CHAPTER 5: FORENSIC TREATMENT

This chapter describes the different types of treatments or interventions that are typically used with the forensic population. Since forensic treatment may encompass many different elements, and since there are many different groups included in the forensic population, we begin by categorizing that population into three general groups based on the extent to which mental disorder is involved in their contact with the legal system. While it has been noted in earlier chapters that the term “forensic” applies to both the criminal and civil sides of the legal system, this chapter discusses only psychological treatments for individuals who come into contact with the criminal justice system, since the psychological treatments that individuals involved with civil litigation or civil commitment receive are no different than those offered to the general public.

With respect to treatment, the criminal forensic population can be broken down into three broadly defined groups. These groups are determined by the extent to which mental disorder is the target of treatment (i.e., intervention). The first group encompasses those individuals for whom mental disorder is the most significant factor in their involvement with the criminal justice system and for whom treatment to target their mental disorder is primary. This group includes those individuals who have been found unfit to stand trial (recall the discussion of fitness to stand trial from Chapter 3) or not criminally responsible on account of mental disorder (NCRMD) (recall the discussion of NCRMD from Chapter 3). The second group encompasses those individuals for whom mental disorder is not a primary target of treatment but is still considered to be a contributing factor to their involvement with the criminal justice system and thus should receive some focus in treatment. Individuals in this group include mentally disordered offenders (MDOs) and sexual offenders, as well as those individuals who are considered to be at high risk for violence and for whom intervention strategies would target risk reduction or risk management. The third group encompasses those individuals for whom mental disorder may play only a minor role in their involvement with the criminal justice system and may or may not be a focus of intervention. This group is composed mainly of offenders who fall under the purview of the criminal justice system (that is, they are either incarcerated or out on probation or parole) and for whom recidivism (re-offending) and rehabilitation are the primary focus of intervention.

Mental Disorder as a Primary Focus of Intervention

For some individuals who come into contact with the criminal justice system, mental disorder becomes a primary issue in their involvement with this system and, as such, becomes the primary focus of intervention or treatment. There are two types of cases in which this occurs: when defendants are found unfit to stand trial (or to proceed with some aspect of their case) and when defendants are found not criminally responsible on account of mental disorder. In these two instances, mental disorder becomes a primary issue in the individual’s involvement with the criminal justice system; thus, the focus of intervention is on that mental disorder.

Unfit Defendants

Consider the following hypothetical example:

Mr. Smith, a 37-year-old white male, was charged with unlawful confinement of his 65-year-old mother after he locked her in the bathroom of her apartment and barricaded the door. Mr. Smith was acting “weird” at the time and was agitated and yelling something about needing to keep his mother locked up so she would not bite him and infect him with rabies. Mr. Smith’s mother was extremely fearful and suffered a non-fatal heart attack while she was locked in the bathroom. Mr. Smith had a lengthy history of mental illness (schizophrenia, paranoid type) and was found unfit to stand trial. He was sent for treatment to restore his fitness.

The processes involving an accused who is found unfit to stand trial include both the judicial and health systems and can be very complex (see Figure 5.1). As you read through this section, consider Mr. Smith in the example above and what type of treatment would be necessary to restore him to competency, and the length of time it would take.Recall from the discussion of the assessment of fitness from Chapter 3 that individuals who are found unfit to proceed are committed for treatment in order to restore their fitness. In most instances, this treatment occurs on an inpatient basis. The defendant is sent to a forensic facility to undergo treatment for some period of time. Although the Criminal Code of Canada permits outpatient commitment for the purposes of restoring competence, this tends to occur less frequently than inpatient commitment.

Approximately 5,000 fitness evaluations are conducted annually in Canada. Both the number of remands for evaluation of fitness and the number of persons found unfit increased steadily between 1992 and 2004—there was a 102 percent increase in the total number of individuals found NCRMD/unfit during this period (Latimer & Lawrence, 2006).1 Latimer and Lawrence project that the population will continue to grow, and by 2015 there will be an additional 2,000 cases of individuals found NCRMD or unfit in the system. They suggest two main reasons for this increase: courts are more likely to find an accused NCRMD or unfit, and more defendants are raising the issue of mental disorder in court.

Treatment of Unfit Individuals

The most common form of treatment for the restoration of fitness involves the administration of psychotropic medication. However, some jurisdictions have established educational treatment programs designed to increase an accused’s understanding of the legal process, or individualized treatment programs that address the problems hindering an accused’s ability to participate in his or her defence (Bertman et al., 2003). In addition, some jurisdictions have implemented treatment programs specifically targeted to those individuals with mental retardation who are found unfit to proceed.

Figure 5.1 Key processes in assessing an accused’s fitness to stand trial

Data was collected from Prince Edward Island, Quebec, Ontario, Alberta, British Columbia, Nunavut, and Yukon. These seven provinces and territories represented approximately 88 percent of cases in the Review Board systems across Canada, so it is reasonable to assume that the report would not be significantly affected by the addition of the remaining 12 percent of the cases in the other six jurisdictions (i.e., Newfoundland, Nova Scotia, New Brunswick, Manitoba, Saskatchewan and the Northwest Territories).

Source: Statistics Canada, Canadian Centre for Justice Statistics, Special Study on Mentally Disordered Accused and the Criminal Justice System (Ottawa: Statistics Canada, 2003), Figure 3.1, p. 13. Accessible here: http://publications.gc.ca/Collection/Statcan/85-559-X/85-559-XIE2002001.pdf.

The success of treatment programs for the restoration of fitness is variable and depends on the type of treatment program and the type of individual targeted. Anderson and Hewitt (2002) examined treatment programs designed to restore fitness in individuals with mental retardation (MR) and found that only 18 percent of their sample was restored. These researchers concluded that, “for the most part, competency training for defendants with MR might not be that effective” (p. 349). Other researchers and commentators have found similar results and have noted the difficulty in treating a chronic condition such as MR (Daniel & Menninger, 1983; Ellis & Luckasson, 1985).

In their study of review boards in Canada, Latimer and Lawrence (2006) found that 39 percent of accused who had been declared unfit were returned to court as fit or had charges dismissed within six months, and almost 82 percent were returned within one year. An examination of the conditions associated with a greater inability to be restored to fitness shows that there are two groups for whom restoration is difficult. The first group is made up of individuals whose unfitness stems from irremediable cognitive disorders, such as mental retardation, whereas the second group is made up of individuals who are chronically psychotic and who have a history of lengthy inpatient hospitalizations (Mossman, 2007).One final note on fitness restoration: in comparison to the literature and research on other aspects of fitness, such as the assessment of fitness, there is a serious lack of literature and research on the treatment or restoration of fitness (Zapf & Roesch, 2011).

Accused Found Not Criminally Responsible on Account of Mental Disorder

Consider another hypothetical example:

Mr. Cook, a 29-year-old white male with a lengthy history of schizophrenia, was charged with trespassing and assault on a police officer after he punched a police officer who was attempting to persuade Mr. Cook to leave the premises of a local grocery store after the store owner complained about Mr. Cook’s loitering. The arresting police officer described Mr. Cook as “agitated and confused.” Mr. Cook was initially found unfit to stand trial and was sent for treatment. He was restored to fitness within four months. Mr. Cook was subsequently found not criminally responsible on account of mental disorder at trial.

The discussion of criminal responsibility in Chapter 3 indicated that a defence claiming an accused is not criminally responsible on account of mental disorder (NCRMD) is rarely used and even more rarely successful (although public perception is that it is used often and mostly successfully). As you read through this section, consider Mr. Cook in the example above. What will happen to him after being found NCRMD? Will he be locked up? How long will he be detained? What criteria will be used to determine when he will be released?

Research examining the characteristics of individuals who have successfully used a criminal responsibility defence shows that this group is mainly “male, between the ages of 20 and 29, unmarried, unemployed, minimally educated, has been acquitted for a violent offense and diagnosed with a major mental illness, and has had prior contact with both the criminal and mental health systems” (Lymburner & Roesch, 1999, p. 215). Latimer and Lawrence (2006), in their study of NCRMD remands, reported that 84 percent of those found NCRMD were male, 68 percent were under age 40, 49 percent had at least one prior conviction (5.5 percent had ten or more convictions), 76.5 percent were charged with a violent offence, and over half had a diagnosis of schizophrenia. Figure 5.2 outlines the general processes involved in a finding of NCRMD.

After Acquittal

The trial judge may decide what happens to an NCRMD offender after trial, or the judge may defer the decision to a Review Board. In general, there are three things that may happen to individuals found NCRMD:

• They may be unconditionally released, in which case they are allowed to leave the court and go home.
• They may be conditionally released, which means they are permitted to live in the community but under certain conditions.
• They may be committed to a mental health facility for treatment.

The Criminal Code directs the decision maker to render a decision that is least onerous and restrictive while satisfying the conditions discussed in the next section. The majority of NCRMD acquittees are committed to public mental health or forensic facilities; it is rare that an individual is simply let go (unconditionally released) at the conclusion of the trial. For those offenders who are placed on conditional release or detained in a mental health facility, the Criminal Code prohibits treatment against the offender’s wishes. However, in some provinces (e.g., British Columbia) all NCRMD offenders are treated under the provincial Mental Health Act, where different provisions might exist for treatment.

Figure 5.2 Key processes in determining criminal responsibility in cases involving mentally disordered accused

Source: Statistics Canada, Canadian Centre for Justice Statistics, Special Study on Mentally Disordered Accused and the Criminal Justice System (Ottawa: Statistics Canada, 2003), Figure 3.2, p. 15. Accessible at http://publications.gc.ca/Collection/Statcan/85-559-X/85-559-XIE2002001.pdf. Reproduced and distributed on an “as is” basis with the permission of Statistics Canada.

The National Trajectory Project (NTP), a large multi-province study of outcomes for those found NCRMD, examined data for a cohort of such individuals in Quebec, British Columbia, and Ontario in the early 2000s. NTP data indicate that approximately two-thirds of the sample was absolutely discharged from Review Board jurisdiction by the end of the study, and the average length of time under Review Board jurisdiction for those who committed violent offences was four years (Crocker, Seto, Nicholls, & Cote, 2013).As discussed in Chapter 3, the majority of NCRMD acquittees have serious, chronic mental illnesses. Data from the NTP indicate that the majority of individuals found NCRMD for violent offences had a psychotic disorder (see Table 5.1).

Criteria for Detention and Release

The Criminal Code directs the decision maker to consider four criteria when deciding whether to detain or release an NCRMD offender: protection of the public, the mental condition of the offender, reintegration of the offender into society, and other needs of the offender. Individuals who have a mental illness and are considered to be dangerous to themselves or others are detained and treated until they are no longer mentally ill and dangerous. These criteria are evaluated annually for each NCRMD offender throughout detention or the period of release with conditions. Once a detained NCRMD offender is no longer considered to be mentally ill or dangerous, he or she is usually conditionally discharged and is permitted to live in the community under certain conditions. Common conditions include taking prescribed medications regularly, being evaluated by a mental health professional periodically, and not carrying a weapon.

Table 5.1 Distribution of Diagnoses for Individuals found NCRMD for Serious Violent Offences

Table information: Missing a diagnosis for one person: N=164. Note: individuals could have more than one diagnosis. Source: From Crocker, A. G., Seto, M. C., Nicholls, T. L., & Cote, G. (2013). Description and processing of individuals found not criminally responsible on account of mental disorder accused of “serious violent offences.” Final report submitted to the Research and Statistics Division, Justice Canada, 2013. Table 3, p. 15. Accessed at https://ntp-ptn.org/NCRMD-SVO-NTPteam_March_2013.pdf. Reproduced with permission of the Minister of Public Works and Government Services Canada, 2013.

Conditional Release

Research examining the rates of conditional release of insanity acquittees shows wide variation across jurisdictions in terms of the proportions of insanity acquittees who are released as well as the types of variables or characteristics related to conditional release (Callahan & Silver, 1998a). An investigation of the factors associated with revocation of conditional release revealed that minority status, substance abuse diagnosis, and a prior criminal history were predictive of having a conditional release revoked (Monson, Gunnin, Fogel, & Kyle, 2001). Factors found to be associated with the successful maintenance of conditional release include being white, married, and employed (Callahan & Silver, 1998b).

Recidivism and Rehospitalization

Research examining recidivism and rehospitalization of insanity acquittees shows (not surprisingly) wide variation by jurisdiction. Lymburner and Roesch (1999) concluded that re-arrest rates during conditional release ranged from 2 percent to 16 percent, with these numbers increasing substantially for longer follow-up periods (i.e., 42 to 56 percent) (p. 230). Heilbrun and Griffin (1993) determined that rehospitalization rates for insanity acquittees on conditional release also varied widely, ranging from 11 percent to 78 percent, but the majority fell between 11 percent and 40 percent.

Treatment Issues for Insanity Acquittees

Salekin and Rogers (2001) provided a review of treatment issues for insanity acquittees. As might be expected, they found that inpatient treatment of insanity acquittees varies by treatment facility. They noted that the most predominant diagnostic category for insanity acquittees is psychotic disorders, with personality disorders being the second most frequent diagnostic category. Substance abuse disorders are also a common co-occurrence for these individuals. Thus, a primary focus of inpatient treatment programs is the reduction or management of psychotic symptoms (such as delusions or hallucinations), most commonly through the use of psychotropic medications. In addition to the administration of medication, specialized treatment programs, such as dialectical behaviour therapy, targeting personality disorders in this group of individuals has been found to be effective in the management of the symptoms associated with violence, suicidality, and substance use (Vitacco & Van Rybroek, 2006).

Of some concern is the apparent focus on primary disorders to the neglect of secondary or co-occurring disorders such as substance abuse. Salekin and Rogers (2001) argue that NGRI patients with substance abuse disorders would gain maximum benefit from treatment programs that address both their primary disorders and their substance abuse disorders. Programs such as relapse prevention training or cognitive-behavioural therapy have been effective in treating substance abuse.

Rogers (1986) noted that although mood disorders, such as depression, are not commonly the primary diagnosis for an NGRI acquittee, a substantial proportion of these individuals experience symptoms of mood disorders at the time of the offence. Rogers also noted that a substantial proportion of insane defendants have experienced severe or pervasive anxiety. Thus, treatment programs that target symptoms such as anxiety and depression in insanity acquittees appear appropriate. In addition to treatments that target symptoms of mental disorder, life skills training, social skills training, and the management of anger, aggression, and violence appear to have a place in the treatment of insanity acquittees (Salekin & Rogers, 2001). Finally, in Canada there are also provisions for community treatment orders and diversion outcomes for some mentally disordered offenders (see Insight 5.1).

Mental Disorder as a Secondary Focus of Intervention

The second group of offenders that we discuss includes those individuals for whom mental illness is not a primary factor in their involvement with the criminal justice system, but it is a factor nonetheless and, thus, should receive some focus in treatment. This group includes offenders who have mental illnesses, sometimes referred to as mentally disordered offenders (MDOs), as well as offenders for whom mental disorder is relevant to their offence behaviour, such as sexual offenders or offenders who are at high risk for violence. Although the term MDO can also encompass those individuals who are found unfit to stand trial and those found NCRMD, we have discussed these groups already and so eliminate them from our discussion here.

Mentally Disordered Offenders

In this section, we assume that the primary emphasis of treatment is the offender’s criminal behaviour; the offender’s mental disorder is a secondary focus of treatment. However, in many cases, treatment programs focus on both mental disorder and criminal behaviour, so attempts to separate these two focuses are unnecessary.

Prevalence of Mental Illness in Jails and Prisons

There is considerable variation in estimates of the proportion of inmates in jails and prisons for whom mental disorder is an issue. Depending upon the type of institution (i.e., jail or prison; see distinction in the next section); the definitions of mental disorder used (e.g., whether estimates include personality disorders and substance use disorders); whether the institution draws inmates from rural, urban, or suburban areas; and the sampling procedures used (i.e., how estimates of mental illness are calculated), rates of mental illness in the offender population can range from less than 5 percent to over 60 percent (Mobley, 2006).

A number of conclusions can be drawn from a review of studies investigating the prevalence of mental illness in jails and prisons. First, there are a large number of people in these institutions with significant mental disorders. Substantial numbers of inmates (perhaps as many as 10 percent) suffer from psychotic disorders, and an even greater proportion (estimates indicate between 15 percent and 40 percent) suffers from depression, anxiety, or other moderate mental illnesses. Larger yet is the proportion that suffers from substance use disorders or personality disorders (estimated at up to 90 percent of inmates) (Ogloff, Roesch, & Hart, 1994). In a 2004 report profiling the health needs of federal prison inmates in Canada, researchers found that 7 percent of inmates at intake had a mental health need that required immediate attention (Correctional Service of Canada, 2004). A higher proportion of inmates reported mental health problems (31 percent of females and 15 percent of males). Moreover, a substantial proportion of incoming inmates (21 percent of females; 14 percent of males) admitted attempting suicide in the preceding five years. A British Columbia study reported similar numbers at the provincial jail level. This study found that the prevalence of major mental disorders in a major metropolitan pretrial jail was 15.6 percent (Roesch, 1995). As well, the prevalence of substance use disorders was exceptionally high, with over 77 percent of inmates considered to have alcohol use or dependence disorders, and over 63 percent with drug use disorders. These disorders cause significant impairment in inmates’ social functioning, both within and outside of the institution. Finally, the rates of mental illness in correctional populations are significantly higher than the rates in the general population from comparable socioeconomic backgrounds (Ogloff et al., 1994; Roesch, Ogloff, Zapf, Hart, & Otto, 1998). Thus, it is clear that mental illness is a significant issue for some proportion of offenders housed in jails and prisons.

The prevalence of mental disorders in jails has led to the development of specialized screening tools devised specifically for mental health screening in jails. For example, in Canada, Nicholls, Roesch, Olley, Ogloff, and Hemphill (2005) developed the Jail Screening Assessment Tool, a semi-structured interview used to screen inmates for mental health concerns, risk of suicide and self-harm, and risk of violence and victimization.

The Distinction between Jails and Prisons

An important distinction exists between jails and prisons in terms of the populations they serve and the types of treatments they are able to offer inmates. Jails are provincial institutions that house defendants at the pretrial stage of proceedings—they have been charged with a crime but not yet convicted. These individuals may have been denied bail or could not meet bail conditions. In addition to pretrial inmates, jails also house offenders who have been convicted and sentenced to a period of incarceration of less than two years. Prisons are under federal jurisdiction and house inmates who have been convicted of a crime and have received a sentence of two years or more. In general, a greater proportion of mentally ill offenders will be found in jails, as compared to prisons, because this is the first point of contact with the correctional system and there is no opportunity to screen out those who might later be diverted or found to be NCRMD.

Mental Health Services in Jails and Prisons

Jails have typically provided little in the way of mental health services, in part because offenders typically have shorter stays and are less able to engage in longer-term treatments, even if they were offered. A national survey of jail mental health services in the United States found that the areas of emphasis in jails were the identification of problems (i.e., screening and evaluating offenders for mental illness, suicide risk, or institutional adjustment problems) and the dispensing of medication. Drug or alcohol services were available in the majority of jails, but psychological counselling was available in less than half the jails surveyed (Steadman, McCarty, & Morrissey, 1989). The situation in Canada is similar, although jails in some of the major metropolitan areas offer screening and treatment services (Nicholls et al., 2005).

As is the case with fitness to stand trial and NCRMD, there are few empirical studies that examine the effectiveness of various types of treatments for MDOs. Thus, this area is ripe for development in terms of both determining the effectiveness of those treatment programs that currently exist and developing alternative treatment programs. What is clear is that effective treatment programs for MDOs must target both the symptoms of mental disorder and the criminal behaviour of the offender.

Sexual Offenders

Sexual offenders constitute only a small proportion of the total number of MDOs; however, various treatment programs have targeted the special needs of this group of offenders. In general, treatment programs for sexual offenders fall into three different categories: nonbehavioural psychotherapy, pharmacological, and behavioural or cognitive-behavioural therapy (Rice & Harris, 1997).

Treatment Programs for Sexual Offenders

A review of the research and literature on these three types of programs indicates that there is little empirical support for the effectiveness of nonbehavioural psychotherapeutic interventions (Rice & Harris, 1997). Pharmacotherapy, the use of drugs as therapy, has proven effective for reducing sex drive in sexual offenders; however, the link between reduced sex drive and reduced sexual recidivism is less clear. Some authors have speculated that offenders who voluntarily accept drugs to reduce their sex drive are already highly motivated for treatment; thus, reduced recidivism in this group may be accounted for by either drug therapy or motivation, or perhaps both (Rice & Harris, 1997).

One of the most important aspects in the treatment of sexual offenders is the monitoring and case management of these offenders once they leave the institution and become integrated back into the community. (Case management and community re-integration are discussed in more detail in the next section.) For many offenders, but especially for sexual offenders, case management and community follow-up are important components of their continued and successful treatment.

Offenders at High Risk for Violence

Examination of the factors related to high risk for violence indicates that certain clinical characteristics are important and should be a focus in the treatment and risk management of these offenders. Risk for violence has been studied in both offender groups and non-offender community samples, and some differences between these two groups have been found.

Mental Disorder and Violence

In non-offender community samples, research suggests that there is a positive relation between some symptoms of mental illness and violent behaviour. For example, 10,000 American adults were surveyed as part of the National Institute of Mental Health’s Epidemiological Catchment Area study, and results indicated that individuals who met criteria for certain serious mental disorders (e.g., schizophrenia, major depression, mania, or bipolar disorder) were six times more likely to self-report violent behaviour within the past year than non-MDOs (Swanson, Holzer, Ganju, & Jono, 1990). In addition, people who met the criteria for substance abuse or dependence were even more likely to self-report being violent. Similarly, researchers in the MacArthur study of mental disorder and violence found that the presence of a co-occurring diagnosis of substance abuse or dependence was a significant factor for violence (Monahan et al., 2001). Link, Andrews, and Cullen (1992) found a positive relationship between psychotic symptoms and violence in a non-offender sample: the greater the number of psychotic symptoms individuals said they had experienced, the greater the number of self-reported recent violent acts. Thus, in non-offender samples, it appears that psychotic symptoms and substance abuse or dependence are important risk factors for violence.

In research that examines samples of criminal offenders, however, it appears that this link between psychotic symptoms and violence is less clear (Rice & Harris, 1997). Instead, diagnoses of personality disorders (especially antisocial personality disorder and psychopathy) and substance abuse have been linked to violent behaviour (Harris, Rice, & Cormier, 1991). It is important to note, however, that in the studies of MDOs, it is likely that psychotic offenders were on medication and thus had their psychoses under control (it is unlikely that a psychotic offender would be released without medication). This may explain the lack of a relation between psychotic symptoms and violence in these groups (Rice & Harris, 1997). Thus, it appears that antisocial personality disorder, psychopathy, and substance abuse are important risk factors for violence in offender samples. It is therefore reasonable to assume that treatment programs and programs for managing risk in offenders should focus on these features.

Treatment of Violent Offenders

The most effective treatment programs are those that target the specific needs of the particular offender. Promising treatment programs for targeting personality disorders and substance abuse include dialectical behaviour therapy and relapse prevention training, respectively. Based on the RNR model developed by Andrews, Bonta, and Hoge (1990), which is discussed in more detail in Chapter 12 of this book, Harris and Rice (1994) examined the treatment literature and offered the following three guidelines for the treatment of violent offenders:

• Risk. More intensive services should be provided to higher-risk cases.
• Needs. Service should target relevant needs of the offender, such as changeable personal characteristics that contribute to the commission of crime. Known relevant targets include changing antisocial attitudes, promoting familial affection and supervision, increasing self-control, replacing lying and aggression with pro-social skills, reducing substance abuse, and improving interpersonal and vocational skills.
• Style of treatment. Behavioural or cognitive-behavioural treatments consistently produce larger treatment effects than other styles of treatment (e.g., non-directive, punitive, insight-oriented, psychodynamic, evocative, and relationship-dependent therapies). In the RNR model this has become known as responsivity, which suggests the treatment programs offered to offenders should be matched to their individual learning styles, motivations, strengths, and abilities.

Treatments based on the RNR model have been shown to reduce recidivism. In one study of a provincial prison, 620 offenders were assigned to either no treatment or treatment groups receiving either 100, 200, or 300 hours of treatment (Bourgon & Armstrong, 2005). A one-year post-release follow-up showed that high-risk offenders who had 300 hours of treatment reduced recidivism from 59 percent to 38 percent. An important finding was that the length of treatment mattered, as high-risk offenders receiving only 100 hours of treatment did not have a lower recidivism rate. Conversely, 100 hours of treatment of medium-risk offenders was enough to reduce recidivism from 28 percent to 12 percent, but increasing the treatment hours did not have any additional impact. The RNR model is discussed in more detail in Chapter 12 of this text.

Difficulties in Implementing Effective Treatment Programs

In general, it appears that we have come to a point in each of the aforementioned areas (fitness, NCRMD, MDOs, sexual offenders, and offenders at high risk for violence) where the focus in the future needs to be on designing, implementing, and evaluating treatment programs. Of course, this is a statement that is easier to make than to fulfill. Numerous obstacles prevent the successful implementation of effective treatment programs, including the fact that, in recent years, the political climate in Canada has become more focused on punishing offenders than on rehabilitating them, as has traditionally been the case. Another major obstacle is the difficulty of implementing behaviourally oriented treatment programs in institutions that are not run in a behaviourally oriented way. That is, the research to date has indicated that the most effective treatments are those that are behavioural in nature, but “the idea that prisons should provide treatment is quite foreign to most staff in correctional institutions. It is difficult to retrain front line medical or security staff to take an approach that emphasizes a behavioural model of patients’ problems, gives patients an active role in their own recovery, and promotes skills training and contingency management as the primary treatment options” (Rice & Harris, 1997, p. 162).

Recidivism and Rehabilitation as the Focus of Intervention

The third group of offenders that we discuss includes those for whom mental illness plays only a minor role in their involvement with the criminal justice system, but whose symptoms of mental illness may become a focus of treatment. As reported, many offenders housed in jails and prisons meet criteria for mental disorders, and an even greater proportion experience some symptoms of mental disorder (especially anxiety or depression), although they may not necessarily meet diagnostic criteria for a particular disorder. In general, treatment programs for those individuals who are not designated as MDOs focus on recidivism rather than on mental disorder or the symptoms of mental disorder, with the exception of substance abuse treatment programs which, technically, focus on issues related to mental disorder, since substance abuse and dependence are relevant diagnostic categories. Thus, our discussion in this section focuses on treatment for general criminal recidivism and substance abuse.

General Recidivism and Rehabilitation

Until the 1970s, the preeminent philosophy in corrections was the rehabilitation, rather than punishment, of offenders. Beginning in the mid-1970s, however, this began to change. More and more, the main philosophy in the United States regarding offenders focused on punishment rather than their rehabilitation. Although this was less true in Canada, recent evidence suggests that more focus on rehabilitation is needed. In the 2010 annual report of Canada’s Correctional Investigator, Howard Sapers raised concerns about the trend of a punitive approach in Canadian prisons. Sapers noted that use-of-force incidents were on the rise in federal prisons, “double-bunking” inmates had increased because of overcrowding, and there were more segregation-like units, which limit offenders’ access to rehabilitation programs. We will review treatment approaches in the next few sections.

Treatment Programs for Recidivism

In general, successful rehabilitation means there is a decrease in recidivism (the likelihood that an offender will commit crimes in the future). Gendreau, Coggin, French, and Smith (2006) examined the vast literature on offender rehabilitation and concluded that a number of variables are associated with successful offender treatment programs. These researchers concluded that treatment programs that are behavioural in nature, that target the criminogenic needs of the offender (that is, the offender’s need to commit crime), and that target the most high-risk offenders are the most effective.

Programs that target the criminogenic needs of offenders focus on changeable variables such as antisocial attitudes and thought patterns, associations with pro-criminal companions, and personality factors, such as poor impulse control and poor self-control (Gendreau et al., 2006). Treatment that helps offenders learn to control their impulses and change their attitudes and thought patterns so they are more pro-social and more likely to associate with non-criminal individuals will reduce the probability that the individuals will commit crimes in the future. Finally, programs that target those offenders who are at the highest risk to reoffend are more effective. Additionally, treatment programs that match treatment providers with offenders based on such characteristics as ability to relate and communicate are most effective. For example, if offenders with lower IQs are matched with treatment providers who can use the more concrete style of communication and thinking these offenders are able to understand and relate to, the treatment will be more effective than if it were provided by people who think and communicate abstractly.

The Effect of Substance Abuse on Recidivism

Substance use is a problem for a large proportion of criminal offenders and is often a contributing factor to criminal behaviour. The vast majority of jails and prisons offer substance abuse treatment programs of some sort; however, the success of these programs is variable.

Treatment Programs for Substance Abuse

A large-scale examination by Miller and colleagues (1995) of the avail able treatment approaches for alcohol abuse indicated that the treatments with the most empirical support are primarily behavioural and cognitive-behavioural approaches, including behavioural contracting, social skills training, behaviourally oriented therapy, and relapse prevention. Those treatments that had the least empirical support included Alcoholics Anonymous (AA), education, lectures, and nonbehavioural therapies. Unfortunately, as Miller and colleagues have pointed out, those treatments that have the least empirical support (such as AA) are the most frequently used in North America.

Relapse prevention, a treatment approach that was originally developed as a means of dealing with substance abuse and other addictive disorders, includes both behavioural skills training procedures and cognitive techniques. This approach has shown success when individuals in treatment can maintain behaviour change and control addictive behaviours. More recently, relapse prevention has been used in the treatment of sex offenders and individuals with other impulsive behaviours, such as domestic violence; it might also prove useful in the treatment of both the psychiatric symptoms and criminogenic needs of MDOs (Rice & Harris, 1997). What appears to set relapse prevention approaches apart from other treatment programs is their strong emphasis on continued monitoring, social support, and general lifestyle change for effective maintenance of the desired behavioural changes. Follow-up and monitoring are crucial components of any successful treatment program.

Community-Based Forensic Treatment

Up to this point, the discussion of forensic treatment has focused on what occurs in some type of inpatient or institutional setting; however, forensic treatment extends into the community and such settings as outpatient clinics, halfway houses, and crisis stabilization units. With the exception of those offenders who have been sentenced to serve life sentences without the possibility of parole, eventually every offender is released back into the community. For some, the criminal justice system maintains some aspect of control over their lives for a period of time through parole or probation. Successful reintegration into the community depends heavily on community-based treatment and monitoring.

Heilbrun & Griffin (1999) present three key features for effective monitoring and treatment of individuals on parole or probation:

• centralized responsibility, with one decision maker or body having primary authority over and responsibility for these individuals
• a uniform system of treatment and supervision
• a network of community services

Heilbrun and Griffin (1999) underscore the “importance of integrating decision making, treatment, and treatment compliance-enhancing strategies, such as careful monitoring” (p. 261).