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R&R for Violent Addicted Offenders in Germany

 

At the Clinic of Forensic Psychiatry in Rostock, Germany, addicted offenders are treated in a closed psychiatric setting. Reasoning and Rehabilitation Program” (Ross, Fabiano & Ross, 1986) was implemented in 2009 in an experimental study with a sample of 31 inpatients randomly distributed among the experimental (R & R) and the control group. Most of the study participants had committed homicide or other serious violent offenses. Prisoners with schizophrenia, organic mental disorders and mental retardation were excluded from the study. The target skills were assessed by treating psychotherapists, primary nurses and by the patients themselves. It was found that problem-solving, awareness of consequences, social perspective-taking, cognitive style, the ability to learn by experience, and persistence in the experimental group were significantly improved. The awareness of consequences has changed significantly as assessed by their psychotherapists, the primary nurses, and the offenders themselves.The current data are similar to our recent work which found significant changes in mental flexibility, plan­ning, and problem-solving (Wettermann et al., 2012, 2011).

Source: A. Wettermann , D. Schläfke , J. M. Fegert (2012) The modification of criminogenic factors on addicted offenders: The effectiveness of the Reasoning and Rehabilitation Program. International Journal of Law and Psychiatry 35, 202206

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R&R2 for Adults with Probationers in Connecticut

The State of Connecticut has been implementing R&R2 for Adults throughout the state with medium and high-risk probationers since 2006. Probationers attend “Alternative (to) Incarceration Centers” in their community on a daily basis to receive the program. A recent evaluation has found that 76.2% of 722 probationers referred to R&R2 completed the program – a remarkable accomplishment given the typically very high rate of drop-outs from programs provided for probationers.

The evaluation also found that probationers who completed R&R2 were more likely to successfully complete probation than probationers who (for various reasons) did not complete the program.

Among the 550 probationers who completed the program 64.5% successfully completed probation. In contrast, of the 172 probationers who failed to complete R&R2, 68.7% failed to successfully complete probation.

Source: Tarallo, Janet R., An investigation into the use of reasoning and rehabilitation II with adult probationers. Thesis - Department of Criminology and Criminal Justice, Central Connecticut State University, 2011

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R&R with Violent, Psychotic Offenders in London

A 2011 randomized evaluation

A randomized control trial of the Reasoning and Rehabilitation (R&R) program with Mentally Disordered Offenders found that participation in the program was associated with improvements in social–cognitive skills, thinking styles and criminal attitudes.

84 men with a primary diagnosis of psychotic disorder and a history of violence in medium-secure forensic units in London England were randomly allocated to receive R&R (n=44) or treatment as usual (control group n=40).

The R&R group demonstrated significant improvements on measures of social problem-solving relative to controls. Some of the benefits were maintained at 12 months post-treatment. Program completers (50% of sample) showed improvements in social problem-solving at the end of treatment and changes in criminal attitudes at 12 months post-treatment.

Source: A multi-site randomized controlled trial of a cognitive skills programme for male mentally
disordered offenders: social–cognitive outcomes. A. E. Cullen, A. Y. Clarke, E. Kuipers, S. Hodgins, K. Dean & T. Fahy Psychological Medicine, 2011,1-13. Online edition.
 

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R&R2 Treatment of ADHD & Antisocial Behavior
A 2011 Randomized Evaluation

Background: Attention deficit hyperactivity disorder (ADHD) is not fully treated by psychopharmacological treatment alone. A randomized controlled trial was conducted to evaluate the benefits of adding to psychopharmacological therapy a cognitive behavior therapy (CBT) group program - the Reasoning and Rehabilitation for ADHD Youths and Adults (R&R2ADHD). The program was developed through an international (U.K./Canada) collaboration (www.cognitivecentre.ca).

Method: 54 adults with ADHD receiving psychopharmacological treatment were randomly allocated to an experimental treatment condition that included R&R2ADHD (n = 27) or to a ‘treatment as usual’ control condition (n = 27) that did not receive the R&R2ADHD program.

Outcome: Measures were obtained 1. before treatment (baseline); 2. after treatment; and 3. at three month follow-up. The measures included a) ratings by independent assessors on ADHD symptoms and impairments; b) self-reported current ADHD symptoms; c) comorbid/associated problems including anxiety, depression, mood instability, antisocial behavior and social functioning.

Results:
Medium to large positive treatment effects of the R&R2ADHD program after treatment were found for symptoms of ADHD and antisocial behavior.
• The magnitude of these effects was even greater at three month follow-up - large positive treatment effects were found for ADHD symptoms,, impairments, and comorbid/associated problems including antisocial behavior.

Conclusions:
The findings demonstrate the effectiveness of R&R2ADHD in reducing ADHD symptoms, improving functions associated with impairment, and reducing antisocial behavior.

Implications:
• R&R2ADHD benefits are robust and multifaceted
• Combined psychopharmacological and R&R2ADHD treatment can improve the benefits of pharmacological interventions.

Reference: Emilsson, B., Gudjonsson, G., Sigurdsson, J.F., Einarsson, E., Baldursson, G., Olafsdottir, H. & Young., S. (2011). “R&R2 Cognitive Behaviour Therapy in Medication-Treated Adults with ADHD and Persistent Symptoms: A randomized controlled trial”. BMC Psychiatry 11:116 doi:10.1186/1471- 244X-11-116. Link (cut and paste into your browser): http://www.biomedcentral.com/1471-244X/11/116
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R&R2 MHP with Mentally Disordered Offenders in England

The "R&R2 for Youths and Adults with Mental Health Problems" program (R&R2 MHP) is currently being delivered in several secure forensic psychiatric hospitals in England. Preliminary results of a controlled evaluation of male patients detained in high and medium security institutions have now been published and are summarized below:

The sample consisted of 70 male patients referred to the program. Fifty-eight were allocated to commencement of the R&R2M programme and 12 were ‘waiting list controls’.

Results:

The program completion rate was 65%

Analysis of records of attendance and the variety of reasons for refusal and/or drop out indicate that the program was "accepted by patients and feasible to conduct with mentally ill forensic patients".

Offenders who completed the program demonstrated significant improvement on two key outcome measures:

1. Violent attitudes (Maudsley Violence Questionnaire - indicates beliefs and rules that may provide support, justifications or injunctions to violence)

2. Disruptive and social problem behaviour (ratings by psychiatric nurses ).

The report concludes that these data suggest that"the program was successful in bringing about a positive change on the two primary outcome measures relating to its underlying aims – the reduction of antisocial thinking and behaviour".

Source: Young S., Gudjonsson, G. & Chick, K. (2010) A preliminary Evaluation of Reasoning and Rehabilitation 2 in Mentally Disordered Offenders (R&R2M) Across Two Secure Forensic Settings in the United Kingdom. Journal of Forensic Psychiatry & Psychology, 21 January 2010 (iFirst).

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OFFENDER PATIENTS IN LONDON

A 2010 preliminary review of the results for seven patients at the Cygnet Wing Blackheath Hospital in London in a multi-centre trial of R&R2 for Youths and Adults with Mental Health Problems indicates inter alia that:

“the R & R II group program is an important tool in attitudinal change. Although participants did not evidence reduced scores in some of the factors assessed e.g., internal motivation to engage in treatment, some areas of social problem solving and their reactions to provocation, importantly, their attitudes toward violence seemed to be more pro-social and their acceptance of violence seemed to decrease. This is a similar finding to previous research, e.g., Young, Chick & Gudjonsson, (2009)”

“ some participants demonstrated a reduction in negative problem solving, an increase in rational problem solving, improvement in how they make sense of a provocative situation, and an increased sense of having control over their lives”.

“Clinically, there appeared to be important ‘group therapeutic factors’ which were of benefit to group members such as increased cohesion, alleviating hospital related anxiety, and a sense of universality”.

Source: ttp://www.cygnethealth.co.uk/locations/blackheath/reasoning-and-rehabilitation2.html

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CANADIAN PENITENTIARIES

A 2009 evaluation report of outcomes for non-Aboriginal male offenders revealed the following for male R & R participants:

changes in attitudes and beliefs that are consistent with program targets

• less likely than the comparison group to be readmitted for any reason (including technical revocations), a new offence, or a new violent offence.

• 31% less likely to return to custody for a new offence

• 27% less likely to be readmitted after release for any reason

• 49% less likely to be readmitted with a new violent offence.

Source: Evaluation Report: Correctional Service Canada’s Correctional Programs, 2009Note: Canadian penitentiaries house offenders sentenced to 2 years or more.

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U.K. National Institute for Health
Clinical Excellence Guidelines

The National Institute for Health and Clinical Excellence (NICE) for England and Wales provides guidelines based on the best available research evidence to inform patients, professionals and the public about appropriate treatment for specific conditions. NICE guidelines for interventions to reduce offending and other antisocial behaviours were developed in 2009 by the National Collaborating Centre for Mental Health of the Royal College of Psychiatrists and the British Psychological Society for two groups of individuals:

1. Antisocial Personality Disorder: The NICE guidelines identify as the "Key priorities for implementation" - "group-based cognitive and behavioural interventions such as Reasoning and Rehabilitation".

2.Psychopathy or dangerous and severe personality disorder: The NICE guidelines recommend cognitive and behavioural interventions such as Reasoning and Rehabilitation. Moreover, the guidelines highlight the necessity of providing on-going follow-up and ensuring close monitoring and also extending the nature of R&R by providing booster sessions and individual sessions - both are now enabled by all R&R2 programs.

Source: NICE (January 2009), Antisocial personality disorder: Treatment, management and prevention. Quick reference guide. www.nice.org.uk/CG77

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R&R Cost-Benefit Analysis

NICE published its cost benefit analysis of Reasoning and Rehabilitation in a 2010 report. The report concludes:

"Group-based cognitive behavioural interventions delivered as Reasoning and Rehabilitation programmes are potentially cost effective in the UK setting. The cost of providing the Reasoning and Rehabilitation programme to an adolescent with offending behaviour was estimated at £121 (2006/7 prices). The reduction in the re-offending rates by providing Reasoning and Rehabilitation to adult offenders yield "cost savings equalling £869" per adult offender over 1 year.

Because Reasoning and Rehabilitation programmes costs £637 per adult offender, the intervention yields an "overall net saving of £232" per adult offender over 1 year. "The intervention became cost neutral over 1 year". Ross & Hilborn stress in their 2008 book, Rehabilitating Rehabilitation, that "the goal of reducing recidivism or re-offending has become the sine qua non of offender treatment programs and the marker of the success of the offender rehabilitation movement. Whereas such a goal may be appropriate to one of the primary purposes of the criminal justice system, it fails to do justice to the many other problems of offenders. We may reduce their  offending but we often leave them to continue to drain the social services system".

NICE also recognizes that assessment of the benefits of R&R should not be limited to recidivism. Its cost-benefit analysis concludes:

Reasoning and Rehabilitation "reduces offending behaviour and this can potentially lead to a reduction in other costs such as healthcare costs and social benefit payments...Other costs, such as healthcare costs and emotional distress of victims, the financial and economic burden to the families of both victims and offenders, and the feelings of fear and insecurity at anticipation of crime were not considered in most documents reporting cost data on offending behaviour. Consideration of these factors might increase the reported figures on cost-savings resulting from reduction in offending behaviour achieved by offering Reasoning and Rehabilitation programmes to adult offenders".

Source: The British Psychological Society and The Royal College of Psychiatrists (2010). Antisocial Personality  Disorder: Treatment, Management And Prevention. National Clinical Practice Guideline Number 77 National  Collaborating Centre for Mental Health commissioned by the National Institute for Health & Clinical Excellence. Note: NICE publications can be obtained at www.nice.org.uk/CG77 or by email: publications@nice.org.uk; or by phone 0845 003 7783.

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R&R2 for Adults in Spanish

A Spanish translation of the R&R2 for Adults program has been developed by Dr. RITA MARTÍN CABALLERO and Dr. JUAN MANUEL BETHENCOURT PÉREZ at the Universidad de La Laguna in the Canary Islands where R&R has been implemented and its efficacy demonstrated for many years - most recently with drug addicts in Tenerife. Contact cognitivecentre@gmail.com for information.

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Motivating Offenders for R&R in Spain - A Six Year Follow-up

A recent study in Spain's Canary Islands has confirmed that providing a "goal oriented approach" such as helping offenders to attain and maintain a job "increases offenders' motivation to engage in the R & R program and therefore enhances its effects on recidivism".

A quasi-experimental study of 117 high-risk repeat offenders, serving sentences for drug dealing, property offences, and offences against the person found that offenders who in addition to R&R training also received "social and employment integration" had lower recidivism than those who received only R&R and those who received neither of those interventions. "Social and employment integration" (SEI) was designed not to increase work skills (as in vocational training programs), but to help offenders find and keep a job by arranging contact with instructors and employers and by fostering the prosocial behaviours required for successful job performance.

Employment training has been a staple international core curriculum of correctional programming for decades. However, this new study confirms earlier research (Martín and Hernández,1995; Martín, Hernández, and Hernández-Fernaud, 2004) which found that vocational training in itself had a very small impact on reducing recidivism when compared to R&R training and to social and employment integration. Moreover, the recidivism benefits of combining R&R training with social and employment integration was greater than implementing social-cognitive skills training or social employment integration on their own.

The long-term benefits of combining R&R with social and employment integration have now been demonstrated by this recent study with a six year follow-up.

Results:

The six-year follow up found that that R&R had a significant positive effect on delaying ex-offenders’ recidivism.

R&R: 18%

R&R + SE:I 27%

Moreover, "the R&R+SEI group evidenced a stable probability of survival (absence of reoffending) over time and a lower rate of recidivism particularly in the late part of the follow-up.

Note: The Spanish version of R&R has been implemented in Spain and in South America since 1996 (Ross, R., Fabiano, E., Garrido, V., & Gómez, A. ,1996)

Source: Martín, A.M., Hernández, B., Hernández-Fernaud, E., Arregui, J.L. y Hernández, J.A. The enhancement effect of social and employment integration on the delay of recidivism of released offenders trained with the R &
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R&R with Prisoners In Iran

The efficacy of a program based on R&R with prisoners in Iran has been demonstrated in a recent experimental evaluation with prison inmates. "About a third of the inmates had committed robbery, about a fourth assault and battery, and about a fifth murder. Nine percent had committed fraud, 8 percent rape, and 8 percent drug
dealing".

"Nearly a third had mental disorders prior to conviction (primarily anxiety, depression, somatization, and obsessive-compulsive disorder)".

Approximately 50% had a history of illicit drug use.

180 prisoners were randomly assigned to one of three groups:

1: individual treatment; 2.: group + individual treatment; 3: controls

Results:

A. Psychological Functioning:

1. Prisoners who received individual the program or individual plus the group program improved significantly more than controls on several measures of psychological functioning (General Health Questionnaire; Symptom Checklist-90-Revised and diagnostic interviews based on DSM-IV).

2. Prisoners who received both individual and group programming improved even more on these psychological functioning measures than prisoners who received only the individual program.

B. One year recidivism:

Control group:                             15 %

Individual-plus-group program:   0%

Source: Psychiatric News (November 20, 2009) and online in the International Journal of Offender Therapy and Comparative Criminology (August 31, 2009)

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R&R with Drug Abusing Offenders in Tenerife, Canary Islands

Dra. Dª A. Rita Martín Caballero conducted an evaluation of the efficacy of R&R with drug addicts in a Day Treatment Centre in Tenerife in the Canary Islands.

The quasi-experimental design pre-post treatment study examined outcome for 58 adult drug abusers receiving the R&R program compared with 177 comparison subjects who did not receive the R&R program. The program consisted of the R&R program adapted for a spanish population with additional emphasis (consistent with the new R&R2 programs) on emotional control (specifically training on attributions, self efficacy and
relaxation techniques).

Results:

Statistically significant differences in favour of the R&R group compared to controls were found in improvements on each of the items in tests of the following: Alternative thinking; Causal thinking; Consequential thinking; Social perspective taking; and Means - End reasoning

Source: Dra. Dª A. Rita Martín Caballero; Dr. D. Juan Manuel Bethencourt Pérez; Dr. Pablo García Medina; Dr. Arquímedes Fernández Valdés; Dr. Gustavo Ramírez Santana (2009). Valoration and Training in Social Competence in drug addicts: a specific implementation with users of the Day Center "Cercado del Marqués".

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R&R with Mentally Disordered Offenders in London

A quasi-experimental evaluation of the efficacy of R&R with male offenders with psychotic disorders was conducted in forensic medium security hospitals in London.

Results:

Psychosocial functioning (problem solving ability and coping) improved after treatment among offenders who received the full R&R program.

Source: Clarke, A.Y., Cullen, A.E., Walwyn, R. and Fahy, T. (in press) A quasi-experimental pilot study of the Reasoning and Rehabilitation programme with mentally disordered offenders. Journal of Forensic Psychiatry and Psychology.

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R&R for Adult Probationers in Jersey, Channel Islands

A 2009 analysis of the outcome over a three and a half year period for probationers in Jersey on the Channel Islands has been reported.

Results:

Statistically significant reductions in risk of re-offending for those receiving the R&R program.

These results support and extend the positive results of two previous evaluations (2001 and 2004).

Source: Dr Helen Miles, Professor Peter Raynor, Ms Brenda Coster (2009) Community Sentences and their Outcomes in Jersey: the third report. http://www.cepprobation.org//uploaded_files/Jer%20rep%20csm.pdf

Earlier reports: 1. Raynor, P. & Miles H. (2001) Risk, Needs and Re-offending: Evaluating
the Impact of Community Sentences in Jersey, University of Wales, Swansea. 2.Miles, H.
& Raynor, P. (2004) Community Sentences in Jersey: risks, needs and rehabilitation. St.
Helier: Jersey Probation and After-Care Service.

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R&R for FINLAND PRISONERS

An evaluation of a 2 year follow-up of prisoners in Finland receiving R&R found the following:

Completion rate among 294 offenders: 66%

•Recidivism ( a new sentence) after 2 years:

Control group:              65%

R&R completers:         49 %

• Probability of recidivism:

average prisoners: 50.6%

average R&R completer: 18.5 %

(difference is about 32 per cent)

•No significant difference between control group and drop-outs.

•No significant difference between controls and R&R completers if prisoners have been in prison 10 or more times

Source: O. Honka, A. Keinänen & S. Tyni (2010)The Impact of Cognitive Skills Training on Post-release Recidivism. University of Eastern Finland (power point presentation). Anssi Keinänen, University of Eastern Finland, anssi.keinanen@uef.fi

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Prevention of Antisocial Behavior in ADHD Children

A Consultant for the Cognitive Centre of Canada, Dr. Susan Young, has announced the launch of the RAPID program – a group program that teaches cognitive, social and emotional skills and moral values to boys and girls (age 9-12) who have some, if not all, of the problems associated with ADHD (e.g. inattention, impulsive behavior, emotional lability, disruptive and oppositional behavior, poor social competence). The cognitive-behavioral, psychoeducational program is designed to enable children to develop better self-control, improve their neurocognitive functioning, problem-solving ability and interpersonal functioning and, thereby reduce their
behavioral problems and increase their academic achievement. The program targets problem behaviors before they become habitual. Dr. Young is a Senior Lecturer in Forensic Clinical Psychology in the Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King’s College in London, UK. and Honorary Consultant Clinical and Forensic Psychologist to the Broadmoor Hospital for mentally disordered offenders.

Reference: Young. (2009). RAPID: Reasoning and Problem Solving for Inattentive Detectives. London: Psychology Services Limited. For information contact PsychLtd@aol.com