Evidence-based group therapy for specific offenses: Are we doing them, and doing them well?

Jaimee S. Mallion, Centre of Research and Education in Forensic Psychology, University of Kent
Nichola Tyler, Centre of Research and Education in Forensic Psychology, University of Kent; Forensic and Specialist Care Group, Kent & Medway NHS and Social Care Partnership Trust
Helen L. Miles, Centre of Research and Education in Forensic Psychology, University of Kent; Forensic and Specialist Care Group, Kent & Medway NHS and Social Care Partnership Trust; Institute of Psychiatry, Kings College London

Evidence-based practice (EBP) advocates that treatments offered to patients should be empirically supported and effective. Group-based treatment is offered in forensic mental health services as a way of assisting forensic patients (FPs) to address their offending behavior. However, little research exists examining how research and practice are integrated in these interventions, consistent with the principles of EBP. This study examined the utilization and evaluation of offense-specific group treatment programs with FPs, with a specific focus on interventions for substance misuse, sexual offending, firesetting, and violent offending. The results highlight that despite frequent use of offense-specific group interventions for FPs in UK forensic mental health services, evaluation is lacking regarding both published evaluations and through routine clinical practice. To ensure consistency with principles of EBP, recommendations are made surrounding the implementation of routine evaluations (e.g., follow-up studies) of offense-specific group treatment programs with FPs.

Evidence-based practice, what works, forensic mental health, offending behavior, group treatment

“Forensic mental health services are tasked with reducing forensic patients’ (FPs’) risk of reoffending, assessing, and treating their mental health needs, and promoting reintegration and recovery. Offense-specific interventions form an essential part of treatment in forensic settings, through addressing both the psychological and criminogenic needs of patients; consistent with the Risk Need Responsivity Model. Interventions abiding to these principles have been shown to have positive results at reducing recidivism.”p.114

“Due to the potential therapeutic and fiscal benefits of group treatment, offense-specific treatment groups are frequently utilized in UK forensic mental health services to address factors related to FP’s offending behavior. Although qualitative research suggests that there are potential benefits of group treatment for FPs, understanding the utilization and effectiveness of offense-specific group interventions for FPs is of critical importance.” p.144

“FPs present with a complex range of psychological, criminogenic, and mental health needs, which are likely to interact in terms of initiating and maintaining offending behavior. Subsequently, standardized group treatment programs developed for non-mentally ill offenders (e.g., in prisons) may not be suitable or adequate to address the needs of FPs and may require adaptation to provide specific focus on issues pertinent to this client group (i.e., the relationship between mental health and offending or risk behaviors). To address this, many forensic mental health services have taken to devising their own group treatment programs or adapting existing prison group treatment programs to target the specific needs of FPs.”p.115

Substance misuse group treatment programs.
“Of the 29 forensic mental health units, from which responses were included in the final analysis, 25 (86.21%) reported having provided group treatment for substance misuse in the past 5 years. The majority of group treatment programs were reported as having been developed “in-house” (n=20, 80.0%). Those services who had bought in manualized programs for group substance misuse treatment were predominantly using programs that were not originally developed for use with forensic patients (e.g., developed for prison populations, adolescents, dual diagnosis patients). All substance misuse group treatment programs were reported to be underpinned by a combination of empirically supported therapies (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectial Behavioral Therapy, Psycho-Education).”p.119

“…fifteen out of the twenty services who had developed and delivered group treatment programs “in-house” for substance misuse reported that they had not conducted any evaluation of the intervention’s effectiveness (75.0%). Of the five services which had conducted evaluations of their group intervention, two reported that this had consisted of examining within-treatment change on pre-post treatment psychometrics for group attendees. The other three services had either examined within-treatment change including a post-treatment psychometric follow up (n=1), examined abstinence rates following treatment (n=1), or had examined patients satisfaction with the group (n=1). Two of the five services who had conducted evaluations had published these.”p.119

Sexual offending group treatment programs.
“Eight out of 29 services (27.59%) reported having provided group treatment for sexual offending in the past 5 years. Individual treatment for sexual offending was reported as being more common than group treatment, with 17 units (58.62%) reporting providing treatment in this format. Of the eight services who reported providing group treatment for sexual offending, six reported having developed their group program “in-house” (75.0%). All sexual offending group treatment programs were reported to be underpinned by a combination of empirically supported therapies (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Psycho-Education).”p.119

“Only two of the services who had developed and delivered group treatment programs “in-house” for sexual offending had conducted an evaluation of the intervention’s effectiveness (25.0%) and only one of these provided details about their evaluation.”p.119

Firesetting group treatment programs.
“Nine forensic mental health services (31.03%) reported that they had previously provided group treatment programs for firesetting in the past 5 years and 12 (41.38%) reported that they had provided individual treatment for firesetting. Five secure units did not respond to this section of the survey (17.24%). Seven out of nine services who had provided group treatment for firesetting reported having developed their program “in-house” (77.78%). The two services that reported having bought in manualised programs for group-based firesetting treatment were using programs specifically developed for forensic mental health patients. All group treatment programs for deliberate firesetting, regardless of whether they were developed in-house or bought in, were reported to be underpinned by a combination of empirically supported therapies (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectiacal Behavior Therapy, Psycho-Education).”p.120

“Four out of nine of services who had developed and delivered group treatment programs “in-house” for firesetting reported that they had had conducted some form of evaluation of the program (44.44%). Of the four services who had conducted evaluations of their group intervention, two had joined together to lead a multi-site quasi-experimental evaluation (i.e., pre-post treatment change using psychometric measures with a treatment group and a comparison group), one had examined within treatment change on psychometric measures for those who attended the group as well as obtaining qualitative feedback from patients, and one other had conducted a qualitative examination of patients’ experience of the group.”p.120

Violent behavior group treatment programs.
“Seventeen services (58.62%) reported having provided group treatment for violent behavior in the past five years. Six units did not complete this section of the survey (20.69%). Ten out of seventeen services reported having developed their group treatment program for violent behavior “in-house” (58.82%). Seven services reported that they had bought in manualized programs for violent offending group treatment from an external source (41.18%); four of these reported using programs that had been specifically developed for use with FPs (57.14%). Violent offending group treatment programs were reported to be underpinned by an array of empirically supported therapies (e.g., Cognitive Behavioral Therapy, Motivational Interviewing, Dialectial Behavioral Therapy, Acceptance and Commitment Therapy, Mentalisation Based Therapy, Psycho-Education).”p.120

“Five services who had developed and delivered group treatment programs “in-house” for violent offending reported that they had evaluated the intervention’s effectiveness (50.0%) Of these five, three had examined within treatment change on psychometric assessments for group completers and one had examined if there was a reduction in violent incidents post treatment. One service did not provide any detail of the methods used to evaluate their intervention. All programs which had been bought in had been subject to external evaluation.”pp.120-121

“EBP [Evidence-based practice] comprises of three key tenets: (1) identifying and integrating the best research evidence as to whether and why a treatment should work (e.g., using empirically supported therapies, using the best theoretical and empirical evidence to guide treatment content/targets, evaluating the effectiveness of the intervention); (2) using clinical experience and expertise when applying research to practice, particularly in under-researched areas; and (3) incorporating client’s values and therapeutic preferences (e.g., responsiveness, engagement, whether individual or group treatment is more appropriate)”p.114-115

“the lack of evaluation of offense-specific interventions for FPs means that practitioners working in these settings have little guiding information as to “what works” with this client group and therefore do not have an empirical evidence base upon which to base their practice.”p.121

“Together the findings of the current study suggest that at present offense-specific treatment for FPs is not sufficiently consistent with the principles of evidence based practice.”.p.122

“Research has identified several common barriers to engagement in EBP including: negative beliefs about EBP and its value in clinical practice (e.g., it restricts individuality), lack of training in EBP and its application, the cost of purchasing EBP materials (e.g., manuals, training packages, new technologies), the lack of inclusion of research in performance targets along with time and funding for such activities, and a lack of awareness of what evidence based products are available. Given these barriers, it is imperative that commissioners, practitioners, and academics working in forensic mental health come together to address these barriers to ensure offense-specific group treatment is both evidence based and is effective in terms of generating positive outcomes for FPs.”p.122

“Future research should explore the possibility of conducting multi-site research to increase sample sizes to achieve statistical power. Further, future research evaluations should adopt rigorous high quality methodological designs since evaluations employing lower quality research designs (e.g., below Level 3 on the SMS) have been found to be weaker in terms of internal validity and potentially biased in their outcomes (i.e., more likely to report a favorable treatment effect).p.122

“Good quasi-experimental designs (either basic or controlled) provide the most feasible high-quality evidence of a program’s effectiveness. Inclusion of a follow up period to examine reoffending rates post-treatment will also enable a more holistic examination of long-term effectiveness as opposed to short-term within treatment change”.p.123

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