio-educative programs, and gender equality, rather than in the implementation of evidence-based programs (Centro de Formación Penitenciaria [Prison Training Center], 2018). Until recently, the rehabilitation approach has been exclusively based on education and vocational training, labor, and some workshops to develop basic social skills and prosocial values (López et al., 2001). Psychologists who deliver these workshops in the correctional system are trained in the classic psychoanalytic approach (Tapias, 2018). The What Works agenda, to implement effective treatment programs, has been widely unknown in Uruguay at all levels of the correctional system. Nonetheless, starting in 2016, a new prison executive director attempted to implement, for the first time, evidence-based practices such as a risk assessment system, a program for women imprisoned with children, and the pioneering program presented here for inmates convicted of sexual offenses.

The Sexual Aggression Control Program in Spain and Uruguay

Since 1996, the Spanish correctional system implemented the program for ICSO called the ‘Sexual Aggression Control Program’ (Garrido & Beneyto, 1996), which includes the evaluation of risk and needs of the inmates, and adheres to the RNR model by focusing on those dynamic risk factors related to sexual reoffending, such as atypical sexual interests, supportive attitudes of sexual offenses, as well as socio-affective and self-regulation problems (Rivera et al., 2006. For the logic model of the treatment, see Table 1). Thus the main aims of the program are: (1) to reduce recidivism and promote social reintegration; (2) to establish adequate and violence-free sexual relationships, and (3) to have a more realistic and responsible thinking of their past criminal activities.

Table 1.

Sexual Aggression Control Program Logic Model.

Problem: Individuals Sentenced for Sexual Offenses Have Multiple Needs and Risks Associated to the Likelihood of Sexual and General Recidivism. Currently, These Needs are not Being Covered by the Uruguayan Prison Service, Increasing Recidivism Rates and its Associated Costs
Inputs (Resources)	Activities	Outputs	Short-Term Outcomes	Mid-Term Outcomes	Long-Term Outcomes
Funding for the program Legislation and practice guidelines Unit staff Train staff Program equipment Participants consent Assessment tools Data collection system Inter-agency collaboration	Phase I: Assessment Risk level Therapeutic outcomes Phase II: Treatment A) Awareness: 6 modules B) Taking Control: 6 modules Group sessions Individual sessions	6 months 3 hours group sessions 1 hour individual session 2 group sessions per week 1 individual session per week	Phase I: Assessment Treatment adjusted to participants’ risk level Therapeutic outcomes (e.g., cognitive distortions) Phase II: Treatment Understanding sexual offense cycle Identifying risks factors Analysis of consequences of own behaviors (decision-making) Recognition of denial	Phase I: Assessment Reducing risk level Improvements in treatment outcomes Phase II: Treatment Recognition of offense responsibility Control of violent/sexual deviant behaviors Acquisition of prosocial skills repertoire Community supervision/re-entry programs	Reducing reoffending Community safety increases Reduction of tax-payers’ costs Higher confidence in the Uruguayan prison service and rehabilitation programs
Assumptions The program is based on theories relevant to sex offending Staff willing to implement the program Program implementation is supported by the direction of the organization Different stakeholders are willing to work together			External factors Community-based support services Legislation Prejudices and strong rejection by professionals in the criminal justice system and citizens News and media (unusual cases) Fragmentation of criminal justice agencies Factors affecting the economy (e.g., political elections) Academia (psychoanalytic approach)

All inmates convicted for sexual offenses closest to their release dates are invited to enroll in the program. Their participation is voluntary, but if inmates participate in the program it increases the likelihood of obtaining earlier parole. The exclusion criteria to participate in this program are: (1) the presence of an active or unbalanced mental or substance abuse disorder that could diminish their capacity to follow the intervention; (2) the presence of psychopathic traits that could favor the manipulation of others; and (3) individuals with a low literacy level that impairs their ability to follow the program activities. The program is administered in groups of 8–12 individuals, which receive two weekly sessions about 2 and a half hours long for 12–24 months depending on the risk level. Additionally, participants receive distinct individual sessions and complete therapeutic assignments before and after the program. Several studies assessed the program effectiveness, reporting a small to medium reduction of recidivism for the treatment group (González-Pereira et al., 2020; Martínez-Catena & Redondo, 2017, 2021; Redondo et al., 2005). Of note, treatment outcome studies that include treatment dropouts in their comparison group, such as some developed in Spain so far, artificially inflate treatment effects (Collaborative Outcome Data Committee, 2007).

The Sexual Aggression Control Program was selected to be implemented in Uruguay because of the common language, the free availability of the program manual, and the positive results achieved in Spain. Undoubtedly, a critical cross-cultural research challenge arises when transferring prison programs from Western countries (i.e., Spain) to Latin-American countries. From a theoretical point of view, several challenges can initially be identified to achieve a successful program transfer such as socio-economic, cultural and institutional conditions. For instance, the Spanish Prison Service invests a significant budget not only to ensure the necessary level of security within prisons, but also to implement evidence-based practices. Conversely, as mentioned previously, the Uruguayan Prison Service faces several difficulties including high levels of violence and a lack of evidence-based programs.

As for cultural challenges, it is clear that having an available manual in Spanish is important to deliver the program, especially in a context with low resources. However, cultural differences can still be large such as different meaning and use of the language or words, different legal categorization of sex crimes, gender and roles differences and societal attitudes towards these differences.

Finally, important challenges to transfer the program from Spain to Uruguay stem from institutional and political conditions toward the ICSO. Spain has a long tradition of delivering evidence-programs including the program for ICSO, and psychologists are supported and trained to deliver the program according to the best practices. Hence, such program transfer processes need to be carefully evaluated.

Methodology of Evaluating an Implementation of a Sexual Offending Program

Process evaluations of specialized programs in prisons, particularly with ICSO, are scarce and unstructured. Some studies have focused primarily on the perceptions of program participants and, occasionally, of program facilitators; other studies have explored the factors that could be associated with program completion (e.g., motivation; Collins et al., 2010; Drapeau, 2005; Geiger & Fischer, 2017). However, important process measures such as program integrity and fidelity, quality of treatment delivery, participants’ responsiveness, program adaptation, context, and evaluation methods are rarely assessed (Duwe, 2015; Geiger & Fischer, 2017; Lösel, 2017; Tyler et al., 2021). Although some studies have highlighted the importance of treatment integrity and replication for successful treatment of imprisoned people (Andrews & Dowden, 2007; Lösel, 2017), guidance to conduct rigorous and structured process evaluations of crime treatment programs is still lacking.

Conversely, in the health field, the process evaluations have substantially improved in the last years. For example, the UK Medical Research Council (MRC) in 2014 provided guidelines for designing and delivering process evaluations of complex medical interventions (Moore, et al., 2015; for examples see Masterson-Algar et al., 2016). To understand better the underlying processes of treatment and to improve its implementation, using mixed-methods and unifying different theoretical models is recommended (Durlak & DuPre, 2008; Wandersman et al., 2008). The main strengths of the process evaluation are that it provides important information about ongoing problems during implementation, how the program was implemented, and the program outcomes, as well as providing a foundation for program maintenance, dissemination, and generalization (see Johnson et al., 2010).

Current Study

Consistent with the MRC guidelines, in the case of the treatment for ICSO in Uruguay, this study examines elements of the process evaluation related to intervention dose, attendance, program fidelity, levels of participation, session utility and exertion, as well as the influence of the prison context in the program (e.g., facilities, ethos, and staff), the prison service, legislation, academia and media. These elements were grouped here in three main domains: (1) Implementation, (2) Participation and Response, and (3) Context. Due to the process derived only from 17 informants (of which only 4 were treated participants), the findings will be treated as descriptive.

Method

In this section, we report how we determined our sample size, all data exclusions, all manipulations, and all measures in the study (Simmons et al., 2012).

Study Design and Data collection

This study is part of the first pilot transfer of the Sexual Aggression Control Program from Spain to a Uruguayan prison. In this framework, the aims of the pilot study were to develop an assessment of treatment outcomes and the evaluation of the process implementation.

The process evaluation methods used in this study are based on the MRC guidelines for process evaluations (Moore et al., 2015). Thus, this is a mixed methods process evaluation, in which quantitative measures of intervention activities (e.g., numbers of participants and dropouts, delivered components, fidelity, and dose) were gathered, as well as a qualitative exploration of the interaction between the intervention, how the staff and participants experience it, and the organizational context where it is delivered (Haynes et al., 2014; Moore et al., 2015). Accordingly, three main domains of the implementation process were explored in this study: Domain 1: Implementation of the intervention; Domain 2: Participants & Response of inmates to the intervention; and Domain 3: Context. An overview of the different methods that were used to collect the data for different domains is shown in Table 2. Each domain addressed different research questions through several types of data and different data sources. As for Domain 1, information about four topics was collected: evaluation of the inmates, dose delivered of the treatment, facilitators (training and skills) and fidelity/integrity of treatment. For Domain 2, three groups of information were relevant: selection process of inmates, response and tailoring between program and inmates’ characteristics. Finally, Domain 3 included all the factors that may influence how the intervention was delivered and received (Haynes et al., 2014).

Table 2.

Process Evaluation Domains, Research Questions and Data Collection (adapted from Haynes et al. 2014, p. 5).

Domains	Research Questions	Core Information	Data Type	Data Sources
Domain 1: Implementation	1. How was the intervention implemented? a. What components were delivered? b. To what extent were the essential elements implemented?	Intervention components selected and how agencies asked that they be tailored What was delivered including: which components; delivery format; facilitators recruitment and preparation; learning materials; the fidelity with which essential elements were delivered; any changes to the plan	Updates/meetings Structured observation for fidelity assessment Semi-structured interview Notebooks Non-participation observation	Program staff implementing and coordinating the intervention Program participants Intervention sessions Fidelity checklist
Domain 2: Participation & response	2. How did people interact with the intervention? a. What were their levels of participation and satisfaction? 3. What effects that are not captured by the outcome measures did the intervention have (including unexpected effects)?	Session participation and responses, including: roles of attendees, proportion of invitees who attended; nature of participation (types and extent of interaction) Participants’ evaluation of intervention sessions How participants and the organizational system responded to the intervention overall (including unexpected effects)	Consent form Non participant observation Notebook Self-reported evaluation feedback Interviews Informal conversations	Participants’ level of attendance Program facilitators Fidelity checklist
Domain 3: Context	4. What was the context of the prison service, and the prison in which the intervention was implemented?	Immediate characteristics of session delivery context (site, facilities, etc.) Organisational context: (1) agency culture, (2) agenda-setting & prioritisation, (3) leadership styles & perceptions of leaders, (4) how this type of interventions are valued, accessed & used, (5) barriers and enablers to implement the program, (6) other contextual factors that may affect outcomes	Non-participant observation Interviews Informal conversations	Program participants Program facilitators Managers responsible for the program in prison Executive member of the prison system Prison officers in the module
Across domains	5. How might the relationships between the program, the people and the context in each agency have shaped variations in these effects? 6. What lessons can we derive from this study that might be relevant for other interventions and settings?

Sample

A convenience sample of key informants (n = 17) provided the primary source of information for the evaluation (see Table 2). The sample included program participants (n = 11) and staff members (n = 6). Staff members included program facilitators and coordinator (n = 3), operational managers within the prison where the program was implemented (n = 2), and an executive member team of the Uruguayan Prison Service (n = 1). All professionals were female except one male. Two professionals had been working for less than 2 years in the Prison Service, whereas the rest (n = 4) more than 2 years.

Program participants were recruited from one of the largest prison facilities in Uruguay (housing more than 3000 inmates). Few inmates were invited to participate in the program (n = 78) because a large number were on remand and did not meet the inclusion criteria to enroll in the program (i.e., sentenced to sex offense(s), having served more than 2/3 of sentence, age range between 18 and 70 years old, not suffering from mental health issues, not illiterate, not in categorical denial of their offending). Twenty inmates initially showed interest but 14 signed the consent form. Among these, two subjects were excluded because of the possible presence of psychopathic features and one subject had applied for prison relocation. Finally, 11 subjects enrolled in the treatment program, of which four participants completed the intervention, six participants dropped out, and one participant was expelled for security reasons (i.e., drugs dealing and debts). Participating in this program (as enrolling in education, work, and workshops) involved the possibility of an early prison release.

Table 3 describes the main criminal characteristics of all participants. Treated participants showed a variety of sexual offenses (contact [n = 2], non-contact [n = 1], and both [n = 1]) and victims’ ages (adult [n = 2], children [n = 2]), but all victims were female and half were non-biological. Most treated participants knew their victims (n= 3) and half had previous non-sexual offenses, but the current sexual offense was the first one. Moreover, all treated participants had substance use problems and nearly all (except one) suffered any type of childhood abuse (i.e., physical, sexual and emotional). Dropouts committed mainly contact child offenses (n = 6) against non-biological daughters (n = 6), and in one case against a non-biological son. All knew their victims. None had previous sexual offenses but nearly half (n = 3) had previous non-sexual offenses. Finally, less than half of the dropouts had substance use problems (n = 3) and one suffered sexual, physical and/or emotional childhood abuse.

Table 3.

Criminal Characteristics of the Program Participants.

Criminal Variable	Treated(n = 4)		Dropouts/Expelled(n = 7)
Criminal Variable	n	%	n	%
Type of offense
Contact	2	50	6	86
Non-contact	1	25	—	—
Both	1	25	1	14
Victim sex
Female	4	100	6	86
Male	—	—	1	14
Victim age
Adult	2	50	—	—
Minor	2	50	7	100
Victim type
Biologic (daughter/son, niece, grandson)	—	—	1	14
Non-biologic (daughter/son in law)	2	50	6	86
Acquaintance	3	75	7	100
Stranger	1	25	—	—
Previous sexual offenses (self-report)
Yes	0	0	0	0
No	4	100	7	100
Previous non-sexual offenses (self-report)
Yes	2	50	3	43
No	2	50	4	57
Illegal/legal substances use at any time of their lives
Yes	4	100	3	43
No	—	—	4	57
Victimization experiences in childhood (sexual, psychical, emotional)
Yes	3	75	1	14
No	1	25	6	86

Measures

Personal, criminal and victims characteristics were collected from inmates using a brief questionnaire (see Table 3).

Fidelity checklist (Hepner et al., 2011) assessed how facilitators implemented the program sessions. It included four areas: cognitive therapy structure (six items), development of a collaborative therapeutic relationship (five items), group engagement (three items), and atypical circumstances (one item). Coders (first and second authors) rated each item using a scale from 0 to 6 score. Both items and scores had a unique description to help the coders. Disagreements were discussed between both coders until reaching agreement.

The feedback questionnaire was developed by the first and second authors, which contained 43 items with multiple choice 4-point Likert scale about the level of satisfaction with the program, group sessions, facilitators skills, and how they saw themselves and their future.

Session logs recorded by a facilitator included information on group attendance, reasons for not attending the session, activities, group dynamics, as well as facilitators and participants’ reflections during the sessions. Each delivered session was contrasted with the program manual available online (Ministerio del Interior [Ministry of Interior], 2021).¹

Semi-structured interviews with program participants, facilitators, and managers. Interview questions were developed by the first and second authors to gather information for the three domains described above. The interview questions were grouped in four main topics: program selection phase, the program, participants’ needs, program improvements. The facilitators’ interview questions were grouped in four major sections: personal and organizational background, program management and participants’ selection, program/modules implementation, adaptation, and issues. The managers’ interview emphasized on the organization (context) so included questions on topics related to their qualifications/training and experience in the role, decision-making within the organization, staff training, organizational culture, structure and capacity to implement the program.

Procedure

The research team was external and independent to the treatment program implementation. The research project was approved by the research committee of the Uruguayan Prison Service.

The evaluated program was applied from August 2017 to June 2018. Two psychologists implemented the group sessions, and another one conducted the individual sessions. The treated men were interviewed and completed the feedback questionnaire after the program (i.e., 9 months), while the dropouts were interviewed immediately after they dropped the program. Interviews lasted approximately 120 minutes and were conducted in a room within the prison. Additionally, the program psychologists were interviewed for approximately 120 minutes, before and after the program implementation in an office at their workplace; whereas two staff members were interviewed during the program at their convenience in their work offices and another one in the researchers’ office. The program coordinator allowed researchers to observe one session of the positive live style module and at the end of the program facilitators shared with researchers the logbooks, which were returned to facilitators at the end of the study.

Researchers explained the purpose of the study to all subjects (treated, dropouts, facilitators and managers), emphasizing voluntary participation, anonymity and confidentiality, no benefits for participating, and subjects’ right to withdraw at any time. Written informed consent was obtained from all subjects. All interviews were recorded and transcribed by the first and second authors.

Data Analysis

As part of the quantitative method, frequencies and percentages were calculated to describe criminal characteristics, delivery components (e.g., recruitment, attendance, reasons for dropping out) and participants’ feedback. These analyses were performed in (R Studio Team, 2020) . As for the qualitative methods, the thematic analysis approach was used (Braun & Clarke, 2006) for coding the interview content in the three aforementioned domains. After reading the transcripts, anchor codes were identified and categorized into different themes and subthemes (see results). Disagreements were solved through discussion between coders (first and second authors). Qualitative data analysis was performed in Microsoft Excel. To increase the reliability of the interview data with program participants and reduce any potential bias, researchers triangulated the information with facilitators (and informally with the frontline staff) and the logbooks.

Results

Considering the three domains evaluated (i.e., Implementation, Participation/Response, and Context), the following section describes each process evaluation component separately to provide further detail on the implementation of the program. This section includes key findings from the qualitative and quantitative elements of the process evaluation where relevant.

Domain 1: Implementation

Evaluation of Program Participants

A key aspect of the RNR model, which underpins the program, is that program participants should complete a risk and needs assessment. Interestingly, a treated participant (Participant 1) pointed this out as a necessity for the positive development of the program:

“I think they [participants] have to go through an evaluation process before [starting the program], because this is not just showing up to knock off (…) a couple of days or a couple of months [from your sentence], (…) you have to talk a lot about the things you did, whether you are sorry or not, because you can be [repentant] or not, then I think you have to evaluate it a lot, you have to assess the person a lot before he is admitted [to the program]” (Treated participant 1).

Although the original Spanish manual prescribes both therapeutic and risk assessments, facilitators in Uruguay did not conduct the assessment because the Uruguayan correctional system does not have validated instruments available to date, neither to carry out risk assessments nor to evaluate the therapeutic needs of the subjects. These deficiencies should be resolved urgently. When facilitators and the program coordinator were asked about the therapeutic outcomes of the program, none knew about them.

“No one knows how to do it [risk assessment] but we are on the way to do it [learn it]” (Facilitator 2).

Dose Delivered

Due to participants not being previously assessed, the risk and needs principles were not met. Conversely, the program duration was planned based on the budget limitations and human resources availability for this program. Paradoxically, despite the initial planned length of the intervention being 6 months, the total program duration was 9 months due to the lack of planning, resulting in a waste of resources.

“We do not time the activities. Participants set the pace. We do not care about the time but achieve the objective” (Facilitator 2)

With regard to the number of hours per week delivered, psychologists planned two weekly 3-hour group sessions, but 2 weekly sessions of 2–2.5 hours were delivered because of managerial and logistical issues. The program session log showed that sessions never started on time and participants did not complete homework tasks, which reduced the dosage received. In fact, all treated participants stated that the program should be longer and more intense.

“I think the program itself would have to be longer. […]. It would have to be the whole year. After 6 months it [the program] will be missed.” (Treated participant 2)

“It [the program] is short. When you start to dig deep it ended. Here it is not easy to live together. I would have set 6 hours, 2 times a week, 9 months. […]” (Treated participant 3)

Facilitators: Training and Skills

The evidence shows that training and supervision are key to successfully delivering the program (Gannon et al., 2019; Tyler et al., 2021). In this sense, two key issues were identified. First, the psychologists were trained in the classic psychoanalytic approach. Second, the psychologists did not hold any specialized training on ICSO nor had previous experience delivering evidence-based programs with ICSO. The lack of training added difficulties in applying the RNR principles in practice, implementing and preparing the program, dealing with manipulation in sessions, resulting in insecurity.

“[The RNR model] rings a bell but I don’t know how to apply it” (Facilitator 2).

“[The third problem is the] inexperience on the topic. The need to have a consultant who knows about the topic. Many times, decisions had to be made based on intuition” (Program coordinator.).

“There are many prison officers, but the issue is the training. They must be trained and guided [supervised]. I feel supported by [name of Facilitator 1] and [name of Facilitator 2] and I have learnt a lot.” (Facilitator 3).

“It seemed to me that many times they [participants] used the program to vent about things [unrelated problems] […] with second intentions: I want to get out of here, I want to do this… You have to set a limit. Because that’s also where the prison officer’s skill is, how far I go to and where I don’t” – (Prison Manager 1).

Despite the lack of training, all participants scored facilitators’ abilities quite high (i.e., very good, excellent). For instance, ten participants (91%) stated that they never felt pressure by facilitators to change before feeling ready, facilitators never put their needs above them, and felt that they and facilitators worked together to overcome their issues. Nine participants (82%) stated that facilitators were (very) quite dedicated in helping them to overcome their difficulties. Eight participants (78%) said that facilitators (very/quite much) understood what they expected from the program. Overall, 10 participants (91%) stated that facilitators were (very) good at implementing the program.

Despite all treated participants observing the facilitators’ inexperience, this was not an issue for them.

“Yes, [the sessions] can be improved by the facilitators. I think they are just beginning [to implement the program], they have not been doing this for a long time, right? As they progress, they will improve” (Treated participant 4).

“They [facilitators] were good, being the first time, they were great. Acquiring the experience takes time. Considering it was the first time they coped with it very well. We all make mistakes.” (Treated participant 3).

The level of satisfaction of treated participants was high because the program helped them to understand themselves better, acquire skills (e.g., self-control) to survive in prison and to stop drugs use.

“[…] And they [facilitators] made me see the reason for my behavior, and that everything can be learned, and that is the most valuable. They made me understand that I could learn again. In other words, beyond everything that I went through in my life [he and the sister were abused and had a violent/alcoholic father, drug abuse], I can change that behavior and I can be another person and that is good” (Treated participant 1)

All participants, including dropouts, would recommend the program to other inmates. Only one dropout, whose offense was child abuse, considered the program useless and hesitated to recommend it, whereas nine (82%) found the program quite/very useful.

“I do not know. I cannot see the usefulness of this program. It depends on whether he is a prisoner who really needs it, or has a really serious case against him.” (Dropout participant 1).

“Yes, many would need it [the program]. Not only for those who have short sentences, those who leave soon, but for those who have a long one, those who have a long time in prison.” (Treated participant 3)

Some dropouts (n = 3) complained about not having a male therapist, this was the reason to dropout the program for one participant. An important reason for the lack of male facilitators was prejudice and reluctance to work with ICSO.

“… and one must be careful in the selection [process for the program staff]. […]. I am sure that, for example, those that were not selected [to implement the program] would not have worked well because they have many prejudices about others, about the inmates, and much more about people who have committed this type of crime.” (Prison manager 1)

“It is hard for me [talking] with women [facilitators], perhaps with a man it is different, and I would have talked about it [the offense].” (Dropout participant 6)

Fidelity/Integrity

All treatment modules were implemented except for the sexual arousal modification, which is only applied for severe cases of atypical sexual interests such as pedophilia, which was not assessed. Again, the lack of knowledge on the RNR model and the cognitive-behavioral approach, plus the lack of supervision, made it difficult to consider the concepts of program fidelity and integrity by the facilitators. As a result, there were several alterations in the original contents of the manual program, such as including new activities from other psychological perspectives (i.e., Gestalt) without consulting the authors’ manual. In addition, the log sessions showed that facilitators did not use the discussions, objectives, clarifications or examples described in the manual and its annexes, nor they did conduct a functional analysis of each crime (i.e., exploring the Antecedents-Behaviors/offenses-Consequences), as the manual describes. As a result, it is possible that participants did not receive an adequate explanation about their criminal behavior and the main factors related to it.

“It was difficult [the defense mechanisms module], because it is difficult to explain a defense mechanism (it is very theoretical), and for them to identify it.” (Facilitator 2)

“The writing does not work so much. There are things that if you do not experience them it is difficult to convey. We are making a manual with suggestions. These manuals are not clear. We put everything, objectives, suggestions and we substantiate them.” (Program coordinator)

Domain 2: Participation & Response

Selection

Participants heard about the program for the first time. All participants stated that the information received about the program was useful and complete, except for two dropouts who stated:

“I would have known in advance the schedule and days [of the program], because [the program] clashed with other activity I was doing [education] and I had to dropout [of the program].” (Dropout participant 3)

“The only thing [I would have liked] to know was if the judge had access to information that I am providing [in the sessions].” (Dropout participant 6)

The main reasons to enroll in the program were: “restoring the damage, change mentality and reducing distress, family support, wanted to be heard, knowing reasons of his offense and obtaining a solution” (n= 6). Two treated participants (out of four) stated that the initial extrinsic motivation they had (i.e., sentence reduction) progressively turned into an intrinsic motivation by the end of the program.

“I started [the program] because of the early release, and then I knew that I was never going to get the early release, and I started getting into it.” (Treated participant 2)

“[I participated] because of the early release. It was not difficult [to make the decision] because I thought about the early release, but then, I kept going because…. Because it helped me, I don’t know. Besides, I wanted to stop using drugs and all that and I couldn’t and yes, after a little while, little by little I was quiting, quiting and now, I don’t even smoke tobacco.” (Treated participant 3)

Despite the high number of dropouts (n = 6, 64%), five dropout participants showed high/very high levels of motivation to start the program again, whereas two participants reported low level of motivation. It is noteworthy that all treated wanted to dropout several times during the program but three did not drop out because facilitators helped them and encouraged them to stay, and another one did not give up because of his mother’s support.

Response

Nine participants (82%) stated that the program did not overlap with other activities (e.g., labor, workshops, and education). However, the session in which participants had to talk about the sexual offense and triggers was a turning point because 4 participants left the program. The reasons provided by participants for dropping out on that moment were: not guilty (dropout 4), participation in other activities (dropout 3 and 6), gender of the facilitators (they would have preferred male therapists) (dropout 4), did not want to remember things/had no words (dropout 2), and nothing else to say in group sessions (dropout 1). Three dropouts would not enroll again in the program but three would do so. Finally, five stated that facilitators understood their reasons for dropping out, while one did not answer the question and the expelled participant commented:

“They [facilitators] could have explained a little more [about] what happened. The only one who explained something was [name of facilitator who conducted the individual sessions].” (Expelled participant)

Treated participants’ opinions on the high rate of dropouts were that having to make deep personal changes and take responsibility for their own crimes were very arduous and painful processes to endure. Considering the responsivity principle, it seems that some participants did not know what to expect of the program dynamics, and they were unwilling to or incapable of talking openly about their offenses, that is, they were not ready yet. Four participants (36%) stated that they did not have any expectation about the program, four (36%) stated that the program fulfilled their expectations, and for two (18%) the program exceeded their expectations.

“… I always said that to start this [program] you must be brave because sooner or later you will have to face things that you will not like, and it is when the brave ones stay.” (Treated participant 2)

“[name of dropout 3] and [name of dropout 6] supposedly dropped out because of education [clashed with the program] but it is not clear to me. I did not enquire much more. I think we should have gone [to the wing] to do an individual intervention.” (Facilitator 3)

To avoid more dropouts, facilitators used the motivational interview and individual sessions once per week (this was previously applied on demand). Facilitators recognized that they learned on the go and it would have been useful to apply the motivational interview from the beginning for retaining more subjects in the program as the responsivity principle posits.

“I think the motivational interview strategy helped. Faced with [participants] demotivation, my red flag goes on and you go. I think this strategy [motivational interview] could have retained some more [dropouts].” (Facilitator 3)

“They [facilitators] explained everything but I did not want to open up.” (Dropout participant 4)

Tailoring

Facilitators had to tailor the writing activities described in the manual to the learning style and skills of participants (responsivity principle), which were described as weak by the program coordinator:

“The most difficult has been the format used. The program is all designed using written exercises, assuming people have high cognitive levels, and the reality is that our prison population does not seem to have the same [writing and cognitive] level as prison populations in Europe or North America. Therefore, applying the program involved a lot of interpretation work and oral transfer. They found it very difficult to write and to do the exercises.” (Program coordinator).

To address this issue, facilitators introduced new activities from other workshops delivered by them and replaced some writing exercises by verbal exercises.

“Yes, there were changes, not in the objectives [of the program], but in the exercises. Masks [from Gestalt approach] were taken, performances were made because they complained about written exercises, they were very tired. They asked for different exercises.” (Facilitator 2)

It is noteworthy that, according to the program coordinator, the Spanish program was selected (among other available programs) because of “free copyright charges, free access to the manual, same language (Spanish) and similar culture”. However, practitioners interpret “similar culture” as solely sharing the same language, when culture might involve other factors such as the prison context and the level of inmates’ literacy. These factors were not taken into consideration by facilitators when adapting and delivering the program.

Another important issue in Uruguay was that the Prison Service could not afford to pay the economic costs that involve transferring a correctional program from high-income countries, suitably adapting it, and evaluating it. As a result, the program effectiveness was at risk.

Domain 3: Context

The program implementation was affected by five main contextual factors:

1. Physical spaces and module architecture seem to be inadequate to implement the program. Contrary to Spanish prisons, in Uruguay the room where the program took place was very cold and far away from the participants’ module of residence. Because of this, participants were exposed to negative comments (e.g., “sex offenders”, “rapists”) by other inmates and police officers on the way to the program room. Additionally, participants had further difficulties in completing their therapeutic homework because they resided in large and noisy pavilions (not in individual cells) with a lack of privacy. Research shows that prescribed therapeutic exercises are relevant not only for therapeutic change, but also a favorable prison environment (Blagden & Wilson, 2019).

2. Time and resource constraints coupled with changes within the Prison Service. Several unexpected changes occurred and affected the program implementation including the drop out of the most experienced facilitator (treatment participants were disappointed); the replacement of the police officers with prison officers in the ICSO’s module; two treated participants were transferred to a unit with high levels of violence because the ICSO`s module was relocated to a module in the new prison; and the reduction of resources for the program (e.g., staff). Finally, the executive director of the Uruguayan Prison Service was replaced; and the new director, who approved this project, showed high motivation, initiative and leadership allowing and boosting the program implementation and evaluation.

3. Lack of financial support by the Uruguayan government to rehabilitation initiatives for prisoners (i.e., evidence-based programs) such as the one described here. The Uruguayan government has not expressed support for evidence-based programs to reduce recidivism. All program managers stated that the organization had a punitive rather than a rehabilitation culture. Neither the government nor the Prison Service were ready to consider the What Works agenda. Within this unfavorable institutional context, most inmates were suspicious about this new program aimed at something as utopian and alien to the institutional culture as rehabilitation.

4. Media and negative public perceptions. During the application of the program, two highly publicized cases by the media involving sexual offenses had additional negative effects on both facilitators and program participants. The program participants felt highly concerned about public reactions and the facilitators started to doubt about the program effectiveness. The media impact of these events was so high that the facilitators had to dedicate a specific therapeutic session to address it.

5. Academia. In Uruguay, the psychoanalysis approach is mainstream in psychology degrees and university training in general. Moreover, there are no postgraduate studies in cognitive-behavioral therapy, criminal psychology, and rehabilitation programs for individuals who commit offenses (Tapias, 2018). As a result, there is a lack of cognitive-behavioral psychologists and the validated and rigorous assessment protocols and measures to evaluate inmates.

Discussion

The application of specialized and complex rehabilitation interventions with prisoners is a challenge for any country. For instance, audits and research studies conducted in England, Israel, New Zealand, Spain, and the United States showed some of the same challenges described in this study when programs for ICSO started to be implemented in these countries. Mostly the difficulties derive from limited or inadequate resources for the program implementation, need for a man-woman therapeutic pair, shortage of prison officers, task overload, and the need for better cooperation between agencies (Beech et al., 2005; Corrective Services New South Wales, 2017; Dean et al., 2017; Duriez et al., 2017; Farringer et al., 2019; Geiger & Fischer, 2017). However, the challenges are even greater in societies such as Uruguay where human and financial resources are more limited (Moore et al., 2013; Schneider et al., 2016). This study focuses on the process evaluation treatment program for ICSO in Uruguay. To do this, the guidelines from the MCR were applied (Moore et al., 2015), so three main domains were analyzed in detail which are discussed below.

Domain 1: Program Implementation

Aside from the material and resource limitations (especially reported in the context domain) this study has shown the relevance of having a good command on the most consolidated theoretical models on (sexual) crimes (i.e., cognitive-behavioral model, RNR model, and theories of sex offending) and effective rehabilitation programs (Gannon et al., 2019; Tyler et al., 2021). As the results showed, the lack of training of the RNR model produced serious alterations on the participants’ evaluation, dosage, fidelity and integrity of the program. Better training of the facilitators to ensure program integrity and fidelity is a main challenge in Uruguay not only to increase therapeutic effectiveness, but also the program cost-effectiveness (e.g., Gannon et al., 2019; Marshall & Marshall, 2021).

In addition, having an open access manual online might be problematic because professionals without knowledge or training have access to it without any supervision, so they may alter the program integrity and fidelity. In this study, facilitators produced substantial alterations of a manualized program and had misinterpretations of the manual program because no training sessions on cognitive-behavioral techniques nor on the use of the manual were offered to facilitators. Although it is accepted that some adaptation of the program is inevitable and indeed may be desirable to fit the specific application context (Durlak & DuPre, 2008), great care must be taken so that the programs’ adaptations are in keeping with the goals and theoretical foundations of the original program (Moore et al., 2013; Savignac & Dunbar, 2014).

Domain 2: Participation and Response

A key issue to work on in future implementations of this program in Uruguay - and perhaps other Latin American countries - is the high dropout rate observed here (64%), particularly when the participants had to talk about their sexual offenses. This high dropout rate was partially expected due to the aforementioned issues, but its magnitude is not comparable with dropout rates in Spain nor the international average rate of similar programs managed by trained staff, which is estimated around 27% (González-Pereira et al., 2020; Larochelle et al., 2010; Olver et al., 2011). Dropout predictors associated with offenders’ criminogenic needs (e.g., motivation, personality variables, and criminal history) should be considered in future implementations to increase adherence to treatment (Larochelle et al., 2010; Olver et al., 2011). Additionally, the program completion was an indicator for early release, as in Spain. However, Spanish facilitators applied motivational techniques before and during the program to reinforce the program participation and reduce dropout rates. Additionally, the difference between Spain and Uruguay regarding earlier release is that Uruguayan inmates can obtain it by assisting with other activities (i.e., education, labor and workshops), so they chose other activities over the program. Other barriers that might be dropout predictors were the adverse environment in prison and the lack of privacy required for homework, which is less common in Western prisons.

Domain 3: Context

The organizational shift towards the RNR model, which made this study possible, was strongly dependent on the leadership of the Prison Service executive director on that time; but this rehabilitation perspective was not embedded in the regular penitentiary organizational policies and procedures. To boost the rehabilitation model in the Uruguayan Prison Service, structural relevant changes are needed such as legal reforms, increase of prison budget, better knowledge of evidence-based international rehabilitation programs, the reduction of institutional fear and resistance towards program innovation, as well as an increased motivation to carry out the necessary organizational changes (Savignac & Dunbar, 2014). By doing this, not only will it increase the implementation of rehabilitation prison programs, but it will also prevent some of the difficulties and barriers reported in this study. Additionally, in this adverse context, in which sufficient human, physical and financial resources are rarely made available to prison systems, this study found that leaders in the organization are crucial to bring the change within the organization (see UNODC, 2010). Finally, cost-benefit studies have shown that it is worthwhile for an organization to commit to evidence-based programming as it reduces reoffending and, thus, the cost for society (Marshall & Marshall, 2021).

In a sense, the difficulties reported in this study could be indirectly related to Uruguayan public opinion unfavorable to offenders’ rehabilitation, who are currently considered irrecoverable subjects (Schneider et al., 2016). For instance, it could be an explanation for the negative attitudes shown by some therapists in the prison system. The gradual change of such punitive public attitudes and policies (i.e., registry for ICSO) is, in our opinion, an important challenge for the society, the prison leaders and the Government of Uruguay, which is beyond the scope of this study.

Embracing the What Works agenda implies that the Uruguayan Prison System should provide program participants with appropriate space and climate to practice the new skills learned in the context of a treatment program (Blagden & Wilson, 2019), as well as to adapt the program to the Uruguayan context and the specific characteristics of the participants (responsivity principle). For example, adapting the activities of the program to the levels of literacy of the participants, the lack of internet resources to do some activities, and addressing the lack of internet and homework resources.

Practical Implications

This study highlights several aspects supported by evidence. First, the importance of adhering to the RNR principles. As the risk and needs principles state, matching the program to the level of risk and the criminogenic needs of participants is critical to maximize the effectiveness of the treatment (Bonta & Andrews, 2017). These principles are difficult to accomplish at the moment in Uruguayan prisons, because risk assessment tools are not systematically applied.

Secondly, the responsivity principle (Bonta & Andrews, 2017) is difficult to apply in the current conditions in the Uruguayan prisons. For instance, adapting the program to the motivational level and other characteristics of Uruguayan participants (e.g., literacy levels), has been identified as an important condition to apply the program in an effective manner. Participation depends on several factors such as denial and minimization (for a review, see Dietz, 2020), the participants openness to discussing their sexual offending, motivation to change, whether they had also associated legal issues (e.g., people who are still appealing against their sentence; Mews, Di Bella & Purver, 2017). In particular, this study shows the importance of the subjects’ openness for discussing their sexual offending and motivation to change. It seemed that most participants were not ready for this yet, and could have benefitted had the first session included motivational interviewing. Moreover, to accomplish with the RNR principles, the appropriate training of facilitators on the intervention model and other cognitive-behavioral therapeutic skills are needed before the treatment is delivered.

Thirdly, the study displays the importance of conducting a process evaluation using a systematic approach to understand the underlying mechanisms affecting the program effectiveness. The process evaluation is not only recommended when a prison treatment program is delivered for the first time, but also in other evaluations such as randomized controlled trials (Moore et al., 2015, 2019).

Finally, this study suggests that there could be legal changes in Uruguay to reinforce the implementation of interventions - changes such as those made decades ago in different developed countries incorporating evidence-based programs as a routine prison activity. This also requires supplying correctional institutions with the necessary budgets for the development of such treatment and rehabilitation activities.

Limitations

First, due to the small sample size and the explorative approach of this study, the results on process evaluation cannot be generalized. It would be beneficial for future applications to also incorporate the risk assessment of participants, both before and after the treatment. This is now being addressed as part of the next stage of improvements of the described intervention. Second, the program sessions were not video or tape-recorded but written in notebooks, so the assessment of program fidelity was difficult because it was not possible to capture elements such as nonverbal communication. Also, the interrater reliability for the fidelity checklist could not be calculated, which could have decreased the validity of this measure. Additionally, treatment facilitators provided vague information concerning the decision-making process for specific changes made in the manual and about the participants’ progress. It is recommended that researchers develop exhaustive guidelines to assess the process of the interventions in a consistent way, which will allow evaluators to replicate and compare results across countries.

Conclusion

Countries such as Australia, Canada, New Zealand, Spain, and the United States have a long tradition in evidence-based practices, which is helping to explore the black box of correctional programs (Schmucker & Lösel, 2015). However, Uruguay, and more generally Latin American countries, are in their infancy in applying the What Works agenda, so this study is an initial opportunity to explore their own black box of ICSO’s rehabilitation mechanisms. Findings suggest that Uruguay needs several changes (e.g., in terms of training, resources, and cultural context) to successfully adopt the rehabilitation ideal and the principles of effective correctional programs to reduce reoffending. We are aware that this is not an easy task even for those countries with long traditions in evidence-based practices. Despite this, the rehabilitation approach is in the direction of a more humane and effective prison management capable of preventing recidivism and future victimization.

Footnotes

Acknowledgments

We are grateful to the inmates, facilitators and managers for their time and valuable contribution in this study. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Uruguayan Prison Service (i.e., National Institute of Rehabilitation, I.N.R). The authors take responsibility for the integrity of the data, the accuracy of the data analyses, and have made every effort to avoid inflating statistically significant results. We are also thankful to Dr Laura Bui and Dr Jonathan Davies for editing the manuscript and the anonymous reviewers and the editors, Kelly Babchishin and Michael Seto, for their comments.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The project was funded by the Comisión Sectorial de Investigaciones Científicas [Sectorial Commission of Scientific Research] [FINCSOC_CSIC_38]. The funders had no role in study design, data collection and analysis, interpolation of this data, decision to publish, or preparation of the manuscript.

ORCID iD

Olga Sánchez de Ribera

Nicolás Trajtenberg

Note

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