Serious and violent offending : psychological risk factors and treatment effectiveness

Background: Violent crime causes extensive suffering and costs to individuals and societies and is a major global health issue. Prevention of violence should occur at several levels, and effective psychological interventions targeting changeable risk factors among violent offenders might reduce recidivism. Aims: First, to investigate if antisocial youth in residential treatment differ from matched general population comparison subjects on three individual psychological factors possible to address in cognitive behavioral therapy (CBT); antisocial cognitive distortions, empathy, and moral reasoning (Study I). Second, to test if an individual CBT module targeting problem-solving, cognitive self-control, and relapse prevention in serious, young violent offenders in residential treatment would add to the effect of treatment as usual (TAU)(Study II). Third, to assess the effectiveness of Aggression Replacement Training (ART), a CBT intervention aimed at reducing aggression and preventing recidivism, among adult offenders in the Swedish Prison and Probation Service (SPPS)(Study III). Methods: We administered self-report questionnaires to 58 (29 male and 29 female) antisocial youth (mean age 15.7 years) in residential treatment and 58 individually matched, non-institutionalized school youth (Study I). Further, in a five-site, randomized controlled trial (RCT), serious, violent male offenders in residential treatment (mean age 17.7 years) were allocated to either TAU plus individualized CBT (iCBT) (n=38) or to TAU only (n=43). The groups were compared on violent and general reconvictions according to the National Crime Register 12 and 24 months after release, aggressive symptoms at 12 months, and changes in self-reported aggression-related measures from inclusion to release (Study II). Finally, we conducted a controlled observational study comparing reconviction rates (National Crime Register) among all 1,124 young adult offenders in prison, on parole or probation within the SPPS that began group-based ART during 2003–2009 with 3,372 control subjects who did not (mean age 25.7 years). Propensity score matching was used to adjust extensively for baseline differences (e.g., sociodemographic variables, criminal history, psychiatric morbidity, and substance misuse) and effect sizes were obtained from Cox regression models (Study III). Results: Antisocial cognitive distortions and less mature moral judgment were more common (moderate to large effects) in antisocial youth in residential treatment than among matched comparison youth. In contrast, we found no differences in self-reported empathy (Study I). Further, intent-to-treat analyses found no meaningful differences between iCBT+TAU vs. TAU only in violent or general reconviction rates among serious young violent offenders at 12- or 24-month follow-ups or self-reported aggressive DSM-5 symptoms at 12 months (Study II). Finally, intent-to-treat analyses suggested no meaningful differences in violent or general reconviction rates for adult offenders beginning ART within the SPPS compared to controls that did not start ART (Study III). Conclusions: Antisocial cognitive distortions characterize antisocial youth in residential treatment and may constitute targets for recidivism-reducing psychological interventions. However, neither the addition of an individualized CBT intervention (iCBT) to TAU nor ART, a group-based CBT intervention, managed to decrease meaningfully reoffending among serious, violent youth in residential care or adult criminal offenders in prisons and probation, respectively. Stronger focus on implementation issues and treatment fidelity might help improve recidivism-reducing efforts with serious, violent individuals in these settings