A Controlled Trial of a Cognitive Skills Program for Personality-Disordered Offenders

Abstract

Objective: There is a need to find effective treatments for individuals with antisocial and borderline personality disorder who are known to be difficult to engage and treat. Many of these individuals share considerable overlap with symptoms of ADHD, hence this study aimed to evaluate the Reasoning and Rehabilitation ADHD program (R&R2 ADHD) among patients with severe personality disorder. Method: A total of 31 males detained in a “dangerous and severe personality disorder” unit completed questionnaires at baseline and post treatment to assess social problem solving, violent attitudes, anger, ADHD symptoms, emotional control, and social functioning. A total of 16 patients participated in the group condition, and their scores were compared with 15 waiting-list controls who received treatment as usual. Results: In all, 76% of group participants completed the program. In contrast to controls, they showed significant improvements in scores with mainly medium effect sizes. Conclusion: R&R2 ADHD was effective in a small sample of severely personality-disordered offenders.

Keywords

ADHD personality disorders social cognition treatment

Introduction

Personality disorder is prevalent in offending populations; a systematic review of 23,000 prisoners found that two thirds were likely to fit criteria for personality disorder (Fazel & Danesh, 2002). The association between personality disorder and offending most likely relates to the complexity and severity of personality disturbance, and the difficulties personality disorder presents in relating to others (Gandhi et al., 2001; Yang, Coid, & Tyrer, 2010), leading to the potential for offenders with severe personality disorder to be classified as “dangerous.” In particular, the combination of antisocial and borderline personality disorders appears to confer a higher risk for violent offending (Becker, Grillo, Edell, & McGlashen, 2000; Howard, 2006; Howard, Huband, Duggan, & Mannion, 2008). A high proportion of these patients display aggressive (88%) or self-harming (49%) behaviors (Daffern & Howells, 2007), and this may be due to poor impulse control, emotional dysregulation, and cognitive skill deficits.

In 1999, the U.K. government initiated a pilot assessment and treatment program for individuals who were considered dangerous and severely personality disordered (DSPD). The concept of dangerousness was classified as being “high risk” of causing significant harm to others (more specifically, “psychological or physical harm that the victim would never recover from”). Severity of personality disorder was classified as either the presence to a sufficient degree of psychopathic traits or a sufficient number of different personality disorders (Department of Health, 2004). By implication, the high-security DSPD services were considered to be housing some of the most dangerous offenders in the United Kingdom. However, following some controversy and uncertainty regarding the effectiveness of treatment, compounded by financial pressures (Duggan, 2011), a recent Department of Health and Ministry of Justice consultation document has proposed the decommissioning of DSPD services (Department of Health, 2011). Systematic reviews have indicated very limited evidence for positive pharmacological treatment effects in people with personality disorder; by comparison, cognitive-behavior therapy (CBT) is an effective treatment (Duggan, Huband, Smailagic, Ferriter, & Adams, 2008; Gibbon et al., 2011). However, treatment noncompletion rates are high and range between 15% and 80% with a median of 37% (McMurran, Huband, & Overton, 2010). The DSPD units often housed these treatment “failures” who were perceived to be “treatment resistant” due to low levels of engagement and high rates of dropout from therapeutic programs (Farr & Draycott, 2007; Sheldon, Howells, & Patel, 2010; Tyrer, Mitchard, Methuen, & Ranger, 2003).

Over the past decade, the growth in research on offenders with severe personality disorder has paralleled that of offenders with ADHD. International studies report a prevalence of ADHD offenders in prison of around 45% in young offenders and 30% of adult offenders. ADHD has been associated with early onset of antisocial behavior, younger age of police contact, criminal convictions, and recidivism (S. Young et al., 2009; S. Young, Adamou, et al., 2011). A Scottish prison cohort study reported high rates of comorbid personality traits in prisoners with ADHD symptoms, and in particular, prisoners with ADHD symptoms had significantly higher rates of comorbid antisocial personality traits compared with prisoners without ADHD symptoms (63% vs. 40%, respectively); however, ADHD symptoms were most strongly related to compulsive (negative relationship, that is, disorganization) and borderline personality styles with large and medium effect sizes (Gudjonsson, Wells, & Young, in press; S. Young et al., 2009). ADHD, followed by prior drug use, was the most powerful predictor of violent offending (S. Young, Wells, & Gudjonsson, 2011).

Prisoners with ADHD seem to be a particularly challenging group to manage within institutions. The Scottish cohort reported that ADHD symptoms predicted aggressive incidents documented in prison records, and this finding remained significant after controlling for antisocial personality traits (S. Young et al., 2009). This supports the findings from other research examining the association between ADHD symptoms and critical incidents in institutionalized youth offenders (S. Young, Gudjonsson, Misch, et al., 2010; S. Young, Misch, Collins, & Gudjonsson, 2011) and personality-disordered offenders detained in forensic mental health settings (S. Young, Gudjonsson, Ball, & Lam, 2003). In the latter study, 78% of patients screened positive for symptoms consistent with childhood ADHD and 35% for persisting ADHD symptoms. While there are likely to be false positives in the data of this study and other prison studies (which typically apply a screening assessment rather than a comprehensive clinical interview), there seems to be an overrepresentation of offenders with ADHD in forensic services, many of whom are unidentified, compared with child rates of 3-5% (Ford, Goodman, & Meltzer, 2003) and adult rates of 2.5% (Simon, Czobor, Bálint, Mészáros, & Bitter, 2009).

Thus, some common themes arise from these two strands of research with both conditions sharing common characteristics and being associated with aggression and offending. There is a particular overlap in symptoms of ADHD and borderline personality traits, with both conditions being associated with emotional lability and impulsivity. Indeed, it has been raised that borderline personality disorder would be better classified as a condition of recurrent unstable mood and behavior, and located within the spectrum of mood disorders (Tyrer, 2009). This may account for an underrecognition of ADHD in patients with personality disorder and contribute to treatments being ineffective (Asherson, Chen, Craddock, & Taylor, 2007).

Studies have investigated the association between ADHD, antisocial behavior, and psychopathy in adolescent and adult samples. The findings are generally consistent in reporting that the association arises from factors related to an unstable and antisocial lifestyle (i.e., Psychotherapy Checklist–Revised [PCL-R] Factor 2) of the Hare Psychopathy Checklist-Revised as opposed to interpersonal callous and remorseless factors (i.e., PCL-R Factor 1); (Abramowitz, Kosson, & Seidenberg, 2004; Colledge & Blair, 2001; Eisenbarth, Alpers, Conzelmann, & Jacob, 2008; Johansson & Kerr, 2005; Kaplan & Cornell, 2004; Langevin & Curnoe, 2010; Mathias, Furr, Daniel, & Marsh, 2007; Sonderstrom, Sjodin, Carlstedt, & Forsman, 2004).

In 2009, the U.K. National Institute for Health and Clinical Excellence (NICE; National Collaborating Centre for Mental Health, 2009) published guidelines for the assessment and treatment of people with antisocial personality disorder. For people with antisocial personality disorder with a history of offending behavior who are in community and institutional care, group-based cognitive and behavioral interventions were recommended that focus on reducing offending and other antisocial behavior. The efficacy of cognitive skills interventions is supported in personality-disordered populations (Huband, McMurran, Evans, & Duggan, 2007), and the guidelines gave an example of the Reasoning and Rehabilitation Program (R&R; Ross & Fabiano, 1985) as a suitable intervention. R&R has a well-established evidence base; a meta-analysis of 16 R&R evaluations found a 14% decrease in reoffending for group participants compared with controls when delivered in institutional settings and a 21% reduction when delivered in community settings (Tong & Farrington, 2006). The program has been found to be effective in two pilot studies of offenders with severe mental illness with improvements in clinical measures relating to social problem solving and coping (Clarke, Cullen, Walwyn, & Fahy, 2010; Donnelly & Scott, 1999). More recently, there has been evidence for its effectiveness in a randomized controlled multisite trial of offenders with severe mental illness with improvement in social problem solving and thinking styles post treatment; improvement in specific social problem solving domains were maintained at 12-month follow-up (Cullen, Clarke, et al., 2011).

However, R&R is a lengthy program of 36 sessions, and treatment dropout was high at 50%; program dropout was predicted by “high risk” inpatients characterized by psychopathy, antisocial personality traits, and violent behavior (Cullen, Soria, Clarke, Dean, & Fahy, 2011). By contrast, a pilot study of a shorter 16-session revision of the program that has been developed for individuals with mental health problems (R&R2 MHP; S. J. Young & Ross, 2007b) and delivered to offenders with severe mental illness in high- and medium-secure mental health services found a dropout rate of 35% (S. Young et al., 2010). The need for successful completion of programmed interventions for offenders should not be underestimated as noncompletion of programs may increase risk because noncompleters have higher rates of reoffending than completers (McMurran & Theodosi, 2007; Palmer et al., 2007). Thus, a primary aim of treatment must be to maintain engagement else the societal gains of effective treatment of some offenders will be offset by those who disengage prematurely. The incorporation of a mentoring role may be one way to improve completion rates as this combines group and one-to-one work, and supports participants in consolidating their learning and maintaining engagement (D. Jones & Hollin, 2004; Hollin & Palmer, 2007).

Given the overlap in symptoms of ADHD and psychopathy and the need to find effective treatments for a population who are known to be difficult to engage, this study trialed a revised version of R&R that has been adapted for ADHD youths and adults (R&R2 ADHD; S. J. Young & Ross, 2007a). A randomized controlled trial of R&R2 ADHD delivered to ADHD adult patients in the community found a drop-out rate of 26% and reported medium to large treatment effects for ADHD symptoms and antisocial behavior, which increased further at 3-month follow-up (Emilsson et al., 2011). In addition, anxiety, depression, emotional control, and social functioning improved at follow-up with large effect sizes. The findings were supported by independent evaluations of ADHD symptoms and global functioning, which had large effect sizes. One advantage of the program is that treatment is supplemented by guided individual mentoring between group sessions, which is consistent with NICE guidance for treatment of antisocial personality disorder (National Collaborating Centre for Mental Health, 2009).

The current study evaluated the effectiveness of R&R2 ADHD using a waiting-list controlled design on a cohort of psychopathic patients detained in a high-secure DSPD hospital facility. Group attendees were compared at outcome on measures of social problem solving, violent attitudes, reaction to provocation (anger), ADHD symptoms, emotional control, and social functioning. It was hypothesized that group participants would show greater improvement than waiting-list controls, who received treatment as usual (TAU), on the total scores of measures post treatment.

Method

Participants

A total of 31 male patients detained under the Mental Health Act in the DSPD Unit at Broadmoor Hospital, which is a high-secure facility, participated in the study. All participants were referred by their clinical team to attend the group. Inclusion criteria for participants were that they (a) were aged between 20 and 60 years, (b) had a primary diagnosis of severe personality disorder, (c) had a history of violent offending (including sexual violence), (d) had not participated in R&R or a similar program previously, (e) had an absence of learning disability (i.e., IQ < 70), and (f) had proficiency in English language sufficient to allow participation in the program. The latter was determined from medical records that record proficiency in English language identified from an admission assessment.

A total of 16 patients participated in the group condition (R&R2A), and their data were compared with that of 15 waiting-list controls, that is, they were on a waiting list to attend the group (TAU).

Intervention

R&R2 ADHD (S. J. Young & Ross, 2007a) consists of fifteen 90-min sessions, excluding a short midsession break. It is a manualized CBT intervention program developed for youths and adults with ADHD symptoms and antisocial behavior. It is a revised edition of the 36-session R&R program (Ross & Fabiano, 1985) that was originally developed as a prosocial competence training program for use in correctional facilities. R&R2 ADHD is a structured, manualized program that aims to decrease impairment of symptoms associated with ADHD (poor attention, impulsivity, and hyperactivity) and improve social, problem solving, and organizational skills. It consists of five treatment modules: (a) neurocognitive, for example, learning strategies to improve attentional control, memory, impulse control, and planning; (b) problem solving, for example, developing skilled thinking, problem identification, consequential thinking, managing conflict, and making choices; (c) emotional control, for example, managing feelings of anger and anxiety; (d) prosocial skills, for example, recognition of the thoughts and feeling of others, empathy, negotiation skills, and conflict resolution; and (e) critical reasoning, for example, evaluating options and effective behavioral skills. The program integrates group and individual treatment, the latter being achieved by the incorporation of a mentoring paradigm whereby a member of staff meets with the patient between group sessions to assist the participant to transfer skills learned in the group into their daily lives. Importantly, the mentoring role is not devised to be an additive individual session but aims to provide a structure for meetings or sessions that are routinely held between the participant and the designated staff mentor (e.g., primary nurse, keyworker, social supervisor). As a structured manualized program for group facilitators and mentors, R&R2 ADHD facilitates consistency in delivery and maximizes program integrity.

Treatment completion

In line with the methodology applied by Cullen, Soria, et al. (2011), a cutoff equating to 80% of the program was applied to classify participants as completers (≥12 sessions) or noncompleters (<12 sessions).

Treatment as usual

Participants were not asked to refrain from engaging in interventions considered to be part of their usual treatment with the exception that the control group was not permitted to attend R&R2 ADHD sessions or other similar cognitive skills programs.

Measures

Baseline assessments

Demographic, diagnosis, and index offense information was obtained from clinical file review at the start of the study. In addition, participants completed the Patient Motivation Inventory (PMI; Gudjonsson, Young, & Yates, 2007) to assess for possible variation in motivation to engage in treatment. The PMI Total score has good internal consistency (Gudjonsson, Savona, Green, & Terry, 2011).

Outcome measures

The following self-report measures were administered at baseline (Time 1) and repeated at postgroup (Time 2) to assess the primary (social problem solving) and secondary outcomes (attitude to violence, reaction to provocation/anger, ADHD symptoms, emotional control, and social functioning).

Social Problem-Solving Inventory–Revised: Short Form (SPSI-R:S; D’Zurilla, Nezu, & Maydeu-Olivares, 2002) is a 25-item questionnaire consisting of five subscales, two measuring problem-solving orientation (positive and negative problem orientation) and three assessing problem-solving style (rational problem-solving, impulsivity/carelessness, and avoidant). A total score can also be obtained with higher scores reflecting better problem-solving ability. North American norms report the measure to have high test–retest reliability and internal consistency, and positive correlations with other social problem solving measures. This measure has been used extensively in the United Kingdom.

Maudsley Violence Questionnaire (MVQ; Walker, 2005) is a 56-item questionnaire that measures cognitive style in relation to violent attitudes. The scale has two factors: machismo (endorsing stereotypical expectations of men as strong and tough) and acceptance of violence (enjoyment and acceptance of violence). U.K. norms have reported that the measure has high internal consistency and has specified differences between mentally disordered offenders (S. Young et al., 2010).

The Novaco Anger and Provocation Inventory: Reaction to Provocation/Personal Affect Questionnaire (NAS-PI; Novaco, 2003) was used to assess cognitive, arousal, and behavioral domains of anger experience. The measure consists of 48 items with higher scores indicating higher anger levels; a total score can also be obtained. U.S. norms have shown the NAS to have high internal validity and test–retest reliability, and the measure has since been used extensively in the United Kingdom. The NAS has been shown to predict violence in mentally disordered offenders (Monahan et al., 2001) and to discriminate between clinically aggressive patients and nonclinical controls (J. P. Jones, Thomas-Peter, & Trout, 1999).

The R&R2 ADHD Training Evaluation–Self-Report Scale (RATE-S; S. J. Young & Ross, 2007a) measure is used to assess ADHD symptoms, emotional control, and social functioning. The measure consists of 32 items providing a total score and four subscales; the antisocial behavior subscale was not used in the present study because some items ask about behaviors over the past month (e.g., have you been arrested or questioned by police). U.K. and Icelandic norms have reported that all the scales have good internal consistency and discriminate functioning in individuals presenting with ADHD symptoms (Gudjonsson, Sigurdsson, Eyjolfsdottir, Smari, & Young, 2009; S. J. Young & Ross, 2007a).

Procedure

Participants were referred by the clinical teams as being suitable for R&R2 ADHD, that is, those presenting with greater PCL-R Factor 2 personality traits and/or symptoms associated with ADHD. After giving informed consent, participants completed the self-reported measures at baseline (Time 1), and data were extracted from the clinical records. Outcome measures were repeated again on completion of the group (Time 2). The timing of the evaluation assessments was the same for the R&R2A and TAU conditions. Group participants attended one of three groups, each running weekly. Participants met with their mentor weekly, between sessions. All R&R2 ADHD facilitators had extensive experience in CBT and attended a 3-day training course in delivering the program provided by S.Y. A core set of three facilitators delivered the program, one of whom was present in each group session. The mentors also received direction through training and written guidelines. Thus, treatment fidelity was ensured by the highly structured style of this manualized program, together with supervision and monitoring of sessions by S.Y., a clinical and forensic psychologist and program author. A log of group attendance and reasons for dropout was recorded weekly. All data were collected by student psychologists who were not involved in facilitating the groups. Information about other interventions was not collected and thus other treatments were not controlled for.

Statistical Analysis

Descriptive statistics summarized demographics, clinical and forensic baseline characteristics. Independent samples t tests were used to examine group differences at Time 1 (see Table 1). Unadjusted mean scores and standard deviations on each of the outcome measures are provided in Table 2. All outcome analyses were intention to treat (ITT), and missing data (n = 4 in R&R2A and n = 3 in TAU) were imputed by last observation carried forward. Differences between the two conditions on the outcome measures were not statistically significant at baseline, nevertheless, to reduce error variance at baseline, an ANCOVA was calculated for each of the dependent variables measuring differences between the conditions in time using adjusted mean scores and standard deviations. The baseline Time 1 scores therefore served as covariates for the dependent Time 2 variables. The effect size was analyzed using Cohen’s d for efficacy measures.

Table 1.

Participant Characteristics Comparing Group Participants and Controls at Time 1.

	Group (n = 16)	Control (n = 15)
	M (SD)	M (SD)	T-score
Age	43.37 (8.81)	36.93 (8.93)	2.02
Length of stay (months)	21.62 (37.16)	32.80 (37.69)	−0.83
PCL-R	28.21 (4.26)^a	29.07 (7.22)^a	−0.38
Patient motivation total	12.62 (1.41)	11.80 (2.65)	1.09
Number of previous convictions	23.75 (25.49)	19.00 (28.21)	0.49

Note: PCL-R = Psychopathy Checklist–Revised.

n = 14.

p < .05. **p < .01.

Table 2.

End of Treatment Outcome Data Comparing R&R2 and TAU Conditions.

	Baseline		Outcome
	R&R2 (n = 16)	TAU (n = 15)	R&R2 (n = 16)	TAU (n = 15)	ITT
Outcome measures	M (SD)^a	M (SD)^a	M (SD)^a	M (SD)^a	F value (Cohen’s d)
SPSI
Positive	10.69 (3.79)	12.40 (5.74)	10.94 (4.39)	11.87 (4.72)	0.49 (—)
Negative	5.56 (3.48)	6.67 (3.79)	4.56 (3.98)	6.80 (4.84)	1.24 (—)
Rational	9.38 (5.31)	10.40 (5.94)	10.19 (6.39)	11.20 (5.86)	0.01 (—)
Impulsivity	6.88 (5.11)	6.47 (4.97)	4.56 (4.62)	6.80 (4.59)	3.99 (.49)*
Avoidance	5.56 (4.35)	5.27 (5.46)	3.38 (3.12)	6.40 (6.16)	8.13 (.62)**
Total	12.41 (3.00)	12.87 (4.13)	13.74 (3.34)	12.35 (4.04)	3.66 (.38)*
MVQ
Machismo	6.69 (7.68)	9.00 (8.42)	4.06 (7.32)	9.53 (11.12)	3.16 (.58)*
Acceptance	5.25 (3.30)	7.00 (3.27)	4.44 (3.60)	6.73 (3.97)	0.59 (—)
Total	11.94 (9.90)	16.00 (9.94)	8.50 (9.56)	16.20 (13.76)	2.73 (—)
NAS-PI
Cognitive	29.62 (6.56)	29.33 (5.05)	26.94 (6.21)	29.33 (5.96)	2.37 (—)
Arousal	28.13 (7.12)	29.33 (5.47)	25.88 (6.75)	30.53 (6.03)	6.17 (.73)**
Behavior	25.88 (6.31)	25.33 (4.91)	22.87 (5.63)	27.13 (6.14)	7.56 (.72)**
RATE-S
ADHD	23.69 (8.95)	25.73 (10.97)	17.69 (7.75)	24.87 (10.04)	5.19 (.80)*
Emotional	37.56 (13.04)	37.93 (12.34)	28.19 (11.43)	34.13 (13.71)	3.30 (.47)*
Social functioning	30.44 (12.80)	35.40 (10.84)	12.75 (7.05)	13.33 (6.68)	2.89 (—)
Total	105.06 (26.46)	110.20 (28.16)	85.93 (26.23)	109.40 (30.24)	5.79 (.83)*

Note: R&R2 = Reasoning and Rehabilitation 2; TAU = treatment as usual; ITT = intention to treat analysis; SPSI = Social Problem-Solving Inventory; MVQ = Maudsley Violence Questionnaire; NAS-PI = Novaco Anger and Provocation Inventory; RATE = R&R2 ADHD Training Evaluation–Self-Report Scale.

Unadjusted means and standard deviations for ITT analysis.

p < .05. **p < .01.

Results

Baseline Characteristics

The sample was predominantly White (n = 27, 87.1%); 3 participants were Black (9.7%) and 1 was mixed race (3.2%). All patients had a history of violence and/or sexual violence. The index offense of almost all of the 31 patients (n = 28; 90%) was violence or sexual violence; 2 patients had an index offense of robbery and 1 had an index offense of arson. There were no significant differences between R&R2A and TAU on prior length of stay at the hospital, PMI motivation to engage in treatment, PCL-R psychopathy, and number of previous convictions. There was a trait for group attendees to be older (p = .53; see Table 1). All participants had a diagnosis of antisocial personality disorder; there were high rates of comorbidity in the sample with 22 patients having ≥2 comorbid conditions, 14 patients having ≥3, 7 patients having ≥4, and 3 patients having ≥5. The most common comorbid conditions were borderline (48%), paranoid (39%), and narcissistic (26%) personality disorders. Other comorbid conditions included histrionic and avoidant personality disorder, pedophilia, Asperger’s syndrome, and compulsive disorder. One patient had a formal diagnosis of ADHD.

Program Completion Rate

Of the 16 participants who commenced the group, 12 (75%) completed the group. The reasons for noncompletion of the group were deterioration in mental state after 5 sessions (n = 1), intentional withdrawal after 8 and 10 sessions (n = 2), and intermittent attendance (n = 1; maximum 11 sessions attended). Group completers attended a mean of 13.33 (SD = 1.15; range = 12-15) sessions, and the noncompleters attended a mean of 8.5 (SD = 2.66; range = 5-11) sessions. There were no significant differences between the two groups for age, t(12.86) = 0.29, p = .78; prior length of stay, t(14) = .82, p = .42; PCL-R psychopathy, t(12) = 0.25, p = .81; and PMI motivation, t(14) = 0.60, p = .56.

Outcome at End of Treatment

Table 2 presents unadjusted means and standard deviations for each of the outcome measures at baseline and outcome for R&R2A and TAU. After adjusting for baseline means, R&R2A scored significantly lower than TAU on the SPSI-R:S Impulsivity/Carelessness and Avoidance Scales and significantly higher on the Total SPSI score with small to medium effect sizes. No significant differences were found on the Positive, Negative, or Rational Problem-Solving Scales.

On the MVQ, the R&R2A participants scored significantly lower than control participants on the Machismo Scale, with a medium effect size, but there was no significant difference in Acceptance of Violence or Total scores.

Reactions to provocation were assessed by the NAS-PI, and R&R2A participants obtained significantly lower scores than the TAU participants at outcome on the Total score, Arousal subscale, and Behavior subscale, all with a medium effect size. There was no significant difference at outcome in the Cognitive domain.

R&R2A participants scored significantly lower than TAU participants on the RATE-S Total score, the ADHD and Emotional Control Scales, with effect sizes ranging from small to large. There was no significant difference on the Social Functioning Scale.

Discussion

This is the first controlled trial study using the R&R2 ADHD, 15-session CBT intervention program with offenders with severe personality disorder. The sample size is lower than planned due to the decommissioning of the DSPD unit at Broadmoor Hospital and associated reduction in bed numbers. This resulted in fewer patients being available for participation in the study. Nevertheless, in spite of the study being potentially statistically underpowered, several significant and robust findings were obtained. These findings demonstrate the effectiveness of the program in improving problem-solving ability and emotional stability, while reducing ADHD symptoms, violent attitudes, and anger problems with mainly medium effect size. These are key problem areas in terms of reducing future offending (Andrews & Bonta, 2010) and were directly targeted by the R&R2 ADHD program.

The pattern of the findings on the different subscales of the SPSI-R:S post treatment (i.e., an improvement on the Impulsivity/Carelessness, Avoidance, and Total Scales and no significant change on the Rational, Positive, and Negative Problem-Solving Scales) is entirely consistent with those found in a pilot study (Clarke et al., 2010) and randomized controlled trial (Cullen, Clarke, et al., 2011) evaluating the effectiveness of the original and longer 36-session R&R program in mentally disordered offenders. This suggests that the R&R programs have differential impact on the varied functional modalities on the SPSI-R:S. The problem areas most improved appear to be those related to problem-solving style rather than positive/negative orientation. Cullen and colleagues (2011) interpreted this pattern of improvement as the R&R being most effective in reducing the tendency of mentally disordered patients to rely on maladaptive approaches when solving problems. This pattern is clearly also relevant to patients with severe personality disorder and taken together with the previous findings among mentally disordered patients, suggests that future offending may be reduced by improved self-control in accordance with a general theory of crime (Gottfredson & Hirschi, 1990).

The present study found that the arousal and behavioral domains of anger on the NAS-PI significantly improved by the end of treatment in the treatment group when compared with that of the control group with medium to large effect size. This finding is important because these scales have been shown to predict violence in mentally disordered offenders (Monahan et al., 2001) and to discriminate between clinically aggressive patients and nonclinical controls (J. P. Jones et al., 1999). Interestingly, Cullen, Clarke, et al. (2011) did not find any significant outcome in their study using the same measure. It may be that anger problems are more amenable to treatment among patients with severe personality disorder than those with severe mental illness, or alternatively, the R&R2 ADHD is more effective in addressing anger-related problems than the original R&R program used in the Cullen et al. study.

Information from the current study’s program drop-out rate suggests that the R&R2 ADHD is feasible in this population. With a drop-out rate of 24%, it seems that this shorter cognitive skills program is more acceptable to patients than the longer R&R (Ross & Fabiano, 1985), which studies have suggested has a considerably higher drop-out rate of around 50% (Cullen, Clarke, et al., 2011; Cullen, Soria, et al., 2011). Dropout was predicted by psychopathy, antisocial personality disorder, and recent violence, which are all characteristics strongly featured in the present study sample. A lower drop-out rate has been consistently demonstrated by studies evaluating R&R2 with 35% dropout reported by mentally disordered offenders (S. Young et al., 2010) and 26% by ADHD patients in the community (Emilsson et al., 2011). Therefore, the shorter revised programs (i.e., the R&R2 ADHD and the R&R2 MHP) may prove more cost-effective than the original R&R program, which contains more than twice as many sessions and retains far fewer patients at completion. The other advantage of the R&R2 ADHD and R&R2 MHP programs is that they contain modules that are specifically relevant to the problems experienced by people with ADHD and/or mental illness, respectively (e.g., sessions that address anxiety, emotional lability, attention and memory problems, impulse control, constructive organization, and planning skills).

This present evaluation of the R&R2 ADHD program suggests that the program is feasible with severely personality-disordered patients in a high-secure unit setting and effective in improving social problem solving ability, reducing antisocial attitudes, reducing reactivity and anger problems, reducing ADHD symptoms, and increasing behavioral control and emotional stability. Taken together, the findings are probably best interpreted within social control and learning theories (Unnever, Cullen, & Pratt, 2003). As with Emilsson et al. (2011), the present findings show that participants who completed the R&R2 ADHD program demonstrated significant improvements on key outcome measures compared with controls. This increase in social problem solving, reduction in antisocial attitudes, and improvement in problems associated with ADHD should be seen in the context of previous outcomes for this group of patients who have been viewed as resistant to treatment and difficult to engage (Farr & Draycott, 2007). The improvement engendered by this program may, therefore, facilitate further treatment relating to specific offending and other factors influencing antisocial behavior problems (e.g., anger management, substance misuse). In addition, the influence of the mentoring sessions may be important to consider when formulating other treatment plans. In a group with high drop-out rates and low engagement, the combination of individual and group sessions may contribute to maintaining engagement. NICE guidelines specifically recommend that for DSPD patients it is necessary to extend the nature (i.e., supplementary one-to-one sessions) and duration (i.e., booster sessions) of an intervention (National Collaborating Centre for Mental Health, 2009). R&R2 ADHD adheres to both of these recommendations through its inclusion of individualized mentoring sessions and the provision of manualized booster sessions (the latter were not included in the delivery of treatment in the current study).

The present study is limited by its sample size, however, good effect sizes were found in spite of the small numbers and the use of a conservative ITT. A second limitation is that results rely on self-reported outcomes; we intended to collect and analyze informant measures, however, due to large amounts of missing data, there was insufficient data for proper analysis. Third, the sample was exclusively adult males diagnosed with personality disorder and therefore, the findings cannot be generalized to a wider offender population. Fourth, the study applies clinical outcome measures to evaluate effectiveness. Most studies evaluating offender behavior programs appraise program efficacy using reconviction rates as an outcome measure. This is important, but it underestimates clinical change, which is a key indicator in mental health populations. Clinical change and reconvictions are important when evaluating treatment programs aimed at mentally ill and personality-disordered offenders. Furthermore, a qualitative study interviewing group participants would provide a rich, experiential perspective of the program content and process.

R&R2 ADHD has been shown to be feasible and effective in a small sample of severely personality-disordered offenders in a high-secure setting. However, the program is still a new intervention and further investigation is needed. Further evaluations should include larger and randomized samples in a range of forensic settings, informant reports of behavior and collateral review, and postgroup follow-up data.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Susan Young is an author of R&R2 ADHD.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Susan Young, BSc, DClinPsy, PhD, is a senior lecturer in forensic clinical psychology at the Institute of Psychiatry, King’s College, London, and honorary consultant clinical and forensic psychologist at Broadmoor Hospital in the United Kingdom. Her main research interests are in the areas of ADHD and forensic psychology.

Gareth Hopkin is a psychology student at University of Cardiff on placement at Broadmoor Hospital.

Derek Perkins, BSc, MSc, PhD, is head of psychological services, Broadmoor Hospital, United Kingdom. Since 1996, he has been a consultant to the Home Office Prison Service and visiting professor of psychology at University of Surrey, United Kingdom.

Catherine Farr, BA, MSc, is lead psychologist in the Personality Disorder Directorate, Broadmoor Hospital, United Kingdom.

Amie Doidge is a psychology student at University of Cardiff on placement at Broadmoor Hospital, United Kingdom.

Gisli Gudjonsson, BSc, MSc, PhD, CBE, is a professor of forensic psychology at the Institute of Psychiatry, King’s College, London, and head of clinical and forensic psychology services in Lambeth, South London, and Maudsley National Health Service (NHS) Foundation Trust. His main research interests are in the areas of forensic psychology. In 2009, the British Psychological Society granted him a Lifetime Achievement Award for his exceptional and sustained contribution to the practice of psychology. He was appointed a Commander of the Order of the British Empire (CBE) in the Queen’s Birthday 2011 Honours List.

References

Abramowitz

Kosson

D. S.

Seidenberg

(2004). The relationship between childhood attention deficit hyperactivity disorder and conduct problems and adult psychopathy in male inmates. Personality and Individual Differences, 36, 1031-1047.

Andrews

D. A.

Bonta

(2010). The psychology of criminal conduct (5th ed.). Cincinnati, OH: Anderson.

Asherson

Chen

Craddock

Taylor

(2007). Adult attention-deficit hyperactivity disorder: Recognition and treatment in general adult psychiatry. British Journal of Psychiatry, 190, 4-5.

Becker

D. F.

Grillo

C. M.

Edell

W. S.

McGlashen

T. H.

(2000). Comorbidity of borderline personality disorder with other personality disorders in adolescents and adults. American Journal of Psychiatry, 157, 2011-2016.

Clarke

A. Y.

Cullen

A. E.

Walwyn

Fahy

(2010). A quasi-experimental pilot study of the reasoning and rehabilitation program with mentally disordered offenders. Journal of Forensic Psychiatry & Psychology, 21, 490-500.

Colledge

Blair

R. J. R.

(2001). The relationship in children between the inattention and impulsivity components of attention deficit and hyperactivity disorder and psychopathic tendencies. Personality and Individual Differences, 30, 1175-1187.

Cullen

A. E.

Clarke

A. Y.

Kuipers

Hodgins

Dean

Fahy

(2011). A multi-site randomized controlled trial of a cognitive skills program for male mentally disordered offenders: Social-cognitive outcomes. Psychological Medicine, 1-13. doi:10.1017/S0033291711001553

Cullen

A. E.

Soria

Clarke

Dean

Fahy

(2011). Factors predicting dropout from the reasoning and rehabilitation program with mentally disordered offenders. Criminal Justice and Behavior, 38, 217-230. doi:10.1177/0093854810393659

Daffern

Howells

(2007). Aggressive behavior in high-risk personality disordered inpatients during prison and following admission to hospital. Psychiatry, Psychology and Law, 14, 26-34.

10.

Department of Health, Home Office, HM Prison Service. (2004). DSPD programme. Dangerous and severe personality disorder (DSPD) high secure services. Planning & delivery guide. Author. Retrieved on December 14, 2011, from http://a1538.g.akamai.net/7/1538/13355/v001/homeoffice.download.akamai.com/13355/Doc/1016/10160069.pdf

11.

Department of Health, Ministry of Justice. (2011). Consultation on the offender personality disorder pathway implementation. Author. Retrieved on December 14, 2011, from http://a1538.g.akamai.net/7/1538/13355/v001/homeoffice.download.akamai.com/13355/Doc/1016/10160069.pdf

12.

Donnelly

J. P.

Scott

(1999). Evaluation of an offending behavior program with a mentally disordered offender population. British Journal of Forensic Practice, 1, 25-32.

13.

Duggan

(2011). Dangerous and severe personality disorder. British Journal of Psychiatry, 198, 431-433. doi:10.1192/bjp.bp.110.083048

14.

Duggan

Huband

Smailagic

Ferriter

Adams

(2008). The use of pharmacological treatments for people with personality disorder: A systematic review of randomized controlled trials. Personality and Mental Health, 2, 119-170.

15.

D’Zurilla

T. J.

Nezu

A. M.

Maydeu-Olivares

(2002). Social Problem-Solving Inventory–Revised (SPSI-R) technical manual. North Tonawanda, NY: Multi-Health Systems.

16.

Eisenbarth

Alpers

G. W.

Conzelmann

Jacob

C. P.

(2008). Psychopathic traits in adult ADHD patients. Personality and Individual Differences, 45, 468-472.

17.

Emilsson

Gudjonsson

Sigurdsson

J. F.

Baldursson

Einarsson

Olafsdottir

Young

(2011). Cognitive behavior therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. BMC Psychiatry, 11, 116-125.

18.

Farr

Draycott

(2007). Considering change: A motivational intervention with DSPD offenders. Issues in Forensic Psychology, 7, 62-69.

19.

Fazel

Danesh

(2002). Serious mental disorder in 23,000 prisoners: A systematic review of 62 surveys. Lancet, 9306, 545-550.

20.

Ford

Goodman

Meltzer

(2003). The British Child and Adolescent Mental Health Survey 1999: The prevalence of DSM-IV disorders. Journal of the American Academy of Child Psychiatry, 42, 1203-1211.

21.

Gandhi

Tyrer

Evans

McGee

Lamont

Harrison-Read

(2001). A randomized controlled trial of community-oriented and hospital-oriented care for discharged psychiatric patients: Influence of personality disorder on police contacts. Journal of Personality Disorders, 15, 94-102.

22.

Gibbon

Vollim

B. A.

Duggan

Khalifa

Stoffers

Huband

. . . Lieb

(2011). Pharmacological and psychological interventions for antisocial personality disorder—Results of two Cochrane reviews. European Psychiatric Review, 4, 52-58.

23.

Gottfredson

M. R.

Hirschi

(1990). A general theory of crime. Stanford, CA: Stanford University Press.

24.

Gudjonsson

G. H.

Savona

Green

Terry

(2011). The recovery approach to the care of mentally disordered patients. Does it predict treatment engagement and positive social behavior beyond quality of life? Personality and Individual Differences, 51, 899-903.

25.

Gudjonsson

G. H.

Sigurdsson

J. F.

Eyjolfsdottir

G. A.

Smari

Young

(2009). The relationship between satisfaction with life, ADHD symptoms and associated problems among university students. Journal of Attention Disorders, 12, 507-515.

26.

Gudjonsson

G. H.

Wells

Young

(in press). Personality disorders and clinical syndromes in ADHD prisoners. Journal of Attention Disorders. doi:10.1177/1087054710385068

27.

Gudjonsson

G. H.

Young

Yates

(2007). Motivating mentally disordered offenders to change. Instruments for measuring patients’ perception and motivation. Journal of Forensic Psychiatry & Psychology, 18, 74-89.

28.

Hollin

C. R.

Palmer

E. J.

(2007). Offending behavior programs: Controversies and resolutions. In Hollin

C. J.

Palmer

E. J.

(Eds.), Offending behavior programs: Development, application and controversies (pp. 247-278). Chichester, UK: John Wiley.

29.

Howard

R. C.

(2006). What is the link between personality disorder and dangerousness? A critique of “dangerous and severe personality disorder.” British Journal of Forensic Practice, 8, 19-23.

30.

Howard

R. C.

Huband

C. D.

Duggan

Mannion

(2008). Exploring the link between personality disorder and criminality in a community sample. Journal of Personality Disorders, 22, 589-603.

31.

Huband

McMurran

Evans

Duggan

(2007). Social problem-solving plus psychoeducation for adults with personality disorder. Pragmatic randomised controlled trial. British Journal of Psychiatry, 190, 307-313.

32.

Johansson

Kerr

(2005). Psychopathy and intelligence: A second look. Journal of Personality Disorders, 19, 357-369.

33.

Jones

Hollin

C. R.

(2004). Managing problematic anger: The development of a treatment program for personality disordered patients in high security. International Journal of Forensic Mental Health, 3, 197-210.

34.

Jones

J. P.

Thomas-Peter

B. A.

Trout

(1999). Normative data for the Novaco Anger Scale from a non-clinical sample and implications for clinical use. British Journal of Clinical Psychology, 38, 417-424.

35.

Kaplan

Cornell

D. G.

(2004). Psychopathy and ADHD in adolescent male offenders. Youth Violence and Juvenile Justice, 2, 148-160.

36.

Langevin

Curnoe

(2010). Psychopathy, ADHD, and brain dysfunction as predictors of lifetime recidivism among sex offenders. International Journal of Offender Therapy and Comparative Criminology, 55, 5-26.

37.

Mathias

C. W.

Furr

R. M.

Daniel

S. S.

Marsh

D. M.

(2007). The relationship of inattention, hyperactivity, and psychopathy among adolescents. Personality and Individual Differences, 43, 1333-1343.

38.

McMurran

Huband

Overton

(2010). Non-completion of personality disorder treatments: A systematic review of correlates, consequences, and interventions. Clinical Psychology Review, 30, 277-287.

39.

McMurran

Theodosi

(2007). Is offender treatment non-completion associated with increased reconviction over no treatment? Psychology, Crime & Law, 13, 333-343.

40.

Monahan

Steadman

Silver

Appelbaum

Robbins

Mulvey

. . . Banks

(2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. New York, NY: Oxford University Press.

41.

National Collaborating Centre for Mental Health. (2009). Antisocial Personality Disorder: Treatment, Management and Prevention. Clinical Guideline 77. National Institute for Health and Clinical Excellence. Retrieved on December 14, 2011, from http://www.nice.org.uk/nicemedia/pdf/CG77NICEGuideline.pdf

42.

Novaco

R. W.

(2003). The Novaco Anger Scale and Provocation Inventory (NAS-PI). Los Angeles, CA: Western Psychological Services.

43.

Palmer

E. J.

McGuire

Hounsome

J. C.

Hatcher

R. M.

Bilby

C. A. L.

Hollin

C. R.

(2007). Offending behavior programs in the community: The effects on reconviction of three programs with adult male offenders. Legal and Criminological Psychology, 12, 251-264.

44.

Ross

R. R.

Fabiano

E. A.

(1985). Time to think: A cognitive model of delinquency prevention and offender rehabilitation. Johnson City, TN: Institute of Social Sciences and Arts.

45.

Sheldon

Howells

Patel

(2010). An empirical evaluation of reasons for noncompletion of treatment in a dangerous and severe personality disorder unit. Criminal Behavior and Mental Health, 20, 129-143.

46.

Simon

Czobor

Bálint

Mészáros

Bitter

(2009). Prevalence and correlates of adult attention-deficit hyperactivity disorder: Meta-analysis. British Journal of Psychiatry, 194, 204-211.

47.

Sonderstrom

Sjodin

Carlstedt

Forsman

(2004). Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: A central problem constellation in forensic psychiatry. Psychiatry Research, 121, 271-280.

48.

Tong

L. S.

Farrington

D. P.

(2006). How effective is the “Reasoning and Rehabilitation” program in reducing reoffending? A meta-analysis of evaluations in four countries. Psychology, Crime & Law, 12, 3-24.

49.

Tyrer

(2009). Primary article for discussion: Why borderline personality disorder is neither borderline nor a personality disorder. Personality and Mental Health, 3, 86-95.

50.

Tyrer

Mitchard

Methuen

Ranger

(2003). Treatment rejecting and treatment seeking personality disorders. Type R and Type S. Journal of Personality Disorders, 17, 263-267.

51.

Unnever

J. D.

Cullen

F. T.

Pratt

T. C.

(2003). Parental management, ADHD, and delinquent involvement: Reassessing Gottfredson and Hirschi’s general theory. Justice Quarterly, 20, 471-500.

52.

Walker

J. S.

(2005). The Maudsley Violence Questionnaire: Initial validation and reliability. Personality and Individual Differences, 38, 187-201.

53.

Yang

Coid

Tyrer

(2010). Personality pathology recorded by severity: National survey. British Journal of Psychiatry, 197, 193-199.

54.

Young

Adamou

Bolea

Müller

Pitts

Thome

Asherson

(2011). The identification and management of ADHD offenders within the criminal justice system: A consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry, 11, 32. doi:10.1186/1471-244X-11-32

55.

Young

Gudjonsson

G. H.

Ball

Lam

(2003). Attention deficit hyperactivity disorder (ADHD) in personality disordered offenders and the association with disruptive behavioral problems. Journal of Forensic Psychiatry & Psychology, 14, 491-505.

56.

Young

Gudjonsson

G. H.

Misch

Collins

Carter

Redfern

Goodwin

(2000). Prevalence of ADHD symptoms among youth in a secure facility: The consistency and accuracy of self- and informant-report ratings. Journal of Forensic Psychiatry & Psychology, 21, 238-246.

57.

Young

Gudjonsson

Wells

Asherson

Theobald

Oliver

. . . Mooney

(2009). Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population. Personality and Individual Differences, 46, 265-269.

58.

Young

Misch

Collins

Gudjonsson

(2011). Predictors of institutional behavioral disturbance and offending in the community among young offenders. Journal of Forensic Psychiatry & Psychology, 22, 72-86.

59.

Young

Wells

Gudjonsson

G. H.

(2011). Predictors of offending among prisoners: The role of attention-deficit hyperactivity disorder and substance use. Journal of Psychopharmacology, 25, 1524-1532.

60.

Young

S. J.

Ross

R. R.

(2007a). R&R2 ADHD for youths and adults: A prosocial training program. Ottawa, Ontario: Cognitive Centre of Canada. Retrieved from www.cognitivecentre.ca

61.

Young

S. J.

Ross

R. R.

(2007b). R&R2 for youths and adults with mental health problems: A pro-social competence training program. Ottawa, Ontario: Cognitive Centre of Canada. Retrieved from www.cognitivecentre.ca