UNDER WHAT CONDITIONS SHOULD A TREATMENT BE EVALUATED Professor Sheilagh Hodgins

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UNDER WHAT CONDITIONS SHOULD A TREATMENT BE
EVALUATED?Professor Sheilagh Hodgins
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AN EVALUATION OF A TREATMENT IS COSTLY AND TIME
CONSUMING

• There must be good reasons to think that the
  knowledge produced will advance understanding of
  how to bring about change in the patients being
  studied.
• Otherwise, findings contribute to a nothing
  works ideology that undermines all efforts at
  promoting change.
• Perhaps evaluations should be undertaken only if
  the principal investigator is willing to wager
  his/her own money that the intervention will be
  associated with positive change in the patients!

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THE PATIENT-OFFENDERS WE WANT TO CHANGE

• A small group of men commit approximately 70 of
  all violent crimes.
• These men present multiple characteristics that
  drive and support criminal offending that have
  been present since early childhood.

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DISORDERS AND CHARACTERISTICS THAT UNDERPIN
ANTISOCIAL AND CRIMINAL BEHAVIOUR

• Individual characteristics persisting from age 2
  or 3
• Antisocial and aggressive behaviour
• Personality traits
• Sensation seeking, novelty seeking
• Lack of guilt, deficient affective experience
• Fearless
• Low verbal IQ
• Lowered stress reactivity
• Developmental delays
• Motor functioning
• Memory
• Vocabulary

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THESE DISORDERS AND CHARACTERISTICS ARE
STRENGTHENED IN THE EARLY YEARS BY THE FAMILY
ENVIRONMENT

• Parents are often antisocial or criminal
  themselves
• Parents fail to appropriately and adequately
  track and sanction the young childs behaviour
• Parents engage in harsh, inconsistent discipline
• Parents reject the child relatively early
• Parents lack personal resources to confront a
  persistently disobedient child and are unable to
  access effective help

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THESE DISORDERS AND CHARACTERISTICS ARE
STRENGTHENED BY THE SOCIAL ENVIRONMENT

• Rejected by peers from a very early age
• Excluded from opportunities to learn
• academic skills and pro-social skills
• Live in neighbourhoods where criminality
• is common and has a certain legitimacy,
• and where illicit drugs and weapons are
• accessible. Such neighbourhoods have a
• greater negative impact on boys with, than
• without, the traits named previously.

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Neighbourhood Nursery
Family Environment
Individual Characteristics
Early Middle Adolescence Young Middle Childhoo
d Childhood Adulthood Age
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Neighbourhood School
Family Environment
Individual Characteristics
Early Middle Adolescence Young Middle Childhoo
d Childhood Adulthood Age
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Neighbourhood School
Family Environment
Individual Characteristics
Early Middle Adolescence Young Middle Childhoo
d Childhood Adulthood Age
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Neighbourhood Work
Family Environment
Individual Characteristics
Desistence
Early Middle
Adolescence Young Middle Childhood Childhood
Adulthood Age
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Neighbourhood Work
Family Environment
Individual Characteristics
Desistence
Early Middle
Adolescence Young Middle Childhood Childhood
Adulthood Age
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Neighbourhood Work
Family Environment
Individual Characteristics
Early Middle Adolescence Young Middle Childhoo
d Childhood Adulthood Age
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Neighbourhood Work
Family Environment
Individual Characteristics
Intervention
Early Middle Adolescence
Young Middle Childhood
Childhood
Adulthood Age
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• A PATTERN OF PERSISTENT ANTISOCIAL BEHAVIOUR
  ATTITUDES
• ?
• PERSONALITY TRAITS
• (and the underlying neurobiology associated with
  the traits)

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PERSONALITY TRAITS ARE STABLE!

• Longitudinal investigations of large samples
  examined over decades confirm the stability of
  personality traits.
• These investigations have shown that the
  traits do not change even following major life
  events.

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AVAILABLE KNOWLEDGE SUGGESTS

• Personality traits are resistant to change
• Behaviours and attitudes may be more amenable to
  change, despite being associated with the traits
• Offenders present multiple behaviours and
  attitudes that support and promote criminality
• These behaviours and attitudes have been present
  since an early age
• Consequently, changing these behaviours and
  attitudes will require intense and prolonged
  treatment.

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BEFORE EMBARKING ON AN EVALUATION OF AN
INTERVENTION, ASK THE FOLLOWING QUESTION

• Given what is known about the offender
  population, is it likely that the intervention
  will effect change?
• Does the intensity and duration of the
  intervention take account of the multiplicity and
  severity of the problems and disorders presented
  by the offenders?

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• Is it reasonable, for example, to think that CBT
  offered twice a week for three hours during four
  months inside a security hospital or a prison
  will change antisocial and/or criminal behaviour?

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A TREATMENT PROGRAMME

• Multiple components each targeting a specific
  problem or characteristic
• A milieu that participates in the change
  process
• Intensity, structure, and time
• Community placements that support the change

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A TREATMENT PROGRAMME

• Multiple components each targeting a specific
  problem or characteristic
• There may be certain problems that have to be
  dealt with before others can be tackled.

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A TREATMENT PROGRAMME

• A milieu that participates in the change process
• Organizing and training institutional staff to
  understand and support change
• Big Problem! Research has consistently shown that
  housing and/or treating antisocial individuals in
  groups fosters antisocial behaviour and impacts
  negatively on positive change!

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A TREATMENT PROGRAMME

• Intensity, structure, and time
• The multiplicity of the disorders and
  characteristics that underpin antisocial and
  criminal behaviour
• The presence of these characteristics and
  behaviour patterns since an early age

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A TREATMENT PROGRAMME

• Intensity, structure, and time
• The multiplicity of the disorders and
  characteristics that underpin antisocial and
  criminal behaviour
• The presence of these characteristics and
  behaviour patterns since an early age

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A TREATMENT PROGRAMME

• Community placements that support change
• Little crime
• No old mates with whom they engaged in criminal
  activities
• No illicit drugs
• Employment

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WHEN THESE CONDITIONS HAVE BEEN MET, IT IS TIME
TO THINK ABOUT AN EVALUATION STRATEGY

• RCTs with each component of treatment
• ? Outcome learning what was taught or absence
  of antisocial and criminal behaviour
• Profiles of patients who benefit and who do not
• Studies to identify the order of components that
  produces the best outcome
• Access to the real world
• An environment that will support the change
• An environment where new behaviours can be
  practiced
• Measuring the impact of the programme
• on official criminality
• on hidden criminality (wife abuse, child abuse,
  elder abuse, stealing and parasitic lifestyle)

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PRESENTLY,

• RCTs with each component of treatment
• ? Outcome learning what was taught or absence
  of antisocial and criminal behaviour
• ? Profiles of patients who benefit and who do not
• Studies to identify the order of components that
  produces the best outcome
• Access to the real world
• An environment that will support the change
• An environment where new behaviours can be
  practiced
• Measuring impact of the programme
• on official criminality
• on hidden criminality (wife abuse, child abuse,
  elder abuse, stealing and parasitic lifestyle)

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CONCLUSIONS

• RCTs and other methodologies for evaluating an
  intervention are simply tools. These tools need
  to be applied in an intelligent manner taking
  account of the available evidence about the
  population to be treated.
• Given what is known about patient-offenders,
  change can be expected from multiple component
  treatment programmes that are intensive and
  lengthy.
• In order that change is maintained, booster
  interventions and support will be required, for
  lengthy periods, in a community environment that
  supports pro-social behaviour.