Transcript Readiness for treatment: Work in progress

Readiness for treatment in
forensic populations
Professor Kevin Howells
Division of Psychiatry, University of Nottingham
Peaks Academic and Research Unit, Institute of Mental
Health
Rotterdam, April 2008
Summary of talk
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Why readiness? Anger interventions studies
Non-completion and drop-out
Impediments to readiness
The MORM model
Recent Readiness measures
CVRTQ data
Readiness in Personality Disorder
Program and organisational readiness
How get to be interested?
• Anger management evaluation studies
• Paradox: good outcomes for clinical pops.
• Own studies: doesn’t work for serious offenders.
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Why not? Multiple pathologies? low program
integrity? Too brief? Low engagement? Low
readiness?. Impediments .
Readiness measures have a significant though
modest correlation with change scores.
How to measure? How to understand?
The problem
• Offenders/patients often fail to complete or fully
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engage in treatment
Low engagement defined by attendance,
cooperation within and between sessions,
willingness to discuss problems, contributions
between sessions – homework, rejecting and
over-critical behaviour in sessions, failure to
complete the program
• See Driescher, Lammers and van der Staak (2004)
The problem contd.
• Non completion and low engagement are
common in forensic programs
• E.g Heseltine et al for anger
management.
• Non-completion may be self, program or
administratively initiated
The problem (contd)
• Non completion and low engagement associated with
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poor outcomes (recidivism), low institutional support for
programs, diminished staff morale, poor audit outcomes
for services
McMurran and Theodosi (2006) reviewed 16 studies
comparing non-completers and untreated. Concluded
“non-completers of both institutional and community
programmes are more likely to recidivate than
untreated”
However the causal mechanisms involved are unclear
and methodological limitations exist for many studies
Readiness for treatment
• Explored in relation to particular
populations and treatment (eg substance
abuse, anger problems)
• Rarely addressed empirically in PD
populations
• Readiness factors influence engagement
and completion and ultimately treatment
outcomes
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1. Howells, K. & Day, A. (2003). Readiness for anger management: Clinical and
theoretical Issues. Clinical Psychology Review, 23, 319-337.
2. Day, A., Bryan, J., Davey, L., & Casey, S. (2006). Processes of change in
offender rehabilitation. Psychology, Crime and Law, 12 (6).
3. Day, A., Tucker, K., & Howells, K. (2004). Coercing offenders into treatment,
Psychology, Crime and Law, 10, 259-269.
4. Williamson, P., Day, A., Howells, K., Bubner, S. & Jauncey, S. (2003).
Assessing offender motivation to address problems with anger. Psychology,
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Violent Behavior.
Crime and Law, 9(4), 295-307.
5. Casey, S., Day, A., & Howells, K. (2005). The application of the transtheoretical
model to offender populations: Some critical issues. Legal and
Criminological Psychology. 10, 1-15.
6. Ward, T., Day, A., Howells, K., & Birgden, A. (2004). The multifactor offender
readiness model. Aggression and Violent Behavior, 9, 645-673.
7. Chambers, J.C., Eccleston, L., Day, A., Ward, T., & Howells, K. (in press). Treatment readiness in violent
offenders: The influence of cognitive factors on engagement in violence programs. Aggression &
8. Howells, K. & Day, A. (2006). Affective determinants of treatment
engagement in violent offenders, International Journal of Offender
Rehabilitation and Comparative Criminology. 50, 174-186.
9. Howells, K. & Day, A. (2007). Readiness for treatment in high risk offenders
with personality disorders. Psychology, Crime and Law: Special Issue: High
risk offenders with personality disorders: Conceptual and scientific bases. 13, 47-56.
10.Casey, S., Day, A., Howells, K., & Ward, T. (2007). Assessing suitability
for offender rehabilitation: Development and validation of the Treatment
Readiness Questionnaire. Criminal Justice and Behavior, 34, 1427-1440.
11. Heseltine, K., Howells, K. & Day, A. (submitted). Anger management with offenders: Effects of readiness and
Background ideas
• Distinguishes motivation, responsivity and
readiness
• Motivation and responsivity are narrower
concepts
• Readiness is more inclusive and
incorporates the other two terms:
specifies conditions for treatment
engagement
Definition
• “ The concept of readiness can be broadly
defined as the presence of characteristics
(states or dispositions) within either the
client or the therapeutic situation, which
are likely to promote engagement in
therapy and which, thereby, are likely to
enhance therapeutic change”
• Howells and Day (2003)
Readiness model
MORM assumptions
• Readiness is function of both internal
(person) factors and external (context
factors) which interact
• Engagement is generally, though not
universally, a predictor of change (a
reduction) in criminogenic and other
clinical needs
Internal readiness conditions:
cognitive
• Attitudes, beliefs and patterns of thinking eg hostile
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beliefs and attributions, low trust
Expectations of therapy, outcome expectancies (may be
based on previous experience)
Perceptions of and beliefs about therapists
Self-efficacy, beliefs about personal change
Attitudes to treatment in a criminal justice context
Beliefs about costs/benefits of treatment cf Health Belief
Model
• See Drieschner et al (2004) for a similar view
Affective
• Distress – initial moderate level has motivating characteristics
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(Beutler et al, 2000)
Emotional reactions to offence and identity as “offender” or
“psychopath” or “dangerous”– ego dystonia
Shame, guilt and remorse (Proeve and Howells, 2005, 2007). The
action tendencies associated with guilt : apologizing, undoing and
repairing damage. Shame: hiding from others, may reduce
readiness
Absence of affective responses (see psychopathy) diminish
readiness
Excessive emotional reactions – dysregulation in Borderline PD
For review see Howells and Day (2006)
Behavioural factors
• Problem recognition (affected by cultural
norms – see prisons)
• Help-seeking (belief they cant change if
unaided)
• Possession of behavioural and cognitive
skills – literacy? verbal ability? Confidence
in groups? Role playing?
Volitional factors
• Intention to pursue particular goals –motivation.
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See Paul Karoly’s goal system theory.
Content (topography) of goals, how goals are
organized and pursued.
Levels of awareness of goals –latent and
phenomenological.
Client goals incompatible with explicit or implicit
goals of the therapy program -> low readiness
Goal attainment deficiencies -> low readiness
Personal identity factors
• Goal priorities/values constitute identity.
Personal identity as a patient, an offender,
a psychopath, a man etc. Alternative
identities available to sustain change?
• Cultural factors – eg Indigenous status
Anger in indigenous men. Day,
Nakata and Howells (2008)
Federation Press
• Over-representation 20% versus 2%
• High violence and anger levels
• 600 different cultures
indigenous
• Anger as uncontrollable
• Anger not differentiated from negative
emotions
• Anger not differentiated from violence
• Anger as intergenerational
• Anger linked to trauma
Indigenous aspects
• Themes of
• Loss
• Family
• Discrimination
• Alcohol
• NEED TO CONTEXTUALIZE TREATMENT
External readiness conditions
• Mandated versus voluntary treatment
• Objective and subjective aspects.
• Perceived level of coercion may be
important in reducing readiness.
• Timing of coercion – eg at the end of a
sentence eg Peaks Unit
• Support factors –family and staff
PD offenders
• Hodge and Renwick (2002)
• “there has been a remarkable lack of consideration given
to the factors underpinning mentally disordered
offenders’ motivation for engagement and participation
in the treatment process…this disregard of motivational
matters occurs despite the fact that…these factors often
bear heavily on clinical decision-making regarding critical
issues such as continuing detention and perceived
dangerousness…examination of motivational issues in
this population is long overdue” (p221)
• DSPD services
How might PD or DSPD influence
these readiness factors?
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Psychopathy
Commonly construed as treatment resistant
Affective deficits – low guilt or remorse
Behavioural deficits – impulsivity, conning, lying
Interpersonal deficits – difficulties in relating to
therapists and group members
Cognitive deficits – low responsibility
Etc etc
See Hemphill and Hart (2002)
Psychopaths and other PDs
• Hemphill and Hart (2002)
• Psychopathic offenders are more likely to be
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disruptive in treatment, more likely to drop out
of treatment, struggle to form therapeutic
alliances:
“psychopathic offenders might further resist
help if they perceive a power differential
between the therapist and themselves and view
therapy as an affront to their attempt to seek
and exert status and influence” p23 ( a
volitional/goal abnormality?)
Gill Attrill et al (HMPS Violent
psychopathic offenders program,
2004): findings
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Need for control and choice impaired engagement
Perceived coercion
Status/power needs
Novelty/excitement needs
Treatment perceived as not relevant to goals
Competitiveness needs
High levels of treatment interfering behaviours in high
PCL-R scorers
• Most of above are volitional/goal readiness deficits
Other PDs – readiness issues
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Low malleability
Co-morbidity with Axis 1 disorders
Stigma – expectations of untreatability
Tyrer et al (2003) “treatment seeking” versus
“treatment rejecting” PDs
Therapeutic Alliance seen by Livesley (2001) as
a precondition for change
Livesley: problem-recognition, self-observation
and self-monitoring deficits – need to be
addressed early in therapy
PD readiness issues
• Schema associated with PDs may impair
readiness
• e.g. “I cannot function without the
support of others” (Dependent PD)
• “I am more special than anyone else”
(Narcissistic PD)
• “Rules are meant for others” (Antisocial
PD)
Cognitive deficits
• St Ledger, Mooney and Cooper (2007)
• Report a range of memory, linguistic and
attentional problems in Peaks population
• How typical?
• Setting up a ward to focus on these
deficits as precursor for treatment
• Tailored educational inputs/modification of
treatment protocol
Program and organizational
readiness
• Program readiness = the Responsivity Principle
• Organisational factors impeding readiness (after
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Hodge and Renwick, 2002, Ginsburg and others)
Perceived lack of safety
Failure to achieve therapeutic milieu
Lack of facilities
Security versus therapy disputes
Adversarial staff-offender relationships in prisons
Non collaborative relationships with prisoners
Pejorative labels – a psychopath
Reinforcement of non-engagement by peers
Readiness of the treatment
environment
• Obstacles to treatment in institutions
• Therapy may not be the therapeutic goal
(prison culture) – culture change and
maintenance are major challenges, not
only in prison but also in forensic mental
health
Monitoring therapeutic climate
• Schalast’s EssenCES measure (Schalast et
al, 2008, Criminal Behaviour and Mental
Health)
• Measures 1) therapeutic hold 2) Mutual
support 3) Safety
Comparison of DSPD and PD Means
Social Climate Means for PD and DSPD
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MEANS
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DSPD March 06
DSPD Oct 06
PD Dec 06
15
10
5
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Essen Safety
Essen Cohesion
Essen
Therap/Hold
Wes
WAAM
GMI
DSPD March 06
8.51
7.66
12.73
20.17
25.06
11.31
DSPD Oct 06
10.22
8.35
13.88
13.22
27.61
12.19
PD Dec 06
11.66
10.76
14.37
12.52
29.89
13.69
MEASURES
Clinical Examples of low readiness
in DSPD (Howells and Tennant,
2007)
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“During his time in prison he was accepted onto
various treatment programmes, but never completed
any” (said of a particular patient){confirms previous
engagement problems and negative expectances}
“On admission to hospital some patients/inmates do
not perceive themselves to have mental health
problems (they are not mad) and therefore (believe
that they) should not be in a health care setting. To be
labelled a patient and be ‘nutted off ’ is a profound
experience, as is being cared for by nurses rather than
prison officers” {identity impairing readiness)
Clinical examples
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“Feeling physically and emotionally safe (is important).
Providing an effective structure to the day is important
for both staff and patients. External controls provided
by the ward regime and rules provide a psychological
internal locus of control. Although patients often
complain bitterly about abiding to rules and
regulations, on further exploration they say they feel
safe. If patients are secure in their knowledge that
staff will deal with inappropriate behaviour then this
may enhance their willingness to engage” {ensure a
treatment-supportive climate in the setting}.
Clinical examples
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“If the person can demonstrate that they are not treatable and
do not engage in therapy, then the hospital should release them,
on the grounds of untreatability ? If patients invest in this belief
and hope that this may help them to be released, then attempts
by clinicians to engage individuals is often met with hostility as
they believe their solicitors will get them out.” {goal is release
rather than to obtain treatment}
“Certain individuals can have a profound effect on others and on
their motivation to engage in the treatment process. What is
valued by some patients is this masculine mystique of being
tough, strong, not losing face and not complying with those in
authority. An uncritical, narrow and rigid concept of masculinity”
{identity, in this case ,exaggerated masculinity, impairs readiness}
examples
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“Individuals can find it re traumatizing to listen to others’
narratives of both abuse and offending behaviour. Resentment,
fear, and shame are just some of the emotions that are
experienced during some group therapy sessions. Afterwards
individuals are sometimes fearful of their own disclosures and are
frightened for their own physical safety”. {affective reactions
impair readiness}
“Individuals with high IQs quickly get bored and become
problematic or mischievous towards others if they are not been
stimulated educationally Likewise those who have learning
difficulties may drop out, to not lose face” {{low program
readiness and responsivity to patient characteristics}
Clinical examples
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“Patients are assessed and their treatment needs are identified
and their treatment plan is neatly presented. Their part in this
process is to agree that they require this particular intervention
and turn up. Clinicians explain how this treatment may help them
in their future. The process begins; the individual attends the
session, doesn’t like particular group members, finds some of the
content boring and quits. His case is reviewed by his clinical team
and a discussion takes place about his drop out. Individuals
naturally try and persuade him to continue, without success. Six
months later a referral takes place for either the same treatment
or to try something else and the process begins again, with half
hearted agreement”. {a nice summary of the sometimes
dispiriting realities of dealing with low engagement in this setting}
Clinical examples
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“Pre-commitment and motivational work is a pre requisite before any type of
formal group work. Clinicians can then individually assess what factors will hinder
and help progress. Individual learning styles should be considered as some
respond better to different styles and methods of delivery”{ensure readiness and
responsivity of the treatment programme itself}
“Previous experience of therapy should also be explored; for some this may have
been aversive. It is important to have these discussions, to explore anxieties and
fears, to ensure the same thing does not happen again” {address negative
cognitive expectancies which impair engagement}
“Feeling physically and emotionally safe (is important). Providing an effective
structure to the day is important for both staff and patients. External controls
provided by the ward regime and rules provide a psychological internal locus of
control. Although patients often complain bitterly about abiding to rules and
regulations, on further exploration they say they feel safe. If patients are secure
in their knowledge that staff will deal with inappropriate behaviour then this may
enhance their willingness to engage” {ensure a treatment-supportive climate in
the setting}.
examples
• “Previous perceived failure should be
analyzed in detail to discover what
factors impeded progress. Many
individuals are ill prepared to go into any
type of group setting without
preparation.” {deal with negative
cognitive expectancies}
Assessing readiness factors
• Modalities: self-report Qs, interviews, case
history, ratings by staff etc
• For an excellent overview of linking
motivational factors to clinical assessment
see Lawrence Jones (2002)
• Some measures from an ARC study
ARC study measures:
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Multifactor Treatment Readiness Interview
Multifactor Readiness Scale
Serin Treatment Readiness Scale
Serin Treatment Performance Scale
Readiness to change questionnaire
Processes of change questionnaire
Working Alliance Inventory
Loza-Fanous Self-Efficacy Questionnaire
MacArthur Perceived Coercion Scale
CV Treatment Readiness Qre
• 40 item self-report
• Derived from MORM categories
• In a recent study of 166 offenders in
Cognitive Skills programme CVRQ showed
acceptable convergent validity (LozaFanous; Processes of Change Q.; Serin
Readiness Scale etc)
CVTRQ (contd)
• Good discriminant validity (Paulhus Deception
Scale)
• Predictive validity (measures of engagement and
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performance in the treatment program)
Factor structure: a) Attitudes and Beliefs about
programs b) Emotional responses to own
offending c) Beliefs about personal responsibility
for offending d) Perceived ability to participate in
the programme
CVTRQ – Violence version
• Day, Howells, Casey et al (in press)
Journal of Interpersonal Violence
In summary
• Low engagement and non-completion are
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important issues
They have adverse effects on outcomes
The Readiness factors include internal and
external readiness variables
Motivation is one component of readiness
PD and DSPD often impair readiness, in ways
that are consistent with MORM variables
Readiness needs addressing at multiple levels –
clinical assessment, intervention and research
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Assessment and therapeutic questions related to readiness
How does the patient perceive the therapeutic program?
Does the patient believe he or she is capable of change?
How does the patient perceive the therapeutic staff and the system?
What expectancies has the patient acquired, e.g. from previous exposure to therapy?
What is the patient’s affective state?
What emotional reactions does s/he have to their offending and other related problems?
What are the personal goals of the patient?
Are personal goals congruent with the goals of the program?
What is the self identity of the patient and is it compatible with treatment?
Does the patient have the behavioural and cognitive skills required by the program?
Does the patient have the capacity to form a therapeutic alliance?
What support is given by staff and other patients for therapeutic engagement?
What support is given by relatives and friends for therapeutic engagement?
How does the patient perceive coercion into treatment?
Has the program been adapted for the (DSPD) population?
Is the climate of the service supportive of engagement, therapy and of change?
contacts
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