Working Alliance and Its Relationship With Treatment Outcome in a Sample of Aboriginal and Non-Aboriginal Sexual Offenders

The Risk, Need, and Responsivity Relevance of Working Alliance in a Sexual Offense Treatment Program: Its Intersection With Psychopathy, Diversity, and Treatment Change

The current study examined the self-reported working alliance of men attending a high intensity sexual offense treatment program and its associations with psychopathy, sexual violence risk, treatment change, and recidivism, in a Canadian sample of 317 incarcerated men followed up an average of approximately 10 years post release. Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-reported total, Task, Bond, and Goal scores were positively correlated with treatment related changes in risk, and inversely associated with Psychopathy Checklist-Revised (PCL-R; Hare, 1991; Wang & Hare, 2003) scores. The Affective facet of the PCL-R, representing the callous-unemotional features of the syndrome, uniquely predicted lower Bond and Goal scores controlling for the other facets. Cox regression survival analyses demonstrated that sexual violence risk predicted increased sexual recidivism while change predicted decreased sexual recidivism controlling for PCL-R total score; however, WAI scores (particularly the Goal component) were also unexpectedly associated with increased sexual recidivism. For violent recidivism, psychopathy, risk, and change incremented the prediction of general violence, while the WAI was not significantly associated with this outcome. A set of parallel analyses, stratified by Indigenous ethnocultural heritage, demonstrated some continuity, but also potential areas of difference, in substantive findings. Risk, need, responsivity implications of the working alliance for the treatment of high psychopathy correctional clientele, and how this may intersect with Indigenous heritage, are discussed.

Culturally appropriate psychotherapy and its retention: An example from Far North Queensland (Australia)

BACKGROUND

Culturally appropriate mental health care is essential in remote Australia. However, while associated with the development of an effective therapeutic alliance, current literature insufficiently reports the retention and psychotherapy outcomes of Indigenous adults. We aimed to describe the characteristics and retention of clients attending the Far North Mental Health and Wellbeing Service (FNS).

METHODS

We conducted a retrospective cross-sectional study on clients who received one or more psychotherapy consultations between 1st July 2019 and 31st December 2020. Population, entrance, and treatment characteristics were described, with retention compared between the major cultural groups. Entrance characteristics comprised referral pathway and reason for presentation and were investigated as alternative predictors of client retention.

FINDINGS

There were 186 non-Indigenous (68.3 % female) and 174 Indigenous (62.6 % female) clients, with a median number of 3.0 consultations (IQR 2.0-5.3). Indigenous status did not significantly predict retention. Referral pathway significantly predicted the number of consultations (Wald X2(6) = 17.67, p = .0071) and immediate discontinuation (Wald X2(6) = 12.94, p = .044), with self-referred clients having the highest retention. Initial presentation reason significantly predicted the number of consultations (Wald X2(5) = 13.83, p = .017), with clients with potential health hazards related to socioeconomic and psychosocial circumstances having the lowest retention. Significantly more Indigenous clients presented for this reason (20.1 % vs 4.3 %).

INTERPRETATION

Comparable retention of Indigenous clients suggests cultural appropriateness of the psychotherapy being delivered by the FNS. Services might use the described therapeutic approach as a guide for culturally appropriate care.

Who With Whom: Matching Therapist and Client in Correctional Institutions

The current study investigated variables that are being considered when assigning psychotherapists to individuals convicted of sexual and violent offences. Its main aim is to inform practitioners and researchers alike of potentially beneficial combinations between therapist and client and infer hypotheses for future studies. A mixed-methods approach, combining interviews and a follow-up questionnaire, was employed. Nineteen interviews with forensic practitioners working in socio-therapeutic facilities in Germany were conducted. Relevant matching criteria were extracted from all interviews. 1.) Capacities of therapist, 2.) therapist's professional background, 3.) (severity of) clinical disorder, 4.) personal fit, and 5.) fit of client into existing groups emerged as top five matching criteria. Directive therapists were viewed as a good match for antisocial or psychopathic offenders. Opinions diverged regarding personality similarity or complementarity in client-therapist dyads. A flexible matching approach may offer unique strengths to enhance treatment outcome. Implications and ideas for future research are discussed.

Treatment Satisfaction in a Civil Commitment Facility for Sexually Violent Persons

Evaluating patient satisfaction in therapeutic settings is consistent with a Risk-Needs-Responsivity (RNR) model. This study provides results from a program improvement initiative in a sexually violent person (SVP) civil commitment facility that queried patients and treatment providers about their satisfaction with therapeutic processes and assessment methods. Overall, patients reported high levels of satisfaction with treatment at the facility, with the highest levels of satisfaction on items about being treated with kindness and respect and staff acting professionally. Providers rated current assessment methods such as the Penile Plethysmography (PPG) assessment, polygraph testing, and neuropsychological testing as most helpful for patients in treatment progress; however, patients rated PPG assessment and polygraph testing as the least helpful of the assessments conducted. Soliciting patient feedback periodically could be important for maintaining treatment engagement and discovering opportunities to enhance patient satisfaction to treatment in a SVP civil commitment setting.

Forensic Experts' Perspectives on Australian Indigenous Sexual Offenders and Factors Important in Evaluating the Risk of Recidivism

Law and ethics require that risk assessment should be cross-culturally valid and fair, but Australian research in this regard is underdeveloped. A logical first step in progressing the work required to build a strong evidence base on culturally sensitive risk assessment in Australia is to determine the expert views of those in the field. We interviewed 13 Australian evaluators who assess Indigenous sexual offenders' recidivism risk to determine their perceptions of the risk assessment instruments they use and the attributes they believe evaluators doing cross-cultural assessments should have. Our central findings are that evaluators use the available instruments because they believe that the same factors predict sexual recidivism for Indigenous and non-Indigenous offenders, but that they do so cautiously knowing the limitations of the instruments. Evaluators nevertheless want more research data to guide them when they use the available instruments to assess people from cultures that differ from those of people in the normative sample. Participants acknowledge that the unique challenges of assessing Indigenous sexual offenders require non-Indigenous evaluators to be culturally competent and confident. These findings should be valuable to evaluators and those who train or supervise evaluators and/or intend to establish or improve the validity of risk instruments in Australia.

Sexbots as Synthetic Companions: Comparing Attitudes of Official Sex Offenders and Non-Offenders

This is the first Italian study to examine views on sexbots of adult male sex offenders and non-offenders, and their perceptions of sexbots as sexual partners, and sexbots as a means to prevent sexual violence. In order to explore these aspects 344 adult males were involved in the study. The study carried out two types of comparisons. 100 male sex offenders were compared with 244 male non-offenders. Also, sex offenders were divided into child molesters and rapists. Preliminary findings suggest that sex offenders were less open than non-offenders to sexbots, showed a lower acceptance of them, and were more likely to dismiss the possibility of having an intimate and sexual relationship with a sexbot. Sex offenders were also less likely than non-offenders to believe that the risk of sexual violence against people could be reduced if a sexbot was used in the treatment of sex offenders. No differences were found between child molesters and rapists. Though no definitive conclusion can be drawn about what role sexbots might play in the prevention and treatment of sex offending, this study emphasizes the importance of both exploring how sexbots are both perceived and understood. Sex offenders in this study showed a high dynamic sexual risk and, paradoxically, despite, or because of, their sexual deviance (e.g. deficits in sexual self-regulation), they were more inclined to see sexbots as just machines and were reluctant to imagine them as social agents, i.e. as intimate or sexual arousal partners. How sex offenders differ in their dynamic risk and criminal careers can inform experts about the mechanisms that take place and can challenge their engagement in treatment and intervention.

[Therapeutic Factors in Offender Treatment: A Systematic Review]

This paper presents a systematic literature review of international research on therapeutic factors in offender treatment. The review was based on the PRISMA criteria; PsycINFO and PSYNDEX as well as references given in included studies were browsed. Only quantitative empirical studies published between 1990 and 2018 were included. In this paper, evidence for common factors (therapeutic alliance, social climate, feedback) and therapist factors (interpersonal skills/characteristics, personality, therapy expectations) from 19 journal articles are reported. Some tendencies emerged, but there was no conclusive evidence on the effect of common factors and therapist factors on the therapy outcome. This non-conclusive evidence is mostly due to the methodological shortcomings of primary studies, heterogeneity of outcome variables and the low number of studies that looked at each of these variables. In sum, there is not enough evidence to date to show a strong relationship between common factors and therapist factors and a (positive) outcome in the treatment of offenders.

An Exploration of Service Providers' Experiences With Latinos Convicted of a Sex Offense

Despite the growing Latino presence in the U.S. criminal justice system and among those who have committed sex offenses specifically, little is known about the barriers and challenges faced by this population when accessing treatment services. This study sought to gather more information about responsivity factors that may be specific to Latinos who have committed sexual offenses. Service providers who worked with Latinos convicted of sexual offenses completed an online survey and answered questions regarding perceived challenges and barriers they encountered when working with Latino clients and were asked to provide recommendations concerning services and treatment provision. Service providers frequently reported issues related to a lack of culturally sensitive services, bilingual professionals, and clients' limited knowledge about the U.S. legal system. Among service providers with experience working with undocumented Latino immigrants, some indicated specific challenges such as stressors related to their immigration status and a lack of resources. Professionals' recommendations were consistent with the challenges reported and findings are discussed as they pertain to responsivity issues in the provision of treatment services to Latino individuals who have committed sexual offenses.

The role of therapeutic alliance in therapy for adults with problematic aggression and associated disorders

The nature and quality of the relationship between therapist and client in psychotherapy, known as therapeutic alliance, have been proposed as one of the most important factors for successful treatment outcome, which has been has robustly supported across many types of treatment, populations, raters of alliance (i.e., client, therapist, or observer), and alliance measures. However, most research on alliance and treatment outcome has been conducted in children and adults with internalizing problems (e.g., mood and anxiety disorders) or children with externalizing problems (e.g., conduct disorder), despite the fact that alliance may be particularly important for adults with externalizing problems such as problematic aggression, who may have high levels of resistance, blaming, and interpersonal problems. Very limited research has examined the role of alliance in individuals who present to treatment due to high levels of aggressive behaviour specifically (e.g., those convicted of a violent offence). The current systematic review examined the extant research on the relationship between alliance and outcome in treatment of highly aggressive individuals, as well as those who are diagnosed with a disorder for which aggression is a primary symptom (i.e., post-traumatic stress disorder, antisocial personality disorder, and borderline personality disorder). Overall, it was shown that alliance has a positive impact on treatment outcome among those engaging in or at risk for problematic aggression. Additionally, the alliance-outcome relationship may be affected by therapy modality, alliance rater perspective, and potential mechanisms of alliance. Implications for future research, including utilizing more primarily aggressive samples, are discussed.

Working Alliance and Psychopathy: Linkages to Treatment Outcome in a Sample of Treated Sexual Offenders

The present study examined the working alliance, as measured by the full-length Working Alliance Inventory (WAI), and its association with psychopathy, treatment completion, and recidivism in a sample of 111 incarcerated adult male sexual offenders. The men completed the WAI 3 months into their treatment program, while psychopathy was measured via file-based ratings of the Hare's Psychopathy Checklist-Revised (PCL-R), and outcome data were collected via the Canadian Police Information Centre. The majority (85%) of high PCL-R scoring men (PCL-R 25+) successfully completed their treatment program, and by and large, the men demonstrated strong working alliances with their primary therapists. The WAI scale components showed differential associations with the structural features of psychopathy. Specifically, the Affective facet was significantly associated with weaker Bond scores, while the Lifestyle facet was associated with lower Task scores; these results were upheld after controlling for scores on the other PCL-R facets. Strength of alliance, however, was not significantly associated with any recidivism outcomes, irrespective of controls for psychopathy. Implications for the treatment of offenders with high levels of psychopathic traits are discussed in light of extant findings and unique features of the therapeutic alliance.

Determinants of Dropout From Correctional Offender Treatment

Research indicates that approximately one third of offenders admitted to social-therapeutic correctional facilities in Germany fail to complete treatment and that treatment dropout is linked to higher recidivism in both sexual and violent offenders. The purpose of this study was to examine determinants of treatment dropout in a social-therapeutic correctional facility in Germany. The sample consisted of 205 incarcerated adult male offenders (49.8% sexual, 38.1% non-sexual violent) admitted to correctional treatment. Completers and dropouts were compared on variables pertaining to demographics, offense type, substance abuse, psychopathy, risk, and protective factors. Univariate analyses showed that treatment dropouts demonstrated significantly higher scores on measures of risk and psychopathy and lower scores on protective factors. Logistic regression analyses identified unemployment, non-sexual violent index offense, higher risk scores (HCR-20), and Facet 1 (interpersonal deficits) of the Psychopathy Checklist-Revised (PCL-R) as significant predictors of treatment dropout. Surprisingly, substance abuse disorder was a negative predictor of dropout. With the exception of substance abuse, the results support the notion that treatment dropouts represent a group of high-risk offenders with particular treatment needs. Practical implications and suggestions for further research are discussed.

Therapeutic Climate Within a Treatment Program for Categorical Deniers

The purpose of this study was to examine whether the therapeutic climate within a sex offender "deniers" program, where denial was not challenged, would be equivalent to the therapeutic climate within a conventional program where sex offenders were admitting responsibility. Using a sample of 77 sex offenders, therapeutic alliance and group climate were measured early and late in treatment. As expected, therapeutic alliance was more difficult to attain with deniers early in treatment, particularly therapeutic bond; however, by the end of the treatment, there were no significant differences in therapeutic alliance. There did not appear to be significant differences in group climate early or late in treatment except for the deniers reporting significantly lower levels of open expression of anger and disagreement within the group and, in contrast to the admitters, making significant improvements in group climate over time. Implications for the treatment of categorical deniers and further research suggestions are discussed.

The Role of Psychopathic Traits in the Development of the Therapeutic Alliance Among Sexual Offenders

There is a growing body of research demonstrating that the therapeutic alliance (TA) affects outcomes among specialized forensic populations, including sexual offenders. Despite this consensus, researchers continue to question whether higher levels of psychopathic traits are conducive to the formation of a therapeutic relationship for high-risk sexual offenders. Thus, the current study adds to the literature by examining the relationship between the TA and levels of psychopathy among a sample of incarcerated sexual offenders participating in sexual offender treatment. Overall, we found no significant relationships between Psychopathy Checklist-Revised (PCL-R) scores and the Working Alliance Inventory (WAI) for either client or therapist ratings. However, when we excluded those offenders who were participating in aftercare, a significant negative relationship was found between client ratings of the Bonds subscale and PCL-R total scores. Next, after controlling for risk and group status (aftercare/non-aftercare), we found no significant differences between either client or therapist total WAI scores when compared by level of psychopathy as measured by the PCL-R (low, >20; moderate, 20-30; and high, >30). Furthermore, when Factor 1 and Factor 2 scores of the PCL-R were examined individually, neither factor significantly predicted either client or therapist total WAI score after controlling for risk and group status. Findings are discussed as they pertain to the treatment of sexual offenders with elevated levels of psychopathic traits.

Sexual Offender Treatment Readiness, Responsivity, and Change: Linkages to Treatment Completion and Recidivism

This study examined the interrelationship of treatment readiness, responsivity variables, and treatment change to sexual offender treatment outcome, featuring the Treatment Readiness, Responsivity, and Gain Scale: Short Version (TRRG:SV). The sample was composed of 185 Canadian federal offenders who attended a high-intensity sexual offender treatment program and were followed up an average of 9.3 years postrelease. Men with higher levels of education, employment history, and cognitive ability and who were married or equivalent, did not have a serious mental illness or intellectual disability, and were not actuarially high risk tended to show higher levels of treatment engagement across the TRRG:SV subscales. Significant pre-post changes, denoting improvement, were observed on the TRRG:SV. In turn, positive treatment engagement assessed by the TRRG:SV was associated with increased risk-relevant treatment change, decreased program attrition, and reductions in sexual and violent recidivism, even after controlling for baseline risk. The role of attention to responsivity variables and treatment readiness to promote client engagement and maximize therapeutic benefit is underscored.