Clients are referred to the STU by Prison Service sentence planning rules and Psychological Service Offices of Community and Probation Psychological Service (CPPS) offices throughout New Zealand.
Whist clients are in the unit waiting to commence the intensive program; they are placed in a ‘starter group’.
As we mentioned before, we were co-faciltators on the starter group programme with offenders. Knowing we had to complete research as partr of our professional treating we decided to study how ‘effective’ this starter group was. Over the past decade behavioral change has been of particular interest within the fields of addiction and offender rehabilitation but t here is little research into the effectiveness of brief interventions with offenders. So we wanted to use a stage based model to assess the effectiveness of the starter group that we developed as co-faciltiators.
Over the past decade behavioural change has been of particular interest within the fields of addiction and offender rehabilitation. As aforementioned. Research has sought to examine why people change and how this change occurs. Commonly asked questions within the field of rehabilitation is why and how do people change? Motivation and readiness have been linked to the concept of change as key factors in the process of WHY people change (Miller & Rollnick, 2002). It is because of this that researchers have investigated the exact role these factors play in treatment and what responsivity barriers these pose to intervention. Questions were asked as to HOW people change..let’s consider this...
There are many models to assess and describe the level and process of change for people (i.e. HOW), but one of the most influential is that of the TTM. This model suggests that people pass through a stages of ‘change’ and levels of motivation as they move to resolve a problem. It is an integrative framework used for decreasing unhealthy or risky behaviours. It incorporates several theories and intervention targets related to both cognitive and behavioural changes and has been used widely to understand treatment ‘readiness’ issues in offender populations. -Motivational readiness to change can be identified across differing stages Each stage represents a specific collection of attitudes, intentions, and behaviours that are typical of individuals at that stage (Prochaska & Norcross, 1999). Let’s look at this now..
Individuals are thought to pass through different stages throughout their change process... Pre contemplation = Contemplation = Preparation = Action = Maintenance = Each stage represents a specific collection of attitudes, intentions, and behaviours that are typical of individuals at that stage (Prochaska & Norcross, 1999).
-This construct has been successfully used to identify treatment targets across a wide range of problem behaviours, such as ... -Within the TTM there has been more evidence generated for the validity of the SOC construct and for its clinical utility, particularly within the field of addiction, than any other model (Norcross 2002a, 2002b).
First Point: However, the SOC construct has clinical utility in offender rehabilitation Second point: Furthermore, although limited, there is research to suggest that stage-based interventions using MI techniques can significantly increase the motivation of high risk violent offenders to complete more intensive rehabilitation programmes (Murphy & Baxter, 1997; Stewart, Hill & Cripps, 2000; Williamson, Day & Howell, 2004).
Point 1: Research has shown that SOC construct is not effective for long term behaviour change and has more utility is shorter term interventions. Point 2: It is not clear how long it takes for someone to pass from one stage of change to the other? (I.e. That it difference between individuals, and even within) Point 3: Self explanatory P oint 4: Offenders behaviour is too complex to be isolated into discrete stages and therefore would be better described in terms of a continuum (Drieschner, Lammers & Van Der Staak, 2004; Williamson et al., 2003).
Point 1: In the aforementioned study, offenders rated as low on motivation failed in their release plans sooner compared to those offenders who were rated as high motivation, who consistently performed better on release. In order to assess the effectiveness of this intervention, treatment gain also need to be considered. Assessing treatment gain in offenders is an important part of any programme evaluation in Corrections and can help one understand the extent to which one has benefited from participating in treatment.
In deciding which instrument to use to measure change, we considered ones which had been used in the past. Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996 ). This 20-item measure assesses readiness for change regarding alcohol abuse. The SOCRATES is believed to describe a motivational process rather than a series of stages. Another similar measure is the Readiness to Change Questionnaire (RCQ; Rollnick, Heather, Gold, & Hall, 1992). This 12-item measure was developed to assess readiness for change regarding alcohol use . University of Rhode Island Change Assessment (URICA) is the most widely studied measure of readiness for change (Sutton, 2001 ). Treatment Readiness, Responsivity and, Gain Scale: Short Version (TRRG:SV) by Serin, Kennedy & Milloux (2005) The Treatment TRRG:SV was specifically designed to assist staff working in Corrections, to systematically assess an offender’s readiness and responsivity to treatment and to subsequently measure any treatment gain. This measure of readiness and responsivity is thought to be critical in the process of determining treatment needs and placement. For example, offenders who score low on readiness and responsivity are thought to benefit from a treatment primer session(s) in order to prepare them for a treatment program with the goal of maximising the potential treatment gains (Serin et al., 2005). Treatment gain is used to provide an overall estimate of an offender’s performance in a correctional program. The TRRG:SV has been shown to have good internal consistency producing a Cronbach α > .67 (Serin, 1995) within an adult prison population.
Fill the gap between primary prevention efforts and more intensive treatment for persons with problematic behaviour. It is plausible that the primary impact of brief interventions is on motivation to change (Miller & Rollnick, 1991).
Selection Process participants drawn from a group of male offenders waiting to commence treatment in the STUs high intensity rehabiltiation programme. All male offenders. Placed on programme based on their RoCRoI score. The RoC*RoI is an actuarial measure that predicts an offenders risk of reconviction and re-imprisonment during a period of five years after release from prison. It is a measure used by the Department of Corrections and is a reliable and accurate predictor of serious recidivism ( Bakker, O’Malley, & Riley, 1999 ). Scores range from 0 – 1, the higher the score the higher the risk. Eligibility for the programme is determined by a RoC*RoI score of 0.7 or above.
A self-report measure for treatment readiness, responsivity and gain, was chosen for this study, the Treatment Readiness, Responsivity, and Gain Scale: Short Version (TRRG:SV) (Serin et al., 2005). This measure systematically assesses an offender’s readiness and responsivity to treatment and to subsequently measure the degree to which gains have been made. The questions on the TRRG:SV address three domains; treatment readiness, treatment responsivity and treatment gains. The treatment readiness domain captures an individual’s willingness to engage in the treatment process, The treatment responsivity domain represents potential responsivity factors in offender’s compliance with, and response to, therapeutic intervention and treatment programs in general. Treatment gain provides an overall estimate of an offender’s performance in the correctional program. Changes in these domains will be used to evaluate the effectiveness of this intervention in increasing the readiness of an individual to engage in treatment, respond to treatment and identify gains that the treatment has established. Procedure All participants signed consent to treatment. The same measure (TRRG:SV) was administered to participants both pre- and post-treatment. All self-report measures were administered in a group format, but completed on an individual basis. Inferential measures The Mann-Whitney U test was used to determine the differences (if any) between pre and post assessment scores of readiness and responsivity. Inter rater reliability The TRRG:SV questionnaires were scored by the two trained facilitators. A measure of the consistency of ratings given by the raters was carried out to check for consistency in the scoring.
To evaluate treatment effectiveness the change from pre-treatment to post-treatment for readiness and responsivity was compared for graduates of the starter programme. Table illustrates an overview of the mean scores across the two domains (Readiness and Responsivity) for pre- and post-treatment. It also highlights the average change scores for the eight participants who completed measures pre and post intervention. The mean overall treatment gain score for participants is also indicated. There is a general trend of improvement across all domains over time, with change being slightly greater in the Readiness domain.
The mean scores for each readiness and responsivity items pre- and post- treatment as well as the mean change score for each item are reported in this table. For each item, the possible range of scores is from 0 to 3; with 3 being the highest possible score The data in the table show a general trend of small improvements across both domains of readiness and responsivity. ‘Treatment Behaviours (which assesses the offenders motivation for treatment) showed the greatest improvement. Treatment behaviours include attendance at interviews, completing out of session work, compliance with treatment, and positive comments about treatment which improved over time. The only area where improvement wasn’t noted was with ‘Callousness’ (an individual’s concept of injury they have caused others), falling under the responsivity domain which deteriorated over time . .
Each individual’s performance in the correctional programme (Treatment Gain) is illustrated in the table. This domain measures the degree to which gains have been made and demonstrate an individual’s performance in the correctional programme. Possible gain scores range from 0 up to 3, with 3 indicating most gain. The table illustrates that gain was evident for each item. The data indicate that the largest areas of gain in participants was in those of ‘Emotional understanding’, a measure of how emotionally connected an individual is to the program content and treatment change requirement; and ‘application of skills’, this item considers the range of skills gained through group participation such as the use and confidence to participate in activities such as role plays.
One way to investigate the treatment effectiveness is to measure the significance of change over time in Readiness and Responsivity. To analyse the reliability of the observed differences in these domains, a Mann-Whitney U test was carried out.
There is substantial amount of research that indicates that drug taking in particular can reduce an individuals motivation and that substance use is proportionally high amongst high risk offenders (Wilson, 2004; Hammersley et al 2003, Byrne & Howells, 2000) The fact that offenders use illicit substances and present with an array of difficulties means that a brief intervention such as this one needs to address these issues which have an impact on ones readiness and responsivity to treatment. Or it could be useful to have a motivational group that addresses solely ones use of substance or gambling behaviour etc...
Of course these treatment plans are only suggestions because a person can move interchangeably through the stages of change. Therefore, a participant may present as being highly motivated one day and lacking in motivation the following day. It is important that facilitators keep this in mind when providing treatment and remain flexible to the ‘here and now’ needs of the participants. Further complicating the issue, is that participants may present at differing stages of change for different psychological problems. With this in mind, it appears that facilitators need to be cautious not to assume for example that because a participant is ready to address their intense anger problem that they are also ready to address their substance abuse
Small Sample Difficult to generalize findings and with small groups, findings can often be over estimated, leading to false positives or false negatives No matched control group The treatment group could not be compared to a group with no treatment which limited the conclusions that could be drawn. Self Report A disadvantage with this type of measure is participants may answer questions with a response that they assume to be more socially desirable or acceptable rather than what they actually believe. Difficult to score due some ambiguous or unrelated responses. Sutton With the TRRG:SV in particular, some researchers have argued that scores from the measure do not demonstrate sufficient convergent validity, and thus the scores are not adequately measuring the same underlying change process (for a review, see Sutton, 2001). No standardized manual for the delivery of this type of intervention. The facilitators were left to their own devices in terms of the sessions and therefore one has to question treatment integrity across studies. To compensate for this the facilitators of this study have since designed a manual (Appendix A) which outlines the contents, theoretical underpinnings, purpose and core learning’s of each session.
Stacked groups Finding differences in readiness and responsivity could have implications for the selection of individuals in the treatment groups. It could be possible to implement the idea behind ‘stacked’ groups. These can be used advantageously to encourage less ready members and solidify those who are more ready. The narratives of those who are at more advanced stages might aid those that are less motivated to build discrepancy and resolve ambivalence. Groups that are relatively equal in their advanced stages of readiness may also create a sense of self efficacy and mutual support. In contrast, groups equalized at less advanced stages might pose a particular difficulty through the strengthening of a deviant norm. Larger Sample The most salient suggestion for further research is to reattempt the current study using a larger sample size with a matched control group. This may lead to clearer outcomes in terms of change and it may allow more conclusive results to be drawn. A follow up study of the current group which examines whether participants change scores were indicative of their likelihood to complete more intensive treatment. This would help establish the longitudinal benefits of brief interventions. Investigate if group cohesion is more indicative of treatment completion than a participant’s stage of change.
Conclusive results could not be drawn, yet it is possible that a brief intervention may be helpful in increasing an individuals readiness to treatment. Further research may yield evidence to warrant the implementation of a brief stage-based motivational intervention in a prison setting
The effectiveness of a brief stage based intervention, Stacey Bowden and Katie-Marie Jervis
THE EFFECTIVENESS OF A BRIEF STAGE-BASED INTERVENTION Stacey Bowden and Katie-Marie Jervis
Overview <ul><li>Why people change </li></ul><ul><li>Stages of Change and Brief Interventions </li></ul><ul><li>Current research </li></ul><ul><li>Method </li></ul><ul><li>Results </li></ul><ul><li>Implications for treatment/further research </li></ul><ul><li>Conclusions </li></ul>
Puna Tatari -Special Treatment Unit (STU) <ul><li>Opened August 2008 </li></ul><ul><li>Puna Tatari is a AA/AB (low/medium) security unit </li></ul><ul><li>Nine month intensive rehabilitation program (STURP; Department of Corrections, 2007) for high risk offenders </li></ul><ul><li>Co-facilitation model </li></ul><ul><li>Offenders often placed in Starter Groups prior to treatment (approximately 8 weeks in length) </li></ul>
Starter group <ul><li>The main aims of the starter group are to: </li></ul><ul><li>Introduce participants to group activities </li></ul><ul><li>Motivate them to participate in group work </li></ul><ul><li>Increase cohesion </li></ul><ul><li>Increase skills in managing behaviour </li></ul>
The Effectiveness of a Brief Staged-Based Intervention <ul><li>Little research into the effectiveness of brief interventions with offenders; especially stage based ones </li></ul><ul><li>To evaluate the effectiveness of the starter group program: </li></ul><ul><ul><li>measures of readiness and responsivity to change from pre-treatment to post-treatment were compared for those prisoners receiving the starter group program </li></ul></ul><ul><ul><li>Treatment gain was also measured at post-intervention </li></ul></ul>
Introduction <ul><li>Background to behavioural change: </li></ul><ul><li>Why do people change? </li></ul><ul><li>(Miller & Rollnick, 2002) </li></ul><ul><li>How do people change? </li></ul><ul><li>(Prochaska & DiClemente, 1992 & 1998) </li></ul>
How People Change <ul><li>The Transtheoretical Model (TTM) </li></ul><ul><li>(Prochaska & DiClemente, 1992 & 1998) </li></ul><ul><li>Integrative framework intended to help develop effective interventions for a range of problem behaviours </li></ul><ul><li>The Stages Of Change (SOC) within the model is the key organizing construct </li></ul><ul><li>Motivational readiness to change can be identified across differing stages </li></ul>
Stage of Change construct <ul><li>Supporting research: </li></ul><ul><ul><li>Addiction (Velicer, Botelho & Prochaska, 1998) </li></ul></ul><ul><ul><li>Weight control (Logue, Jarjoura, Sutton, Smucker, Baughman, Capers, 2004; O'Hea et al, 2004) </li></ul></ul><ul><ul><li>Smoking cessation (Prochaska et al., 1998b) </li></ul></ul><ul><ul><li>Offender rehabilitation which, when applied within a therapeutic setting, has helped in decreasing such unhealthy or risky behaviours (Williamson, Day & Howell, 2004; Tierney & McCabe, 2002) </li></ul></ul>
SOC Construct and Offender Populations <ul><li>The SOC model has been widely used to understand treatment readiness in offenders referred for substance abuse and sexual offending </li></ul><ul><li>(Tierney & McCabe, 2002) </li></ul><ul><li>Stage-based interventions can significantly increase the motivation of high risk violent offenders to complete intensive rehabilitation </li></ul><ul><li>(Murphy & Baxter, 1997; Stewart, Hill & Cripps, 2000; Williamson, Day & Howell, 2004) </li></ul><ul><li>Additionally, the Criminal and Justice Institution (2006) has made recommendations for implementing stage-based interventions for high risk youth. </li></ul>
Limitations of the SOC Model <ul><li>Ineffective for long-term behaviour change (Adams & White, 2004) </li></ul><ul><li>Arbitrary nature of the timelines </li></ul><ul><li>Lack of distinction between stages (Sutton, 2001) </li></ul><ul><li>Offenders behaviour too complex? </li></ul>
Assessing Motivation and Measuring Change <ul><li>Research has supported the utility of the assessment of motivation in predicting risk in offenders (Stewart & Millson, 1995) </li></ul><ul><li>Motivation (low, moderate, high) amongst other factors has been related to release failure </li></ul>
Instruments for assessing therapeutic change and treatment gain <ul><li>Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996 ) </li></ul><ul><li>Readiness to Change Questionnaire (RCQ; Rollnick, Heather, Gold, & Hall, 1992) </li></ul><ul><li>University of Rhode Island Change Assessment (URICA) </li></ul><ul><li>Treatment Readiness, Responsivity and, Gain Scale: Short Version (TRRG:SV) by Serin, Kennedy & Milloux (2005). </li></ul>
Using Brief Interventions to Facilitate Change <ul><li>Brief interventions (15 sessions) have been proven to be effective and have become increasingly valuable in the management of individuals with problem behaviour </li></ul><ul><li>(World Health Organisation, 2001) </li></ul><ul><li>Studies have been conducted world wide to show that brief interventions are often as effective as more extensive treatments in enhancing both motivation and behaviour change: </li></ul><ul><ul><li>Drinking (Kahan et al., 1995; Wilk et al., 1997; Moyer et al., in press;) </li></ul></ul><ul><ul><li>Aggressive behaviour in students (Grossman et al., 1997) </li></ul></ul><ul><ul><li>Phobias (Ost et al., 2001) </li></ul></ul><ul><ul><li>Cannabis use (Martin et al., 2008) </li></ul></ul>
Method <ul><li>Selection Process </li></ul><ul><ul><li>Male offenders in STU </li></ul></ul><ul><ul><li>RoC*RoI > 0.7 </li></ul></ul><ul><li>Participant Demographics </li></ul><ul><ul><li>19 Male in total </li></ul></ul><ul><ul><li>Two samples over two time periods </li></ul></ul><ul><ul><li>Sample 1: 11 participants </li></ul></ul><ul><ul><li>Sample 2: 8 participants </li></ul></ul><ul><ul><li>The mean age of participants was 32 years old (range 18-53) </li></ul></ul><ul><ul><li>Sentences being served ranged from 2.8 years to 20.2 years </li></ul></ul>
Method <ul><li>Measures </li></ul><ul><ul><li>TRRG:SV by Serin, Kennedy & Milloux (2005) </li></ul></ul><ul><ul><li>Readiness, Responsivity and Gain </li></ul></ul><ul><li>Procedure </li></ul><ul><ul><li>Measure administered pre and post treatment </li></ul></ul><ul><li>Inferential Measures </li></ul><ul><li>Inter-rater Reliability </li></ul>
<ul><li>Scores Across all Domains for all Participants in Treatment </li></ul>
<ul><li>Mean Scores at Pre and Post Treatment for Readiness and Responsivity </li></ul>
<ul><li>Mean Treatment Gain scores for each Domain for the Final 19 Participants </li></ul>
Statistical Analyses <ul><li>Mann Whitney U test to analyse the reliability of observed difference in each domain </li></ul><ul><li>Trend of improvement from the pre- to post-treatment in Readiness was marginally significant (P < .05, two tailed test) </li></ul><ul><li>Trend of improvement for Responsivity was non-significant (P > .05, two tailed test) </li></ul><ul><ul><li>Although non-significance was found, the mean scores indicate that the trend of improvement was in the right direction; in that all but one item indicated improvement </li></ul></ul>
Discussion <ul><li>Programme Drop out </li></ul><ul><ul><li>Four (21%) participants dropped out of the programme </li></ul></ul><ul><ul><li>Two participants were removed from the unit because of drug involvement </li></ul></ul><ul><ul><li>One was removed because of underlying mental health issues that needed to be addressed first </li></ul></ul><ul><ul><li>One participant decided to exit the programme in hope of completing a more suitable programme centred on gambling addiction </li></ul></ul>
Implications for Facilitators in Later Treatment <ul><li>This study provided insight into individual treatment needs for each participant </li></ul><ul><ul><li>This allowed the STURP facilitators to design individual treatment plans for the participants prior to them commencing the STURP. </li></ul></ul><ul><li>Participants low scoring on the callousness, denial and treatment support subsections </li></ul><ul><ul><li>High risk participants have very entrenched beliefs related to their offending </li></ul></ul><ul><ul><li>Often see themselves as the victims which entrenches their denial </li></ul></ul><ul><ul><li>A goal for facilitators is to move offenders into a position of acceptance therefore making them more responsive to treatment </li></ul></ul>
Limitations <ul><li>Sample size </li></ul><ul><li>No matched control group </li></ul><ul><li>Self report questionnaire </li></ul><ul><li>Limitations of TRRG:SV (see Sutton, 2001) </li></ul><ul><li>No standardized manual </li></ul>
Where to from here? <ul><li>Stacked groups </li></ul><ul><li>Repeat study with more participants </li></ul>
Conclusion <ul><li>Readiness subscale showed significant changes and there was a trend in the right direction for responsivity </li></ul><ul><li>Further research </li></ul>