THIS CHAPTER PRESENTS A BRIEF OVERVIEW of the scientific evidence in support of alternatives to crime control. While research continues to clearly indicate that the U.S. policy of severe punishment is ineffective, including three National Academy of Sciences Panels (Blumstein, Cohen, and Nagin 1978; Blumstein et al. 1986; Reiss and Roth 1996) as well as the research reviewed in chapter 2, the United States steadfastly plods down that road. It is time to rethink this.
There is a clear need for incarceration for those offenders who pose monumental risks either through their offending or through the inability of our best rehabilitative efforts to change their behavior. For these individuals, incarceration (incapacitation) is an appropriate sentence; thus, prisons are clearly necessary. But let’s also be clear why we have them. They should not be used as or promoted as correctional facilities. Prisons have one primary purpose and that is to separate offenders from the public. It is time to be honest about what prison can and cannot achieve. So this is not a discussion about closing U.S. prisons. It is about using fewer prison resources more wisely, while reducing crime.
For those offenders that are not incarcerated, the direction that the evidence indicates is appropriate is an approach emphasizing a balance between behavioral change on the one hand and risk management, compliance, and accountability on the other. Many criminal offenders come to the justice system with a variety of deficits, impairments, disadvantages, and circumstances that are related to their offending. Thus, part of the direction forward is a concerted and comprehensive effort to effectively change behavior. For those, I propose efforts at behavior change through diversion, intervention, treatment, and rehabilitation, and risk management and compliance through smart sanctioning based on swift and certain punishment, supervision, and accountability.
Efforts should be focused on the implementation of programs, policies, procedures, and interventions that have passed scientific muster as effective in changing criminal behavior (evidence-based practices). The good news is that in 2014, we know, and have known for at least twenty years, that there are effective alternatives to punishment and control, effective both in terms of outcomes and cost. And over time, we learn more and more. We have the tools to significantly impact crime and recidivism. The first step is to sketch out the road map and demonstrate the effectiveness and cost-effectiveness of these alternatives. That is what the next five chapters are about. The second step is to understand the barriers and challenges to implementing these policies on an appropriate scale, and then to develop strategies for addressing these barriers and challenges. I will turn to these issues in the concluding chapter.
While there are exceptions to the norm of punishment, these efforts at behavioral change often involve just going through the motions, only loosely approximating anything with any evidence-based validation, and involve incredibly low standards for “success.” Judge Marcus describes an often too accurate picture of what this process looks like in practice (Marcus 2003: 770):
That this is symmetry rather than science—that we cannot cite these practices as evidence of a responsible pursuit of crime reduction—is obvious from these circumstances: we never ask the programs whether their graduates reoffend; we make no effort to determine which offenders actually benefit and which do not. Instead, we are satisfied when programs communicate effectively with the system to document completion—which we deem “success”—or indicate failure (regardless of any lack of recidivism). Because we make no effort to track the impact of these sentences on criminal behavior, we fail to motivate the programs to compete on the basis of crime reduction; we fill many with offenders they cannot improve, fail to send many offenders to programs that would work for them, sustain some programs that work on no one, and—worst of all—fail to preserve some programs remarkably good at crime reduction. Like “reformation” in general, programs are simply part of the liturgy of the sentencing mantra, rather than a responsibly deployed strategy to serve public safety.
What Judge Marcus is describing is not a lack of information or scientific evidence or evidence-based practices. What he is describing is the disconnect between what we know and how we use it. It describes the inappropriate and inadequate application of “what works.” It describes going through the motions without a serious intent to actually produce measurable results. The failures to adequately address recidivism and crime are not due to a lack of knowledge of what to do, but a failure to fund and properly implement what we do know.
The point is simple, but tremendously important. Knowing what works is necessary, but not sufficient to reduce crime and recidivism. We must also properly implement what we know on a scale that produces measurable impacts on the big picture of crime and recidivism. Let me reinforce this point by way of example. I, in collaboration with a couple dozen or so other stakeholders, was involved in developing a community court. We assessed all of the evidence regarding what such a court should look like, we conducted needs assessments, we consulted with leading experts on community courts, and we took approximately eighteen months to design the court. The court was funded (well below our estimates, but funded nevertheless) and launched in 1999. For the next ten years, it was a dismal failure. The failure was largely due to one significant error in hiring. The individual selected by the city administration to be the court administrator did not understand or embrace therapeutic jurisprudence; he did not believe in rehabilitation. For ten years, he essentially ran the court as a criminal court, and repeatedly gave rehabilitation funds back to the city, which kept his supervisor (the city manager) happy with his performance. While the process of designing the court was quite deliberate and research informed, the effort failed because of a significant flaw in implementation.
So we have to get it right. We have to design it properly, we have to implement it according to the evidence, we have to operate it as designed, we have to evaluate it on a regular basis, then we have to make the changes indicated by the evaluations, and we have to fund it at a level at which it becomes meaningful in terms of crime reduction. Too often, such initiatives have more symbolic value than substantive impact. Drug courts are very popular in the United States, and we know that they work. The problem is that despite their prevalence, drug courts are very limited in terms of capacity, and overall address approximately 5 percent of the need. It is the unfortunate reality today that alternatives to punishment tend to have symbolic significance rather than constitute a primary component of efforts to address crime and recidivism.
THE PRINCIPLES OF EFFECTIVE CORRECTIONAL INTERVENTION AND EVIDENCE-BASED PRACTICES
The evaluation results of effective correctional rehabilitation, treatment, diversion, and intervention started becoming mainstream (mainstream meaning not just academic, but available to and accessible by practitioners and policymakers) twenty-five years ago. Published work by Andrews and colleagues (1990), Andrews and Bonta (1994), Andrews and Dowden (1999), Cullen and Applegate (1997), Gendreau (1996), and Gendreau, Little, and Goggin (1996) constitute the foundation for the principles of effective correctional rehabilitation or intervention. They are based on and supported by hundreds of research studies and meta-analyses, and constitute the evidence-based practices of effective contemporary offender rehabilitation. Meta-analyses have demonstrated recidivism reductions between 25 and 30 percent from the implementation of these principles, and as high as 50 percent for particularly effective configurations.
These principles are not foolproof and they are not the solution to crime and public safety. Interventions based on the faithful implementation of these principles will not always produce typical results. However, the scientific evidence demonstrates without equivocation that these intervention principles produce dramatically greater reductions in recidivism than any other known strategy, and clearly greater reductions than purely punitive approaches.
While some authors group the principles differently, they are, in essence, the following:
1. Conduct thorough, accurate, actuarial-based assessments of risk and dynamic, criminogenic needs
2. Assess treatment readiness and enhance treatment motivation
3. Target interventions:
a. on dynamic (changeable) criminogenic needs (need principle)
b. on multiple criminogenic needs
c. on medium- and high-risk offenders (risk principle)
d. to the personality, learning style, and intellectual capabilities of the participants (responsivity principle)
e. with social learning and cognitive-behavioral modalities, the primary evidence-based approaches to effective behavioral change
f. with the appropriate dosage for the appropriate participants
4. Increase positive reinforcement
5. Adhere to fidelity of design, implementation, and operation, and engage in quality control
6. Provide a continuing care, aftercare, or relapse prevention component
7. Monitor and evaluate programming and create structures for feedback
8. Engage ongoing support in natural communities
9. Provide extensive skill training for staff
1. Conduct Thorough, Accurate, Actuarial-Based Assessments of Risk and Dynamic, Criminogenic Needs
Using validated, standardized screening and assessment instruments to measure crime risk and criminogenic needs has been a primary component of evidence-based practices in criminal justice for over two decades. Today, accurate risk and needs assessments are a well-established best practice that is used to mitigate the risk to public safety, to determine what criminogenic needs should be addressed with what level of intervention, to more efficiently and effectively allocate intervention resources, and to measure or monitor treatment progress. The most recent generation of risk and needs assessment instruments (fourth generation) permit the measurement not only of the presence of particular criminogenic needs, but their severity as well (Andrews, Bonta and Wormith 2006; Ferguson 2002; Jones et al. 2001). Dynamic needs assessments are also useful for measuring treatment or intervention progress (for example, the Addiction Severity Index or ASI).
The importance of using accurate, validated, standardized risk and needs screening and assessment instruments is directly related to the effectiveness and cost-effectiveness of correctional treatment. Absent accurate diagnoses of offender needs and appropriate classification of an offender in terms of risk, “offenders enter a treatment lottery in which their access to effective interventions is a chancy proposition” (Latessa, Cullen, and Gendreau 2002: 48).
As of 2007, validated needs assessment instruments were used by approximately 58 percent of prison, jail, and community corrections officials for substance abuse screening, and by 34 percent for a risk assessment (Taxman et al. 2007). Use of standardized instruments varies by facility type: roughly 75 percent of drug treatment prison facilities use them, 50 percent of general prison facilities, 40 percent of community correction facilities, and 20 percent of jails.
Regardless of the challenges involved, criminal justice practitioners, from prosecutors and defense lawyers to judges to corrections officials, should be making decisions based on valid information. Subjective judgments do not and should not take the place of validated risk and needs assessments. However, the use of judgments or information other than validated assessments still seems to be as likely as not in many correctional settings.
While using such assessments is clearly indicated as a correctional best practice, such information is also essential to prosecutors, defense attorneys, and judges in making diversion decisions and sentencing decisions. There are no systematic data on the prevalence of the use of assessments for diversion and sentencing. Virginia appears to be one the few states (as of 2009) to systematically use a standardized risk assessment for sentencing adult offenders. A survey of agencies involved in pretrial diversion indicates that all survey respondents used either eligibility criteria or a risk assessment to determine appropriate individuals for diversion (National Association of Pre-Trial Services Agencies 2009). The survey also reported that 58 percent use “other assessments” to fashion supervision plans and treatment needs.
It is important to emphasize the need to use scientifically reliable and valid assessments. What some jurisdictions and agencies use may be considered “validated” in some regard, when in effect, the assessments are inappropriate. For example, the assessment instrument used by the Texas Parole Commission to assess the risk of reoffending for sex offenders (the Static 99), and in turn to assist with release decisions, has an item for age that simply differentiates those above and below the age of twenty-five. In essence, a ninety-year-old sex offender will have the same risk as he did at age twenty-six (all of the items are static, meaning unchangeable, therefore the assessed risk does not change over time). The likelihood of reoffending is associated with a number of factors, including the obvious and very important effect of age. The problem seems clear. “Validated” does not necessarily mean accurate.
2. Assess Treatment Readiness and Enhance Treatment Motivation
Simply ordering someone to treatment is shortsighted, counterproductive, and an inefficient use of expensive treatment resources. Assessing treatment readiness is an effective and productive way of determining who among those in need of a particular intervention is appropriate, and who is inappropriate for treatment at a given point in time. Treatment readiness has been shown to predict program retention and completion, and is useful for matching individuals to particular levels or intensities of treatment (Osher and Kofoed 1989; Peters, Bartoi, and Sherman 2008). Matching individuals to particular stages of treatment is based on the premise that stage-specific interventions will enhance retention and completion. Treatment readiness instruments can also be used to monitor changes in motivation and readiness over the course of treatment.
There are several validated instruments that assess readiness for substance abuse treatment, psychiatric treatment, co-occurring disorder treatment, and cognitive skills training, among others. The most common instruments are designed to assess readiness for substance abuse treatment, instruments such as the Circumstances, Motivation, Readiness, and Suitability (CMRS) Scale (DeLeon and Jainchill 1986); Readiness for Change Questionnaire (RCQ) (Rollnick et al. 1992); Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) (Prochaska and DiClemente 1992); and the University of Rhode Island Change Assessment Scale (URICA) (DiClemente and Hughes 1990).
Motivation for treatment can be enhanced by utilizing a variety of incentives and sanctions, as well as approaches like motivational interviewing, by providing a respectful, empathetic, encouraging environment for the screening and assessment process, and by maintaining positive and encouraging attitudes throughout treatment (Castonguay and Beutler 2006).
3. Target Interventions
Targeting interventions in terms of needs, risk, responsivity, and dosage highlights the fundamental importance of accurately assessing needs, risk, and treatment readiness. Absent this information, intervention is often a waste of resources.
DYNAMIC (CHANGEABLE) CRIMINOGENIC NEEDS (NEED PRINCIPLE)
Focusing on dynamic criminogenic needs presumes a needs assessment process that identifies the existence of problems and deficits and provides sufficient information on severity to allow prioritization of needs. The goal is to intervene with regard to the primary needs that are related to criminal offending. Determining which needs are more or less related to the propensity to engage in crime is not always intuitive. But there is a growing research base of evidence that indicates which typically are and are not criminogenic. Research has demonstrated, for example, that antisocial attitudes, antisocial friends, substance abuse, lack of empathy, and impulsive behavior are criminogenic circumstances. Research has also demonstrated that anxiety, low self-esteem, poor physical conditioning, medical (nonpsychiatric) needs, feelings of inadequacy, and depression are generally noncriminogenic.
MULTIPLE CRIMINOGENIC NEEDS
It is a rare circumstance in which a criminal offender presents with only one primary criminogenic need. Crime is a product of many factors, including disadvantage, poverty, unemployment, educational deficits, mental illness, drug abuse or dependence, neurocognitive deficits and impairments, among others. But correctional treatment or intervention, when provided at all, typically focuses on just one need or deficit.
The reality is much more complex. Psychopathology is typically the result of heritable vulnerabilities interacting with the environment. Biological vulnerability, when combined with high-risk environments (poverty, parental neglect or abuse, exposure to violence), can produce a variety of psychopathologies. Co-morbidity rates are quite high among offenders, especially with regard to substance abuse. For example, individuals who present with externalizing disorders such as conduct disorder have a reasonably high vulnerability to internalizing disorders such as depression and substance abuse. Awareness of these considerations at the diagnostic phase can be very useful in identifying co-morbidities.
The research is clear: addressing multiple primary criminogenic needs produces substantially greater reductions in recidivism than just addressing one or two (Andrews and Bonta 2007; Andrews, Dowden, and Gendreau 1999; Carey 2011; Dowden 1998; French and Gendreau 2006). Carey (2011) reports that meta-analysis demonstrates that addressing six criminogenic needs reduces recidivism by 50 percent; addressing 5 reduces recidivism by 30 percent; four by 25 percent; three by 20 percent; two by 18 percent; and addressing one results in minimal impact. The research also clearly indicates that prioritizing criminogenic needs in terms of level of need/severity produces better recidivism reduction outcomes. For example, someone who is abusing drugs will likely need to have the substance abuse addressed first because drug abuse probably interferes with other therapeutic interventions.
Moreover, research confirms that while there are a wide variety of criminogenic needs, there are eight that are most consistently related to recidivism, and four of them have been identified as having the greatest impact (Andrews, Bonta, and Wormith 2006). The so-called central eight needs, with the primary four listed first, are: antisocial behavior, antisocial attitudes, antisocial peers, and antisocial personality; the remaining four are family stressors, substance abuse, lack of employment and education, and poor use of leisure time. These eight needs do not preclude identifying and treating others that may be precursors of these, independent of them, or aggravators.
MEDIUM- AND HIGH-RISK OFFENDERS (RISK PRINCIPLE)
The risk principle is based on long-term research, which indicates that low-risk offenders do not require nor do they benefit as much as medium- and high-risk offenders from extensive and intensive treatment and case management (Andrews and Bonta 2003; Clear 1981; Palmer 1995). At the same time, there is research that indicates that extremely high-risk offenders may not respond well to treatment and are disruptive to therapeutic interventions.
On balance, the risk principle indicates that the optimal targets for correctional intervention are those assessed as medium and high risk. Treatment intervention and case management should be used in an effort to reduce risk.
RESPONSIVITY PRINCIPLE
In addition to matching risk level, treatment readiness, and level of motivation to the appropriate treatment programming, the responsivity principle also includes the consideration of additional factors that likely impinge on the success of treatment. It is clear that one size does not fit all. There are a number of offender characteristics that are relevant to consider before intervention. These include cognitive abilities, gender, mental health status, language fluency, and intellectual/learning capacity, among others. The point is simple: Do what it takes in terms of appropriately fitting offenders and programs such that barriers to successful outcomes are minimized. As Beauchaine and colleagues (2008) note, neurobiological considerations, as a consequence of heritable tendencies and interaction with the environment, can produce psychopathologies that impinge on an individual’s abilities to understand, comprehend, and communicate. Understanding and taking into consideration these biosocial vulnerabilities can facilitate more efficient and effective matching of offenders to programming. Matthys, et al. (2012) note that neurocognitive dysfunctions associated with oppositional defiant disorder (ODD) and conduct disorder (CD) among children and adolescents likely compromise the effectiveness of social learning interventions. The neurocognitive implications of ODD and CD include compromised ability to understand consequences of behavior, problem solving, attention, cognitive flexibility, and decision making. Thus, the effectiveness of a cognitive-behavioral therapy (CBT), social learning intervention may be limited by these characteristics of participants. Success is enhanced by incorporating these factors in the decision-making process. Failure to consider them can hinder success (Andrews and Bonta 2007; Cullen and Gendreau 2000).
Research by Andrews, Dowden, and Gendreau (1999) indicates that adhering to the three principles of risk, needs, and responsivity reduced recidivism by an average of 25 percent; adhering to only two of the principles reduced recidivism by an average of 18 percent; and adhering to just one essentially did not reduce recidivism.
COGNITIVE-BEHAVIORAL MODALITIES
Another evidence-based finding is that the most effective intervention modalities for behavioral change are social learning, cognitive-behavioral approaches. Cognitive-behavioral therapies (CBT) are the most appropriate for changing antisocial thinking and cognitive distortion, and developing problem-solving skills, new ways of thinking, and other prosocial skills. CBT is based on the observations that thinking affects behavior, antisocial and distorted thinking can lead to criminal behavior, ways of thinking can be influenced, and changing how and what we think changes how we feel about ourselves and our behavior (Latessa n.d.).
Cognitive-behavioral programming should be highly structured, focusing on social learning and modeling and the acquisition of new skills, behaviors, and attitudes. They target peers, attitudes, values, anger, substance abuse, and so on. Training family on appropriate behavioral techniques is also important. Successful family-based approaches, among others, include Functional Family Therapy (Alexander et al. 1998), Multi-Systemic Therapy (Borduin et al. 1995; Schaeffer and Borduin 2005), and the Teaching Family Model (Kingsley 2006).
Most importantly, meta-analyses have confirmed that cognitive behavioral therapy reduces recidivism by least 25 percentage points more than other therapeutic modalities (Landenberger and Lipsey 2005; Lipsey, Landenberger, and Wilson 2007).
APPROPRIATE DOSAGE FOR THE APPROPRIATE PARTICIPANTS
How long an individual is in treatment should be driven by clinical decisions of the severity of the need and the risk level, not by funding, policy, or the simple decree of a prosecutor or judge. It is a waste of resources for someone who has been homeless and addicted to alcohol and drugs for fifteen years to be placed in an outpatient treatment program or even a thirty-day residential program. In all likelihood, the dosage is simply inadequate. This seems obvious to many, but this scenario of inappropriate treatment dosage is played out on a daily basis in probably every jurisdiction in the United States.
Higher-risk offenders require more structure and intervention than lower-risk offenders. As general guidelines, higher-risk offenders should be in structured, prosocial activities between 40 and 70 percent of the time over a three- to nine-month intervention period. Higher-risk offenders need 200 to 300 hours of intervention over a six- to twelve-month period. Medium-risk offenders generally require 100 hours over a three- to nine-month intervention period (Andrews and Bonta 2007; Bourgon and Armstrong 2005; Gendreau and Goggin 1995). These are suggestive dosage guidelines, designed to reflect the fact that individuals differ in important ways and that these differences must be taken into account. At the same time, there will be exceptions. That is why is it vital to get as much information as possible, similar to a medical diagnosis or emergency department triage. Guesswork can be quite counterproductive.
4. Increase Positive Reinforcement
While criminal offenders will, from time to time, require punitive responses to violations of rules and conditions, research clearly supports the minimization of negative reinforcement in correctional rehabilitation. When punishment/sanction is necessary, it should be quick and expected (swift and certain are the two aspects of punishment for which there is evidence of a deterrent effect).
Behavior change is facilitated and motivated by a balance of positive and negative reinforcement. Research by Andrews and Bonta (2006), Gendreau and Goggin (1995), Gendreau (1996), Gendreau, Little, and Goggin (1996), and Gendreau and Paparozzi (1995) indicates that the optimal ratio of positive to negative reinforcement is four positives for every one negative. The point is that an exclusively negative, punitive environment is not conducive to positive behavior change.
5. Adhere to Fidelity of Design, Implementation, and Operation, and Engage in Quality Control
Program integrity is fundamental for program success. Research clearly indicates a significant relationship between successful program outcomes and the fidelity used in developing and operating a program as the evidence shows it should be developed and operated (Latessa and Lowencamp 2006). This is not to say that local jurisdictions cannot or should not adapt programs to local circumstances and needs. However, in so modifying programs, it is important that the primary or key components remain intact or are modified in ways that research evidence supports.
6. Provide a Continuing Care, Aftercare, or Relapse Prevention Component
Common sense and evaluation research converge on the issue of continuing care or relapse prevention. One of the more common and avoidable “cracks” that individuals fall through is the failure to provide ongoing support and relapse prevention. The direct treatment effect is dramatically weakened or lost if ongoing support is not in place. This is particularly the case with substance abuse treatment and mental health treatment. For much of the history of correctional intervention, it seems that the philosophy that we have “done enough” by providing direct drug treatment has been the working assumption. The evidence indicates, however, that the resources spent on that treatment are wasted without an effective relapse prevention program in place.
Aftercare or continuing care typically requires developing collaborative relationships with community-based providers. Obviously, it is important that aftercare programming is evidence based, so an important criterion for establishing these relationships is to assure that programs utilize evidence-based methods.
7. Monitor and Evaluate Programming and Create Structures for Feedback
Presumably, correctional programming is designed, implemented, and operated with certain expectations and goals in mind, both process and outcome expectations and goals. All too often, “assessments” of performance are either general observations or seat-of-the-pants guesses. From an administrative perspective, goals are often in the form of money spent and people processed.
Valid, systematic process and outcome evaluations may seem like overkill to some, but it is the only way to know if and how the program is operating as intended, what is working more and less well, and importantly, how it can be improved and rendered more cost-effective. Developing appropriate, relevant metrics for evaluation is critical to the process and requires a clear understanding of the program. For example, appropriate metrics for a drug diversion program probably include program retention and program completion (and of course, any clues regarding who stays in the program and who graduates). But should recidivism be an outcome measure? For policymakers, recidivism is the metric, the end game, the common currency that all understand. Whether recidivism is an appropriate outcome measure for a drug diversion program depends on the types of interventions and programming that are provided. If the programing is primarily drug and alcohol treatment, recidivism is likely not appropriate (except reoffending involving drugs or alcohol). Most offenders have a variety of criminogenic circumstances, and unless the programming addresses these, recidivism reduction is unrealistic. Relapse should be the outcome measure instead.
Assuming that evaluation processes are in place, it is fundamentally important to make constructive use of the findings by providing feedback channels. Program fidelity, quality control, and staff performance, among others, are critical to meeting the goals and objectives of the program. Proper evaluation data are the only mechanism for taking corrective action, knowing if the program is operating as designed/intended, and if the staff is performing to expectations.
8. Engage Ongoing Support in Natural Communities
The logic is simple and intuitive: place offenders in prosocial environments in which there are existing networks that provide meaningful, productive connections, both people and activities, and help offenders strengthen their own prosocial skills and behaviors. Research indicates that recidivism is reduced when offenders’ families are engaged in their activities and when offenders have positive, meaningful connections to a prosocial environment (Bonta et al. 2002; Clear and Sumner 2002; O’Connor and Perryclear 2002; Shapiro and Schwartz 2001).
9. Provide Extensive Skill Training for Staff
This is another obviously important component of successful correctional rehabilitation: assure that the staff is competent, motivated, and properly trained to provide cognitive-behavioral and social learning strategies, and assure that behavioral change is reinforced. This requires extensive training and retraining, and not all probation officers, parole officers, prison and jail staff, diversion court staff, among others, have the aptitude and the motivation to acquire and maintain the appropriate skills. There is the added challenge of the historic priority of risk management among those staff in charge of diverted and released offenders, for example, the cop versus social worker dichotomy that has been pervasive among parole and probation officers.
These are the current evidence-based tools or best practices that have been shown to reduce recidivism. Which of these are more and less important in reducing recidivism is a question that science is unable to answer with precision at this time. Clearly the risk principle (the who of correctional intervention), the need principle (what is targeted), the treatment principle (how to change behavior), and program integrity (how well behavior is changed) are the key elements. The evidence points to the conclusion that all of these principles should be implemented for maximum benefit. What should guide program development and operation is an overall problem-solving perspective. A problem-solving approach is one based on enhanced, accurate information (risk and needs); a focus on individuals and individual circumstances and needs, not categories of people and not one size fits all; community engagement; collaboration with community stakeholders; enhanced expertise at key decision points (for example, referral to diversion, sentencing); accountability; and importantly, creatively addressing (problem solving) the barriers and challenges to successful outcomes.
There are a growing number of meta-analyses of evaluations of what works to reduce crime and recidivism. These usually focus on particular programs such as drug courts or in-prison vocational training. One of the more comprehensive such analyses was conducted by Aos, Miller and Drake (2006b) at the Washington State Institute for Public Policy. Aos and colleagues not only estimate average effect sizes (crime/recidivism impacts), they are also able to attach economic benefits to categories of programs and produce net economic benefits. Their analysis is based on a statistical review of 571 evaluations of programs that passed muster as a “rigorous” evaluation. The primary criterion for being considered rigorous is that the evaluation must include a nontreatment or treatment-as-usual comparison group that is well matched to the treatment group. This Washington State Institute for Public Policy report is one of the more useful consolidations of existing research on what works. It provides direction to policymakers in terms of the types of interventions or programs for optimal recidivism reduction and cost-effectiveness. The specifics of the design, implementation, and operation of particular programs and the incorporation of the principles of effective correctional interventions require consulting other source materials.
The overall results, while general and approximate, are quite encouraging in providing viable, effective and cost-effective, evidence-based alternatives to traditional incarceration and community supervision.
To keep this in proper perspective, the goal here is to strike a balance between (1) incarceration and tough correctional control for those who are particularly dangerous, high-risk, habitual offenders for whom behavioral change has failed or is not deemed possible or appropriate, and those who commit particularly reprehensible crimes and are deserving of retributive punishment; and (2) concerted efforts at behavioral change through scientifically demonstrated effective policies and programs aimed at addressing criminal circumstance and criminogenic need. The evidence is clear. We know how to better and more cost-effectively reduce recidivism and, in turn, victimization.
At the same time, this is an uphill battle as adoption and implementation of these evidence-based practices (EBPs) is limited. Recent surveys of justice agencies and community-based providers of treatment and intervention for justice-involved adults and juveniles show sporadic adoption of EBPs for drug treatment programming. Most justice agencies and community-based providers for correctional drug treatment that employ any EBPs employ, on average, 60 percent of those indicated by the research. In addition, research indicates that the least-used EBPs are those modalities that have the greatest research support and that have been repeatedly shown to have the greatest impact on drug treatment outcomes (for example, cognitive-behavioral therapy and therapeutic communities [Henderson, Taxman, and Young 2008]).
Community-based treatment providers adopt EBPs more often than correctional organizations. Factors associated with adoption include being community based, absence of a punitive focus, being an accredited provider, and being connected to a broader network of providers. Moreover, the adoption of EBPs in correctional settings is significantly related to organizational leadership and culture. Leadership with background and experience in social/human services and favorable beliefs and attitudes about treatment and rehabilitation, as well as a culture of performance enhancement, training, and internal support for innovation, are characteristics of those institutions with greater adoption of EBPs (Friedmann, Taxman, and Henderson 2007).
IMPLEMENTATION OF EVIDENCE-BASED PRACTICES
Just because there is scientific evidence that a set of practices reduces recidivism does not mean that implementing those practices in a particular venue or setting will produce the same results. There is substantial evidence showing that real-world applications of effective demonstration programs can and do fall short in terms of treatment effects (for example, Andrews 2006; Bourgon et al. 2009). As Andrews notes (2006: 595):
Implementation of effective human service is not simply a matter of selecting an evidence-based program off the shelf. Even well-researched (“blueprint”) programs such as Aggression Replacement Training, Functional Family Therapy, and Multisystemic Therapy failed in Washington State when not well implemented. … The negative experience of England and Wales with the large-scale implementation of cognitive skill programs such as Reasoning and Rehabilitation is an intriguing and challenging story. … One cannot read the transcript of a roundtable discussion on the lessons of Project Greenlight without feeling the sting experienced by the Vera Institute of Justice and New York corrections team. … How is it, they ponder, that a reentry program designed with reference to “what works” could actually increase recidivism rates?
As Lowenkamp, Latessa and Smith (2006) tell us, there is a significant and substantial relationship between program characteristics (fidelity or accuracy of implementation and operation) and program effectiveness. Unlike the Nike tagline, it is not a matter of just doing it. It is a matter of doing it correctly. Technology transfer is one of the most significant challenges facing corrections today. There are two primary components to effective technology transfer: the technology itself and the transfer process. Thus, it is the responsibility of researchers and practitioners involved in development and implementation of EBPs to demonstrate not only what works, but also how it works. Knowing that a pilot or demonstration program works in a controlled environment is quite different from implementing it in real-world settings in which a variety of constraints and barriers challenge the fidelity of implementation. The point is simple but often missed: evidence-based programs and practices are not self-implementing or self-executing. Yet agencies and organizations routinely launch programs or sets of practices without careful consideration of the particulars of, for example, the organizational change process or the culture of the agency.
Fixsen et al. (2005) conducted an extensive review of the implementation of human service programs and practices in a wide variety of public and private settings. On balance, they affirm what was just discussed: proper implementation (fidelity) is far more difficult than developing the practices and programs themselves, and that the technology is much better understood than the technology transfer process. Their review and analysis is designed to improve effective implementation of evidence-based practices through identification of primary barriers and challenges to implementation, as well as key efficiencies in the implementation process.
Programs and practices have measurable outcomes and so does implementation. Integrity/fidelity can be measured, and determining whether implementation has been done correctly can assist program managers in refining the operation of programming. The primary outcomes of successful implementation (Fixsen et al. 2005) are: changes in the behaviors, attitudes, knowledge, and skills of professional practitioners and other relevant organizational staff; changes in organizational structures and cultures (changes in values, beliefs, attitudes, ethics, philosophies, policies, goals, procedures, decision making) that support the behavior change of the professional staff; and changes in the relationships with consumers, clients, patients, stakeholders, and partners.
The stages of the process of implementation identified by Fixsen and colleagues’ research include: exploration and adoption, program installation, initial implementation, full operation, innovation, and sustainability.
Exploration and Adoption
There are many reasons why local jurisdictions adopt and attempt to implement an innovative or evidence-based practice or program. Often it seems that a new idea is adopted because of the perception that everyone else is doing it. Community policing and broken windows initiatives come to mind, as do drug courts. Often these programs are adopted before there is much evidence that they are effective in what they are designed to do, and often before there is much implementation experience or shared implementation knowledge to assist the adoption and installation process. Sometimes implementation of evidence-based programs is mandated from above, for example when a state legislature requires drug courts in jurisdictions that meet a certain population size criterion, but provide little guidance for adoption and implementation (the Texas legislature did this with drug courts in 2001).
In the best of circumstances, exploration is a segment of the process that focuses on assessing local community needs, the match between community needs and the program/innovation, the availability of local resources, and a deliberate and informed decision whether or not to proceed. That decision should not be based on the perception that the innovation is a good idea, but whether it is a significant value add, the extent to which it is needed, and whether it is feasible in terms of available resources. Making these decisions should typically involve conducting needs assessment research, sizing or scaling the need, identifying appropriate programs or interventions that best address those needs, assessing the fit between the program and the needs, and laying the ground work for a decision to proceed (if that is decided). The process should be need driven and not program driven.
One of the key functions or roles in implementation is the “purveyor,” “change agent,” or “program consultant.” This is the person, persons, or organization that is responsible for the idea or concept of the practice or program. “A purveyor works in more or less organized ways with the intention to implement a specified practice or program at a particular location” (Fixsen et al. 2005: 14). Individuals or organizations that fill the purveyor role over time can gain important experience and knowledge regarding the implementation process and can therefore expedite the successful implementation of programs and practices. Organizations that at least partially fulfill that role are the Center for Court Innovation, the Bureau of Justice Assistance, and Community Oriented Policing Services, among others.
A critical element of the exploration and adoption phase is gaining political support at all appropriate levels, from state and local government to relevant stakeholders and interest groups, service providers, and consumer groups. This support is initiated in the exploration and adoption phase, but is essential for the entire implementation process, as well as for the sustainability of the initiative.
Fixsen and colleagues (2005) reviewed the implementation of programs and practices in “community” settings and identified several factors supported by research that facilitate successful implementation. In this context, I use the term “community” to mean stakeholders external to the organization or agency in which the program is being implemented. These include:
• Mobilizing local interest, consensus, and support, and identifying local champions; articulating how the innovation contributes to the big picture; developing a marketing strategy.
• Encouraging community participation in decision making.
• Developing understanding and commitment to the initiatives.
• Clarifying feasibility by identifying how the innovation fits into existing organizational structures or how new structures and operational mechanisms will work.
• Assuring that stakeholders have an ongoing monitoring function and that they participate in long-term sustainability.
• Assuring program/practice implementation readiness by enhancing awareness and familiarity and benefits, and identifying barriers and strategies to addressing them.
Program Installation
The installation phase, which follows the decision to proceed, involves the nuts and bolts of the process, including the commitment of resources, structural supports, any relevant legal changes, and so on. Collateral elements include funding streams, human resource considerations, development of policies and procedures, creation of referral mechanisms, reporting requirements, securing physical space and required technology, among others.
Initial Implementation
Implementation requires varying levels of change in skill levels, organizational capacity, organizational structure, roles and responsibilities, and organizational culture. As Fixsen and colleagues (2005) note from their research, implementation is often confronted by fear of change, a culture of and investment in the status quo, and “diamond-hard inertia.” These barriers are often encountered while attempting to engage the inherently difficult task of developing and implementing something new and innovative to the organization or agency. Overcoming these difficulties requires careful planning, key political support, appropriate purveyors, the relevant implementation elements, an effective marketing plan to sell the ideas internally and externally, the ability to communicate effectively with a variety of audiences, effective organizational leadership to move things forward, and mechanisms and processes to change internal beliefs, attitudes, and ways of thinking and doing (culture change). By way of example, the culture change could involve creating an environment in a justice agency whereby every individual embraces the responsibility for recidivism reduction, much in the same way that the Nordstrom culture is one in which all employees care about and deliver an exceptional customer experience. It is the idea that the culture creates ways of thinking and believing that result in actions and behaviors that produce consistent, productive, mission-driven results.
Full Operation
Full implementation is reached “once the new learning becomes integrated into practitioner, organizations, and community practices, policies and procedures” (Fixsen et al. 2005: 16). This is the point at which the program is at staffing and client capacity, referral channels are fully operational, practitioners are fully engaged in implementing evidence-based practices with skill and fidelity, the organization is providing all relevant supports, and the community embraces the innovation. Over time, the definition of treatment as usual changes to reflect the new ways of doing business, program benefits begin to be realized, and the new policies and procedures become routine. As program fidelity hits prescribed criteria, outcome targets should approximate the levels of the demonstration or original EBP.
Innovation
One size does not fit all, thus it is reasonable that implementation will differ by site depending on the unique characteristics each site exhibits. Implementation is an opportunity to learn both positives and negatives, what is successful and what is not. Implementation sites differ and offer different barriers and efficiencies to implementation. How the barriers are addressed and the efficiencies are leveraged provide opportunities to innovate. As Fixsen et al. (2005: 17) note:
They [unique conditions at a site] also present opportunities to refine and expand both the treatment practices and programs and the implementation practices and programs. Some of the changes at an implementation site will be undesirable and will be defined as program drift and a threat to fidelity. … Others will be desirable changes and will be defined as innovations that need to be included in the “standard model” of treatment or implementation practices.
The key of course is differentiating between fidelity drift and innovation. The prescribed path is to first implement the program as described and then to innovate as indicated. That way, the innovation is not based on an effort to circumscribe perceived difficult fidelity standards. Research clearly indicates that innovation after full implementation was more successful than modifications made before full implementation.
Sustainability
The environment changes, funding ebbs and flows, well-trained staff and practitioners leave, leadership changes, stakeholders and partners come and go, political alliances evolve, and champions/advocates move on. The goal is to sustain the effort in the context of a changing environment.
There are six identified core components of implementation that research shows create, support, and enhance high-fidelity, EBP behavior and actions (Fixsen et al. 2005; Bourgon et al. 2010a). One is practitioner and staff selection. It sounds simple. Create a set of guidelines and qualifications and it’s done. However, getting the criteria and qualifications right and properly/correctly identifying staff is often more challenging. Identifying staff and practitioner criteria requires a fundamental understanding of the EBPs for which staff are being hired. Some jurisdictions may have a larger pool of candidates than others, so those with limited availability of qualified candidates will have to address that issue. Some compromise may be required, thus knowing the potential impact of such compromises needs to be on the radar of the key decision makers.
Training is another core component. Preservice and in-service training not only teach the proper protocols, roles and responsibilities, and rules and procedures, they also teach and reinforce what is often a new agency or departmental culture. Getting all relevant participants on the same page regarding mission, vision, philosophy, and values is critical. Knowing what to do, when to do it, and how to do it does not in fact assure it gets done and done properly. On the job training is the more effective way to teach more specific job skills.
Ongoing staff evaluation is key to knowing how well practitioners and support staff are engaging the EBPs. Evaluation not only serves to assess performance and fidelity, it can also provide corrective action to remedy deficiencies that can be addressed in hiring, training, and coaching. Facilitative administration refers to a management perspective and approach that provides key leadership and support, leaders that understand and agree with the premises of the initiatives and programs being implemented, and support for the mission and culture required to produce the desired outcomes. Facilitative leadership also promotes a learning and problem-solving environment, and a culture of professional development. Clearly, facilitative administration is an ongoing focus and process that continually assesses and improves. Finally, systems interventions are linkages with external resources necessary to maintain ongoing funding and human resources and other organizational needs.
With all of these pieces in place, the core components and the proper phases or stages of implementation will substantially improve the likelihood of success. However, it is important to emphasize that all components and all phases are important. Programs have failed due to a lack of appreciation for a seemingly minor detail or element. Success generally requires that all factors are considered and addressed. Failure only requires one mishap.
One of the major sources of variation in the quality of human service provision is that many are practitioner centered, thus all hinges on the expertise of the practitioner and the type and nature of services provided. Successful intervention programs should be evidence-based program-centered or evidence-based practice-centered, rather than practitioner centered.
One additional factor that is implicit in some of the discussion above is the role of politics. Assuring buy in by internal staff and administration, local stakeholders, elected officials, and policymakers can be critical for the viability of an initiative. Lack of appropriate funding can easily render a program or initiative ineffective or compromised. Thus, having key community leaders on board with an initiative may be an important component in persuading local county or city elected officials to properly fund a program. Assuring that all relevant stakeholders are informed can prove important down the road. Thus, a new EBP for offender rehabilitation may require an in-depth understanding of the local political arena and contact with interested parties and stakeholder groups (such as law enforcement, prosecutors, the defense bar, judges, the religious community, victims groups, county and city elected officials and administrators, probation officials, local political party officials, the mental health community, housing authorities, the medical community, and the many components of the non-profit sector, including treatment providers, the school district/board, and so on). Obtaining local support from all relevant sources is critical for the success of many initiatives, especially community-based initiatives. Fixsen and colleagues (2005: 68) summarize the issues surrounding implementation as follows:
Implementation practices function in a complex ecology of best intervention practices, organizational structures and cultures, policy and funding environments, and community strengths and needs. Given the preponderance of evidence from a variety of sources, implementation appears to be a crucial component of moving science to service with fidelity and good outcomes for children, families, and adults.
Andrews (2006) has identified additional key components of the implementation of the risk-need-responsivity (RNR) principles and some barriers to effective implementation and operation of EBP programming. Use of structured, validated risk and need assessments is critical, but the impact of their use is mitigated if the information they provide is not routinely and comprehensively incorporated into case and program planning and management. Another is the perception that the highest-risk offenders are untreatable and thus are sometimes excluded from services. Another barrier to successful intervention is that high-risk offenders may be less motivated to participate in treatment. Understanding that higher- and moderate-risk offenders are not equally motivated to participate in programming is important. So is utilizing techniques to enhance motivation and treatment readiness.
Not all cognitive-behavioral programs and therapists are created equal. Some programs that are labeled cognitive behavioral fall far short of the criteria for true cognitive programming. Moreover, there is a profound shortage of qualified cognitive behavioral therapists in the free world, and there is reason to believe the situation is similar if not worse in corrections. While some therapists/counselors may be considered or call themselves cognitive behavioral, the reality may be quite different. Assure that the therapeutic staff is properly qualified and engage ongoing training and supervision of clinical and other staff involved in programming.
Finally, Andrews (2006) emphasizes the importance of ongoing assessment or monitoring, feedback, and corrective action. Part of this process is the assessment of program integrity/fidelity over time and identification and implementation of changes as warranted to remain in compliance with EBPs.
THE BIGGER PICTURE OF BEHAVIORAL CHANGE: WHERE WE GO FROM HERE BASED ON OUR EMERGING UNDERSTANDING OF NEUROCOGNITIVE IMPAIRMENTS
The preceding discussion constitutes what is currently known about general evidence-based practices for behavioral change of criminal offenders. I discuss specific EBPs in more detail in later chapters. I am now going to take the discussion of behavioral change beyond the core correctional practices to focus on what the evidence suggests is needed in the future. The point is that EBPs are necessary for efforts at behavioral change and recidivism reduction. Necessary, but not sufficient. There is much more that is research based that has not worked its way to the level of discussion and consideration in criminal justice policy, let alone as EBPs. These include addressing the complexity of criminogenic, collateral cognitive, and behavioral impairments with which criminal offenders present, the inadequacy of current screening and assessment, and the lack of true clinical diagnosis, among others.
There are many mental health conditions that are relevant to understanding criminal involvement and/or relevant to the behavioral change process. In addition to the criminogenic factors that assessments are intended to identify, there are many developmental, cognitive, and mental health conditions or disorders that may or may not impact criminal offending, but which may significantly and substantially impact the intervention, treatment, and rehabilitation process. Mental illness is clearly implicated in the commission of violent crime. Individuals with diagnoses of major depression, bipolar disorder, anxiety disorders, and schizophrenia are at greater risk of committing violent crimes than individuals without those conditions. The risk increases in the presence of multiple psychiatric disorders. This is especially evident when co-occurring disorders include substance abuse, and antisocial personality disorder, and/or psychopathy.
Substance abuse/addiction and mental health problems can lead to or cause cognitive and behavioral impairments, impairments related to psychosocial and interpersonal functioning, and executive functioning. Functional impairments are important to assess because they can and do impact the ability to effectively interact with treatment and supervision staff, engage and participate in treatment, and successfully complete treatment and supervision. In turn, the presence of such impairments challenge effectively adhering to the responsivity principle discussed previously.
Peters, Bartio, and Sherman (2008) assert that cognitive and behavioral impairments are not typically a focus of screening and assessments, although they are often more important in predicting treatment outcome and identifying the nature of particular treatment interventions. As Peters, Bartoli and Sherman (2008: 13) note, “an understanding of functional impairment, strengths, supports, skills deficits, and cultural barriers is essential to developing an informed treatment plan and to selecting appropriate levels of treatment services.” While it is critical to identify (screen and assess) criminogenic deficits, it is also critical for effective and successful intervention to identify collateral impairments that are vital to informing the intensity, duration, type, and scope of treatment, as well as supervision strategies.
The point is that criminal offenders often present with very complex developmental, cognitive, and mental health challenges. To be effective, behavioral change intervention processes must appreciate this complexity, utilize screening and assessment procedures and instruments that are designed to capture the variety of circumstances and deficits, develop treatment plans that reflect primary and secondary intervention priorities, and then engage the variety of evidence-based interventions relevant to the individual’s circumstances. I now turn to a more detailed discussion of neurobiological and neurocognitive factors involved in criminality and in the intervention process.
Neurobiological and Neurocognitive Considerations
The past ten to fifteen years have ushered in a remarkable amount of knowledge about the role of neurobiological and neurocognitive disorders and criminal offending. Much of this has been driven by enhanced technology such as the electroencephalograph, functional magnetic resonance imaging (fMRI), positron emission tomography (PET), transcranial magnetic stimulation (TMS), and diffusion tension imaging (DTI), among others.
There are several terms that are used to describe this focus on the brain and crime: the neurobiology of criminal behavior, neurocriminology, and biosocial criminology. Regardless of the label, the basic premise is that a broader understanding of crime and criminality should incorporate the fact that humans have brains, genes, hormones, and an evolutionary history. In turn, the knowledge from these disciplines (behavior genetics, neurobiology, evolutionary science) should be integrated into theories of crime as well as intervention, rehabilitation, and prevention strategies. Such an approach takes away from the naïve nature versus nurture position to one of nature by way of nurture—the interaction of biological tendencies with the social and physical environment. Humans have genetic predispositions, not genetic determinism. There are no criminal genes, but there are genes that predispose some to low IQ, low empathy, low self-control, and impulsiveness, factors that have been identified as criminogenic. Thus, genes facilitate behavioral tendencies that are conditioned by and respond to the environment.
Neuroscience addresses the mechanisms whereby interactions and experiences in the environment affect or condition behavioral tendencies. Neurobiology focuses on the cells of the brain (neurons) and communication among neurons through substances called neurotransmitters. Our interactions, experiences, observations, thoughts, and feelings are registered in our brains through new connections among brain cells. These neural connections, some of which are established early in development through the influence of genes and other inputs (which are established on an ongoing basis through interaction with the environment) determine how we think, perceive, feel, interpret, and react to the social and physical environment. The neural connections shape our thoughts, emotions, and feelings, our self-identity and our personality. They are experience dependent, shaped by the environment in interaction with genetic influences.
Neurocriminologists are primarily interested in the fact that while basic human functions such as heart rate and breathing are hardwired in the brain, most other behavior is acquired through interactions and experiences in the environment. These interactions and experiences largely shape the neural connections in our brains, which in turn influence out thoughts, perceptions, and behaviors. As Walsh (2012: 139) describes it:
Neural networks are continually being made and selected for retention or elimination in a “use it or lose it” process governed by the strength and frequency of experience. Retention is biased in favor of networks that are most stimulated during early development. … This is why bonding and attachment are so vital to human beings, and why abuse and neglect are so injurious. Hormones released by chronic stress can cause neurons to die, and children with high levels of these hormones experience cognitive and social development delays. … As Perry and Pollard (1998) point out, “Experience in adults alters the organized brain, but in infants and children it organizes the developing brain” (p. 36). Brains organized by stressful and traumatic events tend to relay events along the same brain pathways laid out by early events because pathways laid down early in life are more resistant to elimination than pathways laid down later in life. A brain organized by negative events is ripe for antisocial behavior.
Neuroscience research has consistently demonstrated that exposure to adverse events and experiences can have long-term impacts on neural networks, which have substantial consequences for behavior. Exposure to poverty, low social status, violence, abuse, neglect, hostility, and academic failure is registered in the brain and can lead to substantial levels of anxiety, anger, hostility, fear, and in turn antisocial behavior.
In the most basic sense, we are able to successfully navigate the social environment when we appropriately respond to rewards and punishments with a socially appropriate approach and avoidance behavior. Central to this premise is the regulation of behavior though the behavior activating system (BAS) and the behavior inhibiting system (BIS), both of which are part of the limbic system, with extensions into the prefrontal cortex of the brain. The BAS is largely associated with the neurotransmitter dopamine and thus the pleasure areas of the brain. The BAS is like an accelerator, motivating the individual to pursue rewarding stimuli. It is influenced by the pleasure principle and is the “biological raw material representing drives for acquiring life sustaining necessities and life’s pleasures” (Walsh and Bolen 2012: 20). The BIS, which is associated with the neurotransmitter serotonin, reflects the moral and social rules and norms that an individual internalizes during socialization. The BIS is sensitive to punishment and serves as the brake that, when properly operating, prevents us from excess. The neurotransmitter dopamine facilitates goal-directed, rewarding behavior, and serotonin functions to moderate behavior. If the BAS/BIS is out of balance, whereby the BAS dominates (excess dopamine and insufficient serotonin), that imbalance can result in sensation-seeking behavior, impulsiveness, low self-control, low empathy, and behavior driven by reward and relatively insensitive to punishment or consequences. The outcomes can include addictive behavior, antisocial behavior, and criminal behavior. “Serotonin and dopamine are powerful regulators of behavioral and cognitive functions, thus any aspect of reduced or enhanced serotonergic or dopaminergic functioning results in emotional, behavioral and cognitive dysregulation” (Walsh and Bolen 2012: 20). Moreover, as Berman, Tracy, and Coccaro (1997) report in their review of the research on serotonin levels among criminal offenders, low serotonin activity is related to aggressive behavior. A meta-analysis conducted by Moore et al. (2002) reports that the effect size for the relationship between serotonin levels and antisocial behavior is –.45, indicating an effect of medium magnitude. Hormones also play a role in criminality. For example, cortisol is part of the body’s stress reaction system and works to mobilize the body’s resources in times of stress. Many studies have documented lower cortisol levels among antisocial children, adolescents, and adults, indicating that such individuals may be less influenced by stressors and may be less concerned with any potential consequences for their actions (Rudo-Hutt et al. 2011). Rudo-Hutt and colleagues (2011: 25) conclude from a review of research and meta-analyses that “overall, these findings suggest that hormones and neurotransmitters often interact with social and environmental factors to increase the likelihood of antisocial behavior.”
A third behavioral system of relevance here is the fight or flight system (FFS), regulated by the neurotransmitter epinephrine or adrenaline. A properly functioning FFS will mobilize the body for appropriate action under various circumstances; for example, flight when confronted with fear. However, a weak FFS can contribute significantly to antisocial behavior because the FFS functions to inhibit behavior via conditioned and unconditioned fear. Inappropriate responses to fear include antisocial behavior.
The prefrontal cortex (PFC) is the part of the brain that is responsible for executive functions, including planning, analyzing, synthesizing, making moral judgments, and modulating emotions (Walsh 2012). The PFC requires optimal levels of dopamine, among other things, thus improper levels of dopamine can impact PFC functioning, executive functions, and criminality. So can injury to the PFC, as well as other deficits and disorders. Attention deficit hyperactivity disorder (ADHD) has been implicated in weaker PFC activation, increasing the risk of antisocial behavior. fMRI and PET scans have consistently found links between lower PFC functioning and impulsive criminal behavior. Deficits in prefrontal functioning are quite common among violent, aggressive, and antisocial groups, and reduced prefrontal lobe activity is associated with antisocial individuals (Fabian 2009). Prefrontal lobe functioning is related to understanding and processing information, communication, interpreting others’ reactions, abstract reasoning, impulse control, emotional regulation, and empathy, among others.
A primary takeaway at this point is that our brains capture the variety of interactions we have in the social and physical environment. The fact that our brains register these events and experiences, some of which are negative, toxic, and/or dangerous and threatening, creates the potential for implicating neurological factors in antisocial behavior. The consequences of these neurological factors include intellectual and cognitive impairment, compromised executive function, lack of empathy and self-control, addiction, and aggression, among others. The sources of these neurological consequences are as varied as alcohol and nicotine consumption by the mother while pregnant, poverty, lack of proper maternal attachment, trauma, and violence, among others.
EXECUTIVE DYSFUNCTION
Executive function is an umbrella term that refers to cognitive processes that facilitate goal-directed behavior. Executive processes are fundamental to higher brain function, including goal setting, planning, analyzing, goal-directed activity, attention, response inhibition, self-monitoring, understanding consequences, and complex cognition. It allows individuals to be self-sustaining and self-reliant, and is considered necessary for proper adult conduct. Executive functioning, which is associated with the prefrontal cortex of the brain, can have substantial consequences for cognition and behavior. Executive dysfunction has been consistently linked to cognitive development disorders, psychotic disorders, affective disorders, and conduct disorders. Factors that interfere with normal brain development can affect the prefrontal cortex. Toxins such as alcohol, drugs, lead, and tobacco can enter the fetus and disrupt brain development, including affecting the PFC, resulting in compromised executive functioning and a heightened risk of antisocial behavior (Beaver, Wright, and Delisi 2007).
Executive dysfunction is also implicated in criminal behavior. A meta-analysis of thirty-nine studies and over 4,500 participants on the relation between executive dysfunction and antisocial behavior (Morgan and Lilienfeld 2000) revealed a robust and statistically significant relationship. The effect size is medium to large. More recent research by Barbosa and Monteiro (2008) finds a clear relation between criminal recidivism and executive dysfunction (impulsivity, distraction, lack of self-control, difficulty using environmental feedback in regulating behavior, exhibiting behavior that is inappropriate for the social context). Moreover, Hancock, Tapscott, and Hoaken (2010) report a significant relationship between executive dysfunction and violent criminal offending.
Another meta-analysis investigated the relationship between post-traumatic stress disorder (PTSD) and executive functioning. Polak et al. (2011) reviewed eighteen studies involving 1,080 subjects and over 600 controls that showed that PTSD subjects had significantly impaired executive functioning. Hawkins and Trobst (1999) show from their review of research that there is a relationship between weak executive functioning and aggression and violence. Another review by Brower and Price (2001) finds similar evidence for a significant link between frontal lobe dysfunction (executive dysfunction), and aggression and antisocial behavior. Brower and Price (2001: 724) conclude:
The studies surveyed in this review indicate that clinically significant frontal lobe dysfunction is associated with aggressive dyscontrol. Subjects with both traumatic and neurodegenerative disorders primarily involving the prefrontal cortex display increased rates of aggressive and antisocial behaviour compared with subjects who have no, or non-frontal brain injury. Studies employing neuropsychological testing, neurological examination, EEG, and neuroimaging have also tended to find evidence for increased rates of prefrontal network dysfunction among aggressive and antisocial subjects.
The research on executive dysfunction and antisocial behavior shows a clear link between lack of control and elevated impulsivity, and antisocial behavior and aggression. Executive dysfunction is also linked to schizophrenia, ADHD, autism spectrum disorder, and bipolar disorder. There are a number of standardized tests or assessments for executive function that are widely used and validated. These include the Clock Drawing Test, the Stroop Test, the Wisconsin Card Sorting Test, and the Train-Making Test.
INTELLIGENCE
The deficit in IQ among criminal populations has been well documented (Savage, Ellis, and Kozey 2013) and recent research has uncovered a common genetic basis for low IQ and antisocial behavior (Koenen et al. 2006). Moreover, low IQ is quite likely a function, in part, of cognitive deficits or impairment (Yoshikawa 1995). While IQ per se is related to criminal offending, the subscales of Verbal and Performance IQ have been shown to differ among individuals engaged in antisocial behavior. Specifically, there is a tendency for offenders to exhibit not only lower IQ, but also lower Verbal compared to Performance IQ. Verbal IQ measures fact-based knowledge and Performance IQ focuses on spatial and nonverbal reasoning (Walsh and Bolen 2012).
Research by Moffitt (2006) and many others implicates intellectual functioning with chronic offending. Moreover, Moffitt reports that long-term chronic offending (life-course persistent) is associated with low intellectual ability, reading difficulties, and lower scores on neuropsychological tests.
POVERTY, NEGLECT, AND DISORDERED ATTACHMENT
We have long known about the link between poverty/disadvantage and crime. Criminal offenders are predominantly lower income and crime tends to cluster in areas of socioeconomic disadvantage. We also now have a clearer understanding of how poverty affects the brain. For one, recent research (Hook, Lawson, and Farah 2013) shows that poverty is related to executive functioning both directly as well as indirectly through poverty’s impact on parenting. The research is clear: children who are exposed to poverty score lower on a variety of cognitive and behavioral assessments, including memory, attention, language skills, impulse regulation, achievement, IQ, and functional literacy. Nobel, Norman, and Farah (2005) conducted a comprehensive study of socioeconomic status (SES) and cognitive functioning among kindergarten children. The research focused on the potential effects of SES on five neurocognitive domains or systems, including the prefrontal/executive system and the language system. The findings indicated that SES is significantly related to the executive and language systems. While language effects are important, the executive functioning deficits among those in poverty are of direct relevance to antisocial behavior and crime. Farah and colleagues (2006) focused on identifying the neurocognitive systems responsible for the poverty-IQ link, or as they put it, “how and why might a sociological construct, SES, be associated with brain function?” They found substantial disproportionate effects on the prefrontal/executive function systems of working memory and cognitive control, as well as language and memory, which involve the left perisylvian and medial temporal areas of the brain.
Research has revealed a strong correlation between income and child neglect/abuse (Sedlak and Broadhurst 1996). Loughan and Perna (2012) investigated the effects of poverty and neglect/abuse (physical, sexual, and emotional). Unsurprisingly, their analysis revealed significantly below-average IQ, academic ability, memory, and executive functioning. The combination of poverty and neglect/abuse is also associated with significantly higher diagnoses of developmental delay, ADHD, conduct disorders, anxiety disorders, PTSD, personality disorders, learning disabilities, and emotional/behavioral disorders.
Psychopathy, sociopathy, and antisocial personality disorder are generally synonymous terms that describe a clustering of traits or characteristics such as narcissism, irresponsibility, sensation seeking, risk taking, deception, impulsiveness, lack of remorse, lack of empathy, lack of self-control, and shallow affect. Walsh and Bolen (2012: 163–164) indicate that under the right (or wrong) circumstances,
[a]buse and neglect, combined with prenatal insults to normal brain development, both of which are more common in lower-SES environments, lead to early predisposition to antisocial behavior which, with the right genetic profile, may reach psychopathic/sociopathic proportions. … Thus, this study, along with many others that have looked at the neurobiological consequences of abuse and neglect, shows that children who suffer early socioemotional deprivation can indeed develop a number of the neurobiological abnormalities seen in psychopathy.
Recently, considerable attention has been focused on the prevalence, nature, and consequences of disordered attachment, which tends to be associated with neglect, poverty, parental substance abuse, and other parental psychological disorders. Research has revealed that a lack of a proper attachment relationship (a close, secure emotional bond) between an infant and the primary caregiver has very important consequences for behavior, especially antisocial behavior and violence. The development of a secure attachment relationship intervenes against or mitigates subsequent antisocial behavior and cognitions. A proper attachment relation can mitigate subsequent antisocial and violent behavior by promoting or facilitating the regulation of impulses and emotions, development of empathy and prosocial values, effective management of stress, and development of a positive self-image (Levy and Orlans 2000). Absence of a proper attachment relationship can have substantial consequences for cognitive, intellectual, emotional, and social development, as well as affective and behavioral regulation. The common consequences of disordered attachment include impulsivity, anger, aggression, lack of conscience and empathy, and extreme oppositional behavior.
EXPOSURE TO VIOLENCE
Exposure to violence is largely, though not exclusively, a consequence of poverty, disproportionally affecting low-SES, urban, minority youth. Research indicates that the vast majority of youth living in poor, inner-city neighborhoods have witnessed violence, and over two-thirds have been victims of violence (Fitzpatrick and Boldizar 1993; Scarpa 2001). There are a variety of negative consequences of exposure to community violence, including aggression, PTSD, anxiety disorders, depression, dissociation, impaired academic functioning, lower IQ and reading ability, and lower high school graduation rates (Stein et al. 2003). Clinical research on exposure to violence shows consistent neurological and physiological effects, including dysregulation of the hypothalamic-pituitary-adrenal axis (HPA), which is responsible for regulating the stress response. This dysregulation of the HPA axis can lead to chronic hyperarousal (contributing to hypervigilance), or a dissociative response of reduced responsiveness, which can contribute to depression. Exposure to violence has been shown to result in various externalizing problems, including antisocial behavior, aggression, and violence. Exposure to violence is also associated with internalizing problems such as depression and anxiety (Lynch 2003).
TRAUMA AND POSTTRAUMATIC STRESS DISORDER
Research by Breaslau et al. (1998) estimates the lifetime exposure to one or more DSM-IV defined traumatic events at 90 percent. The most common is the unexpected death of a relative or friend. Assaultive violence is more common among men, low-SES individuals, and nonwhites. Over 50 percent of inner-city residents experienced assaultive violence, compared to 33 percent for residents of other, non-inner-city areas. The estimated probability of any traumatic event leading to PTSD is approximately 9 percent. Assaultive violence poses the greatest risk of PTSD (21 percent). In most cases, research shows PTSD symptoms lasted more than six months.
Additional research utilizing a hospital intercept approach of low-income, nearly exclusively African-American males and females seeking care in primary care and OBGYN clinics at an urban public hospital (Gillespie et al. 2010) found lifetime PTSD prevalence of over 46 percent. The primary source of the originating trauma was interpersonal violence. Alim and colleagues (2006) found similar lifetime PTSD rates (51 percent) for urban African-American subjects in a primary care intercept setting. These high PTSD prevalence rates among poor, urban, minority populations have been replicated time and time again. Moreover, co-morbidity of PTSD with other mental disorders is common. The National Co-Morbidity Survey revealed that among those with PTSD, the co-morbidity rate was 48 percent for major depressive disorder, 22 percent for dysthymia, 16 percent for generalized anxiety disorder, and 30 percent for phobia. Women exhibited more panic disorder and men exhibited co-morbid alcohol and drug abuse, and conduct disorder.
PTSD consists of four primary behavioral clusters: reexperiencing the traumatic event(s), for example having flashbacks; avoiding situations or places that remind one of the event(s); feeling emotionally numb, experiencing memory problems, and trouble concentrating; and feeling anxious or hypervigilant, angry, irritable, and engaging in self-destructive behavior such as substance abuse. Trauma exposure and PTSD can manifest as well in self-destructive behavior, aggression, and mood and personality shifts. Research is clear that traumatic events alter the structure of the brain, fundamentally alter brain development, and can have substantial impacts on the limbic system, which is responsible for controlling emotions, among other things. Freidman (2000) notes in a review of PTSD and brain abnormalities that PTSD is related to impaired cognitive capabilities.
Meta-analysis cited by Polak et al. (2011), as well as research by others (Gilbertson et al. 2001; Johnsen and Asbjornsen 2008; Stein et al. 2003), demonstrate a clear link between PTSD and impaired cognitive and executive functioning. There is additional evidence that the severity of PTSD symptoms is more influential on executive functioning impairment than the character or frequency of the trauma.
The relationship between trauma and antisocial behavior has been well documented. Violent victimization and exposure to violence both heighten the risk of committing antisocial acts and violence, with the common element of trauma. Aggression and criminal behavior are statistically linked to child abuse and its associated traumatic effects. As Ardino (2012) notes, the more common risk factors for PTSD and posttraumatic reactions, antisocial behavior, and aggression are poverty, abuse and neglect, sexual molestation, and exposure to violence in the community or household.
Criminal offenders present with a significantly higher prevalence of trauma and posttraumatic stress disorder and related symptoms. The prevalence of trauma and PTSD among offender populations varies considerably from study to study, with low end rates from around 4 percent to as high as 65 percent lifetime prevalence of PTSD, but more recent research (Goff et al. 2007) found estimates between 4 and 21 percent. There is also clear evidence of co-morbidity of PTSD with substance abuse, and recidivism rates for the combination of disorders are significantly higher than each disorder separately (Ardine 2012).
Looking at this differently, a very high percentage of individuals with PTSD have criminal justice involvement. Donley and colleagues (2012) researched a sample of inner-city individuals at primary care clinics in a metropolitan hospital. The vast majority were African American and poor. The authors found that 88 percent of male civilians with PTSD had been arrested, 87 percent had been jailed, 36 percent had been imprisoned, and 37 percent had been charged with a violent offense, rates much higher than non-PTSD controls. The results show that trauma exposure and PTSD symptoms are both related to significant justice system involvement, although the design was not able to determine whether trauma/PTSD led to justice involvement, justice involvement led to trauma/PTSD, or both.
ATTENTION DEFICIT HYPERACTIVITY DISORDER
Attention Deficit Hyperactivity Disorder (ADHD) seems to be the diagnosis de jure for children engaged in challenging behaviors. However, whether ADHD is overdiagnosed is not the issue at hand. Our concern is the prevalence of ADHD in the criminal justice population, and in turn what we know about the neurological and neurocognitive implications of ADHD. Study after study, in the United States and other nations, among juvenile and adult populations all confirm the hard fact that ADHD is a substantially important risk factor in criminal offending. Prevalence rates among prison inmates range from roughly 25 percent to as high as 65 percent. Co-morbidity for substance abuse is also common, with estimates as high as 85 percent among prison inmates (Walsh and Bolen 2012).
ADHD is clinically defined as ongoing inattention and/or hyperactivity or impulsive behavior occurring in various settings, and uncharacteristic in frequency and severity in terms of the individual’s developmental stage. There are three types of ADHD: the primarily inattentive, the primarily hyperactive/impulsive, and the combined, hyperactive and inattentive. The combined is the most common of the three. Although typically considered a childhood and adolescent disorder, it is clear that depending on the definition and symptoms, significant proportions of cases will persist into adulthood.
The relation between ADHD and crime can be better understood by investigating the neurological implications. ADHD is consistently and substantially linked to deficits of the PFC (again, that part of the brain responsible for executive functioning, moral judgment, and social cognition), including reductions in gray matter volume as well as alterations in PFC circuits and impaired PFC activation in behavior and attention regulation. Behavioral manifestations of ADHD that are relevant for understanding criminality include general executive function deficits, impulsivity, lack of self-control, being present oriented, and an inability to delay gratification.
What Does It All Mean?
First, it does not mean that implicating the brain, genes, and the environment through these examples excuses criminal behavior. This is not an effort to minimize or mitigate culpability or responsibility, or to create new affirmative defenses for defendants going to trial.
What it does mean is that the landscape of criminal circumstance is much broader and deeper than most discussions of criminogenic factors and correctional rehabilitation/treatment. The concern here is not the one-off offenders who make a few bad decisions that lead to limited criminal involvement (the adolescent limited offenders). They will not require the attention and resources that I am discussing. However, many chronic, persistent, habitual offenders have neurocognitive and psychosocial impairments, including spatial and verbal impairments, impairments of memory and nonmemory cognitive function, intellectual impairments, executive dysfunction, and so on. Raine and colleagues (2005) conclude that longer-term habitual offenders (life-course persistent) have pronounced and profound neurocognitive and psychosocial impairments that distinguish them from others. Brain scans comparing antisocial individuals with controls reveal significant reductions in the frontal lobe of the brain (between a 9 and an 18 percent reduction), that part of the brain responsible for executive functioning, among other things. Comparisons of the brains of psychopaths with controls showed deformations in the amygdala and up to an 18 percent reduction in the volume of the amygdala, which is a part of the limbic system responsible for memory and emotional regulation. Other research implicates the amygdala in borderline personality disorder, psychopathy, binge drinking, aggression, and anxiety. A 2005 review of neuroimaging studies of aggressive, violent, and antisocial individuals by Bufkin and Luttrell (2005) shows consistent patterns of brain dysfunction and criminal activity, involving the prefrontal lobe, the temporal lobe, the relative balance of the activity between the prefrontal cortex and the subcortical structures, and the neural circuitry regulating emotion in aggressive and violent behavior. They conclude (2005: 187): “Research emanating from affective, behavioral, and clinical neuroscience paradigms is converging on the conclusion that there is a significant neurological basis of aggression and/or violent behavior over and above contributions from the psychosocial environment.”
These are just examples of the neurological involvement in crime, not an exhaustive discussion of the neurocognitive, neurobiological, and genetic issues relevant to a more comprehensive and accurate understanding of crime, its origins, and correlates. What this means is that it is necessary to look more broadly in terms of understanding criminal risk, screening and assessment of criminogenic needs, and intervention, treatment, and rehabilitation. This accumulating knowledge about neurocognitive and neurobiological implications in criminal behavior provides a greatly enhanced opportunity to obtain much more and much better clinical and criminogenic information. Some of the neurocognitive and neurobiological knowledge will be relevant to assessing criminal risk. It will be relevant for assessing criminogenic needs as well as better understanding the etiology of various criminogenic conditions. Neurocognitive and neurobiological impairments and deficits will constitute some of the criminogenic circumstances that will be the targets of interventions (discussed shortly). This knowledge will inform treatment planning and intervention, in compliance with the responsivity principle of matching treatment to the abilities and circumstances of offenders. For example, Fishbein et al. (2006) and Van Goozen and Fairchild (2008) suggest that neurobiological impairments may negatively disrupt cognitive processing in therapeutic interventions. Cornet and colleagues (2013) suggest that such neurobiological impairments may be a significant source of variation in outcomes of CBT interventions with criminal offenders, in addition to fidelity issues, treatment setting, and other individual offender characteristics.
Neuroplasticity: The Brain Changes
The obvious question as knowledge continues to accumulate about the involvement of the brain and brain functioning in crime is: What can we do? Can this information move beyond just a broader understanding of crime to implementing this knowledge to reduce crime and recidivism? The answer is an unequivocal yes.
Plasticity is a fundamental and intrinsic property of the human nervous system. It refers to changes in neural pathways and synapses, rewiring of neuronal circuits, which result from training, changes in behavior, the environment, neural processes, and bodily injury. Plasticity is the process that permits the brain to modify its genomic restrictions by adapting to environmental stimuli and experiences. This process is one of reorganization and adaptation, whereby the circuits or connections among neurons are established, eliminated, or reinforced. These changes to the connections or pathways among neurons, which occur throughout the lifetime, are a product of stimulation from the environment in a variety of forms. As Pascal-Leone et al. (2005: 377, 396) describe this process:
Behavior will lead to changes in brain circuitry, just as changes in brain circuitry will lead to behavioral modifications. … Plasticity is the mechanism for development and learning, as much as a cause of pathology and the cause of clinical disorders. Our challenge is to modulate neural plasticity for optimal behavioral gain, which is possible, for example, through behavioral modification and through invasive and non-invasive cortical stimulation.
In effect, plasticity means that the brain can and does adapt and reorganize itself according to experience-dependent changes. Robertson and Jaap (1999) outlined a rehabilitation process for individuals with brain impairments, based on the observation that “recovery of neuropsychological functions is achieved largely by the reorganization of surviving neural circuits to achieve the given behavior in a different way” (1999: 544). In developing this rehabilitative process, they note: (1) the brain is capable of a large degree of self-repair through synaptic turnover (synaptic connections changing over time, synapses connecting, disconnecting, reconnecting); (2) synaptic turnover is to a certain extent experience-dependent and is a key mechanism for learning and recovery of function; (3) recovery processes following brain damage share some mechanisms with normal learning; and (4) experiences and inputs available to damaged circuits will shape synaptic interconnections and therefore assist recovery. In effect, reorganization, brain plasticity, neuroplasticity, or nervous system plasticity all refer to a process of regeneration and recovery that is similar to how normal learning occurs, and plasticity is a lifelong characteristic of the brain and the central nervous system.
More recently, Vaske, Galyean, and Cullen (2011) identified research that supports their contention that cognitive-behavioral therapy (CBT) is appropriate for rehabilitation of many criminal offenders. This is based on the processes of brain plasticity and the knowledge that cognitive-behavioral therapy involves areas of the brain that are implicated in criminal offending due to particular structural and functional deficits in those areas, deficits that lead to behavioral manifestations of poor problem-solving, coping, and social skills. Research shows that CBT leads to changes in brain functioning in areas of the brain that are associated with a variety of these skills. Vaske, Galyean, and Cullen (2011: 97) provided compelling testimony about the importance of CBT for correctional interventions:
The ability to show that interventions, such as CBT, activate if not reshape neuropsychological processes opens fresh vistas for demonstrating why treatments are capable of effective, meaningful offender change. Accordingly, efforts to move toward a biosocial theory of offender rehabilitation may provide a powerful rationale for why treatment intervention must be a core goal of the correctional enterprise.
Neuropsychologists have extended the logic of recovery from brain injury to treatment of neurocognitive deficits in criminal justice or correctional populations. As discussed above, executive functioning is often compromised among the offender population as a result of a variety of causes. Those executive functioning deficits are often implicated in crime and recidivism (for example, deficits in planning and decision making, inhibition, cognitive flexibility, and understanding consequences). It is suggested that these deficits are not only related to offending, but also interfere with offenders’ ability to benefit from psychosocial interventions (Ross and Hoaken 2010). These researchers note that there is little evidence to indicate that correctional rehabilitation programs effectively identify, target, and address executive functioning deficits among criminal offenders. They suggest that the effective practices for intervening with executive functioning deficits in those with acquired brain injury (ABI) can be used to develop protocols for treating correctional populations, citing the similarities in the ABI and correctional populations regarding executive functioning. The primary approach is twofold: cognitive retraining, which is designed to assist the brain’s ability to recover functioning through reorganization and regeneration of neural circuitry, and teaching compensatory skills to replace and/or compensate for deficits (Ross and Hoaken 2010). The research on interventions with ABI and schizophrenia patients provide several evidence-based practices (Rohling et al. 2009) and indicate substantial applicability of nonforensic cognitive rehabilitation (such as plasticity-based computer programs and paper and pencil exercises). The research indicates three primary recommendations going forward: individualized functional assessment of executive functioning; individualized functional rehabilitation utilizing a broad-based, multimodal approach that addresses not only the manifested problem, but also the potential contributors; and opportunities for relevant application of skills in the real world. Ross and Hoaken (2010) concluded that implementing appropriate screening and assessment methods with problem-solving skills training and computerized or paper and pencil cognitive rehabilitation programming that focuses on identified deficits and has opportunities for feedback about progress, with application in real-world settings and contexts, should add significant value to the rehabilitation of offenders with executive functioning deficits.
The bottom line is this. Heritability may set an individual’s path in the direction of antisocial behavior and that may or may not be reinforced by experiences, observations, and activities in the environment. Or, independent of any genetic implication, an individual’s experiences may create neural pathways that facilitate antisocial tendencies. The brain can tend toward antisocial behavior and can be further trained toward antisocial behavior by interactions and experiences, an experience-dependent process. Trauma, lack of attachment, brain injury, or growing up in poverty and abuse may create antisocial behaviors. However, neuroscience shows us that the brain is malleable, ever changeable. Knowledge of how neural connections form has provided us with additional tools for behavioral change. By developing new neural pathways or reinforcing others, experience-dependent plasticity can redirect a brain from an antisocial trajectory to a prosocial lifestyle.
By way of example, what is now known about the impact of trauma and PTSD on brain structure and function clearly indicates that the justice system should embrace the tenants of trauma-informed care, which is being disseminated by the Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA’s protocol includes a concerted effort to screen and assess for trauma and PTSD, and incorporate such information into treatment plans. Trauma-informed care treatment services are “interventions designed to address the specific behavioral, interpsychic, and interpersonal consequences of exposure to sexual, physical and prolonged emotional abuse” (SAMHSA 2011)
While cognitive behavioral programming is a primary focus of justice evidence-based practices, the findings from neuroscience indicate that correctional CBT (when implemented according to the EBP standards) may not be enough to effectively change antisocial behavior. In many situations, medication may be indicated. In addition, neuroscience has shown that some actions are deeper in the brain than the prefrontal cortex. These automatic thoughts, feelings, and emotions should be considered in the bigger picture of correctional rehabilitation. Many CBT programs concentrate on thinking and reasoning and tend to ignore the role of emotions. A broader understanding of the role of emotions and how emotions and thoughts impact each other will enhance programming designed to mitigate antisocial behavior.
The point is not to replace CBT. Instead, these observations from neuroscience should be incorporated to enhance and improve CBT. Research indicates significant variation in the outcomes of CBT. Some of that is due to inadequate implementation and failure to adhere to other principles of effective interventions. Some of it is due to not considering and addressing neurodevelopmental and neurocognitive factors. Reasoning and Rehabilitation 2 (R&R2) was developed in Canada at the Cognitive Centre of Canada, University of Ottawa. R&R2 is a neuroscience- and neurocriminology-informed, revised CBT intervention program, which is designed to promote prosocial neurological development. R&R2 is based on research conducted over the past twenty years on motivating individuals, the relationship between antisocial behavior and cognition, the role of emotion in prosocial competence, developing empathy, prosocial modeling, crime desistence, cognitive neuroscience, and relapse prevention. There are several modules focusing on different subgroups. Evaluation results indicate substantial increases in program retention and completion as well as substantial recidivism reductions for a variety of subgroups (Cognitive Centre Canada, cognitivecentre.ca/content/news).
GETTING IT RIGHT
It is time for criminology to embrace the biosocial paradigm. More importantly, it is time for practitioners, professionals, decision makers, and policymakers to appreciate the added complexity of crime due to the evolving understanding of neurocognitive and neurodevelopmental factors and, in turn, what this evolving understanding tells us about what it takes to effectively reduce recidivism. We have been saying for several years now that we have the tools to reduce recidivism. That was premised on the evidence-based practices outlined at the beginning of this chapter. We are now getting the tools necessary to address the neurodevelopmental issues that are so clearly implicated in criminal behavior, as well as desistence from crime. What is left is to get it right.
The opportunity is here for the U.S. criminal justice system to get serious about rehabilitating criminal offenders. Clearly, not all offenders can be treated, and there are many whom we cannot treat or for whom we will not want to try. However, the remaining majority of offenders are those that current (and evolving) knowledge about EBP and neurodevelopmental interventions should be directed.
The evidence is clear regarding what risk factors, disadvantages, situations, circumstances, experiences, histories, deficits, and impairments should be screened and assessed. There are also sufficient knowledge and tools for effectively intervening in many cases. What is required is funding, expertise, and a culture conducive to effective rehabilitation. We need to clarify how we sort those who go to prison and those who we decide to rehabilitate (this is discussed in later chapters). Once we decide to rehabilitate, we need to get serious. Donald Andrews, who is one of the key figures in developing effective correctional rehabilitation principles and programming, says it precisely: program/intervention quality must be a matter of policy (Andrews 2006).
In 2006, the American Psychological Association developed a policy statement on evidence-based practices in psychology (APA 2006). The goal of evidence-based practices in psychology (EBPP) is “to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention” (2006: 280). The following is extracted from the section of the policy statement regarding assessment, diagnostic judgment, systematic case formulation, and treatment planning (APA 2006: 276).
The clinically expert psychologist is able to formulate clear and theoretically coherent case conceptualizations, assess patient pathology as well as clinically relevant strengths, understand complex patient presentations, and make accurate diagnostic judgments. Expert clinicians revise their case conceptualizations as treatment proceeds and seek both confirming and disconfirming evidence. Clinical expertise also involves identifying and helping patients to acknowledge psychological processes that contribute to distress or dysfunction. Treatment planning involves setting goals and tasks of treatment that take into consideration the unique patient, the nature of the patient’s problems and concerns, the likely prognosis and expected benefits of treatment, and available resources. The goals of therapy are developed in collaboration with the patient and consider the patient and his or her family’s worldview and sociocultural context. The choice of treatment strategies requires knowledge of interventions and the research that supports their effectiveness as well as research relevant to matching interventions to patients.
There are many elements of the APA EBPP statement that are fundamental to successful intervention, behavioral change, and recidivism reduction. These include evidence-based assessment and diagnosis that reflects the individuality and complexity of cases; developing case treatment plans based on individual pathology, complexity, assets and characteristics; matching treatments to individual characteristics; and modifying the treatment protocol over time. These are basic principles that should be embedded in all aspects of behavioral change interventions in correctional settings.
Many other professional associations and organizations involved in behavioral health care have similar policy statements regarding professional conduct and evidence-based practices. These include the American Psychiatric Association, which has similar clinical guidelines that reflect evidence-based practices for psychiatric diagnosis, development of a treatment protocol, and ongoing clinical treatment, as well as professional social work, and drug and alcohol treatment. Why should practitioners involved in behavioral change in the criminal justice context be exempt from the practices and guidelines developed for professionals engaged in behavioral change in the free world? Why should efforts at behavioral change in criminal justice be limited in terms of expertise and standards of care? Clearly, they should not, but the current status of correctional rehabilitation indicates they fall short.
In addition to what the research indicates are EBPs, it is obvious that given what we currently know and what we are learning on an ongoing basis, there is a critical need to enhance clinical expertise in addressing the criminogenic needs of offenders. This need is at the beginning of the process in assessment, diagnosis, and development of a treatment plan, as well as in the treatment and aftercare phases. Given the scientific evidence implicating the impacts of poverty, trauma, abuse/neglect, among others on cognitive, emotional, neurodevelopmental, and behavioral functioning, and the numbers of offenders with multiple criminogenic needs (among other considerations), the clinical picture becomes quite complex.
That complexity requires substantial changes regarding clinical expertise in the process of assessment, diagnosis, treatment planning, and intervention. It is not just that probation officers, drug court judges, or prosecutors or trial court judges need to be aware of the complexities of offenders’ situations. They need to recognize where their experience and expertise is insufficient and be able to consult with appropriate clinical experts. This requires not only the ability to know when a situation requires enhanced clinical expertise, but also requires having the resources and the available experts to bring on board. The same considerations apply to correctional treatment programs, whether institutional- or community-based. Treatment providers will need to have the expertise to deal with populations of individuals with complex situations. For example, treatment providers will need to be trained to recognize the impacts of trauma and be able to address those impacts in, for example, a substance abuse treatment protocol.
The point is a simple one to make. If we do not ramp up efforts to proactively and effectively address significant criminogenic needs of offenders with appropriate, evidence-based strategies and expertise, as well as going beyond the standard evidence-based practices in understanding, identifying, and treating offenders’ neurocognitive and neurodevelopmental impairments, we will simply continue to see the revolving door spin. Moreover, we need to be able to identify the spectrum of needs, prioritize them, and develop treatment plans that consider the severity of needs, as well as the appropriate sequence of treatment (that is, in many instances it makes sense to treat substance abuse first because substance use often compromises other interventions). A simple point to make, yet challenging to implement. But if the United States can build the largest prison system in the world, implement substantial changes to sentencing laws nationwide, dramatically change the culture, beliefs, and attitudes about crime and punishment, and launch and fight a monumental War on Drugs, efforts that required massive resources, public support, cooperation, and collaboration of many different constituencies and interests, and significant statutory changes, certainly it can muster the will and the resources to follow what the evidence indicates and get it right. There are many reasons why the stakes are quite high in this effort, not the least of which is the fact that with appropriate and adequate behavioral interventions, we have the ability to prevent millions of avoidable criminal victimizations, reduce crime, and save public revenue.
