Table of Contents

I. Title…………….………………………………………………………………………....2
II. Objectives………………………………………………………………………………..3
III. Introduction……………………………………………………………………………4-7
IV. Intervention with Mentally Ill Offenders……………………..…………………….8-15
a. Targeting factors associated with criminal risk
b. Grounding interventions in cognitive-behavioral theory (CBT)
c. Using simple treatment heuristics
d. Incorporating homework into the therapeutic process
e. Using structure to facilitate learning
f. Intensifying services
g. Therapist’s cultural competence
III. Intervention for Intellectual Disability Offenders……...……………………….......16-20
IV. Summary………………………………………………………………………………..21-24
V. Post-test………………………………………………………………………………….25-
27
VI. References…………………………………………………………………………………28
INTERVENTION WITH MENTALLY DISORDERED OFFENDERS
Objectives:
1. To know how mentally disordered offenders are treated in the criminal justice
system.
2. To examine the different evidence-based practices for intervening with
incarcerated offenders.
3. To identify the goals of different therapeutic interventions for mentally
disordered offenders.
 INTRODUCTION

The Philippines is an autonomous republic located in the Western Pacific, with a

population of over 100 million people (Philippines Statistics Authority, 2016). Despite its
size and its reputation for highly trained healthcare professionals, there is a paucity of
epidemiological evidence for mental disorders in the Philippines. What is known,
according to the 2010 census, is that 200,000 people were identified to have a disability
due to a mental disorder (Philippines Statistics Authority, 2010). This equated to 14% of
a total of 1.4 million Filipinos with disabilities.

An overpopulated prison system is a natural consequence of an underdeveloped prison

and correctional framework. The Philippines ranks as the most overcrowded
incarceration system in the world, with a startling overcrowded population rate of 436%.
While there are a reported 933 prison facilities around the country, as of November
2019, they prove to be insufficient to contain the 215,000 documented prisoners. Aside
from the blatant lack of space for additional prison facilities, there are likewise
insufficient programs to alleviate the dilapidated prison conditions, largely due to an
amalgamation of several factors, including rampant corruption in the government, the
congested dockets of the court system, funding constraints, and failure of the
Department of Justice (DOJ) to monitor persons who have either served their sentence,
currently in detention, or more merely awaiting trial. Undoubtedly, such overpopulation
also exacerbates the mental health of inmates. Given such a situation, as well as
statistics that prove that around 17%–20% of the adult population suffers from
psychiatric disorders, the need to address the mental health needs of inmates and
those awaiting incarceration, through a more unconventional and specialized approach,
is all the more warranted.

Despite these problems, raising awareness of mental illness in recent times has led to
increased governmental application and focus. Much credit for this is due to the
Philippines Psychiatric Association (PPA). Founded in 1972, the PPA has worked
tirelessly to promote mental health as a priority in the Philippines and it has advocated
for the enactment of comprehensive mental health legislation into law in the form of a
mental health act.

Proposed more than 3 years ago, the Philippine Mental Health Act no. 11036
was passed in the congress and senate in 2017 (Senate Bill No. 1354, 2017) and
signed into law on 21 June 2018. Prior to this bill, the Philippines were one of a minority
of countries with no mental health legislation. Clinicians lacked guidance on legal and
ethical aspects of their practice, and patients' rights were not clearly defined – for
example, the usual practice was for patients who lacked the capacity to be ‘signed in’ by
a next of kin. The passing of this bill is a major milestone in the history of psychiatry in
the Philippines. The bill, the first in the country's history, provides a rights-based mental
health legislation. It mandates the provision of psychiatric, psychosocial, and
neurological services in all hospitals and basic mental health services in community
settings. Compulsory treatment is limited to hospital settings, and the Act does not
provide for compulsory community treatment.

Basic Mental Health services are effective in correctional settings. Morgan and
colleagues conducted a meta-analysis of 26 studies and found that mental health
treatments resulted in improved mental health functioning (e.g., reduced symptom
distress) improved coping skills, and improved institutional adjustment and behavioral
functioning in offender populations ( Morgan, Flora, Kroner, Mills, Varghese and Steffan,
2012).

In a similar meta-analytic study, Martin, Shannon, Wamboldt, and Wooten (2012) also
found that mental health services resulted in decreased symptom distress and greater
overall mental health functioning. Morgan, Flora, et al (2012) focused on psychological
interventions primarily in correctional settings; whereas Martin, et.al included system-
oriented services (e.g., mental health court) for incarcerated and non-incarcerated
offenders.
When treating imprisoned offenders with mental illness, service providers tend to place
more emphasis on basic mental health services (e.g., symptom management and
stabilization) than on rehabilitative efforts, such as risk-need or preparing inmates for
release (Bewley and Morgan, 2011). It is likely that service providers opt for providing
basic mental health services, at least in part, due to offender needs. However, offenders
with mental illness have some of the same risks as their offender peers who are not
mentally ill.

According to the research, examining two independent samples of incarcerated

offenders (n=414 and 4, 204) showed that incarcerated offenders with mental illness
produced levels of criminal thinking and antisocial attitudes consistent with non-mentally
ill inmates (Morgan, Fisher, Duan, Mandaracchia, and Murray, 2010; Wolff, Morgan,
Shi, Burning, and Fisher, 2011). Offenders with mental illness are likely to face other
primary criminal risk factors, including occupational limitation, impaired family relations,
and substance abuse. In fact, the evidence is so compelling that it is now recognized
that the offender incarcerated due to complications with mental illness is the exception
(Skeem, Manchak, and Peterson, 2011); thus, when working with offenders with mental
illness, service providers target dual issues of mental illness and criminal propensity.

Treatment providers in correctional facilities provide effective basic mental health

services. Specifically, a comprehensive meta-analytic review of interventions for
incarcerated offenders found significant improvements in general mental health
outcomes, improved coping skills, and improved institutional adjustment with fewer
behavioral problems (Morgan et. al., 2012)--all goals of basic mental health services in
jails and prisons. Similar outcomes were obtained in a separate meta-analysis, with
reductions in symptom distress and improved functioning (Matin, Dorken, Wamboldt,
and Wooten, 2012).

These meta-analyses also provide important insights into effective therapeutic

strategies. Morgan, flora, et.al., (2012) found that the use of homework (with emphasis
on active homework exercises that required offender activity, such as practicing learned
skills or social interaction), the behavioral practice of new behaviors, and an open
treatment admission policy all contributed to more favorable outcomes. Martin et.al.
(2012) found that continuity of services between institutions and community, allowing for
some level of voluntariness in the intervention, and non-specified treatment duration as
opposed to time-limited services all produced more favorable outcomes.

Treatment preparation and readiness have been understudied with offender populations
(Williamson, Day, Howells, Bubner, & Jauncey, 2003). In spite of the dearth
of research examining the effect of offender motivation, readiness for change, and
therapeutic resistance on outcomes of interest (e.g., desistance), we do know that
interventions aimed at increasing offender motivation and decreasing therapeutic
resistance can be achieved (Morgan et al., 2007; Newbern, Dansereau, & Pitre, 1999;
Shearer, Myers, & Ogan, 2001). Notably, increasing offender motivation for change
increases continuity of care via treatment follow-up (aftercare), which contributes
to desistance (Burdon, Messina, & Prendergast, 2004; McGrath, Cumming, Livingston,
& Hoke, 2003). Thus, all correctional interventions should address issues
of motivation and resistance in the early stages of treatment, and motivational
interviewing appears to be a particularly promising approach. Specifically, integrating
motivational interviewing into existing therapeutic programs may go a long
way toward increasing offender participation in treatment (Chambers, Eccleston, Day,
Ward, & Howells, 2008), and subsequently reducing premature therapeutic
terminations (e.g., treatment dropouts).
 INTERVENTION WITH MENTALLY ILL OFFENDERS

Treating offenders presents many challenges and difficulties; however, rehabilitative

programs and interventions have proven effective in helping inmates achieve
positive outcomes, including decreased distress, improved mental health functioning,
reduced recidivism, and, possibly of greatest importance, desistance. Based on
the evidence to date, we have preliminary support for evidence-based practices for
intervening with incarcerated offenders. These include targeting factors associated
with criminal risk, grounding interventions in cognitive-behavioral theory (CBT),
using simple treatment heuristics, incorporating homework into the therapeutic
process, using structure to facilitate learning, and intensifying services. One additional
treatment issue that warrants discussion is the therapist’s cultural competence
which is included in the discussion below.

Treatment Targets are the risk principle, from RNR, which provides a road map for
targeted interventions aimed at reducing recidivism and increasing desistance. Risk-
Needs-Responsivity is the most influential model for the assessment of offenders. The
RNR model has been elaborated upon and contextualized within a general personality
and cognitive social learning theory of criminal conduct. Briefly, the three core principles
can be stated; Risk Principle matches the level of service to the offenders’ risk to re-
offend. Need Principle which assesses criminogenic needs and targets them in
treatment. Responsivity Principle maximizes the offender’s ability to learn a
rehabilitative intervention by providing cognitive behavioral treatment and tailoring the
intervention to the learning style, motivation, abilities, and strengths of the offender.
There are two parts to the responsivity principle: general and specific responsivity.
General responsivity calls for the use of cognitive social learning methods to influence
behavior. Cognitive social learning strategies are the most effective regardless of the
type of offender (i.e., female offender, aboriginal offender, psychopath, sex offender).
Core correctional practices such as prosocial modeling, the appropriate use of
reinforcement and disapproval, and problem-solving (Dowden & Andrews, 2004) spell
out the specific skills represented in a cognitive social learning approach. Specific
responsivity is a "fine-tuning" of cognitive behavioral intervention. It takes into account
the strengths, learning style, personality, motivation, and bio-social (e.g., gender, race)
characteristics of the individual.

In an impactful book titled The Psychology of Criminal Conduct (fifth edition), Professors
Andrews and Bonta (2010) discussed the “Central Eight '', which is the idea of eight
criminogenic risks and need factors. We call them the ‘Eight A-Ls’ (think of 8 ALvins).
Anti-social behavior, Antisocial personality, Anti-social attitudes, Anti-social peers, Lack
of happiness and stability in relationships, and marriage, Lack of stability in
employment, and achievement, Lack of prosocial leisure, and Lifestyle of alcohol, and
drugs.

The 4 ‘A’s are Antisocial behavior: History of involvement in a number of anti-social acts
in various settings; Antisocial personality: Disorder is characterized by a pervasive
pattern of disregard for and violation of the rights of others. Those with antisocial
personalities tend to have a personality style that can be irresponsible, aggressive, and
violent, impulsive, and may fail to conform to social norms and laws (this includes
features such as being impulsive, pleasure-seeking, aggressive, hostile, and irritable);
Anti-social attitudes and cognitions: Attitudes, values, beliefs, and rationalization of
thinking to justify criminal actions. Offenders generally exhibit certain thinking errors,
such as a sense of entitlement, self-justification, blaming others, and taking on a ‘victim
stance’ (e.g., “the police is out to get me”). They often misinterpret neutral remarks as
threats (e.g., “he shows me no respect, so I hammered him”); Anti-social friends, peers,
and associates: This is the idea that social learning occurs by mixing with the ‘wrong
company’. Gang connections are particularly a problem. In a local study of 300 youth
rioters (aged 21 years and below) by the Subordinate Courts of Singapore, 87.6% were
reportedly involved with gangs (The Subordinate Courts of Singapore, 1998). In another
study in 2005 by Dr. Chu Chi Meng and colleagues at the Ministry of Community, Youth
and Sports in Singapore (now Ministry of Social and Family Development), they
explored the sociodemographic characteristics, risk, and rate of criminal recidivism in a
cohort of 165 male youth offenders in Singapore (Chu et al., 2012). Of this group, 58
were gang-affiliated. They found that gang-affiliated youth offenders were more likely to
have histories of substance use, weapon use, and violence than non-gang-affiliated
youth offenders. Gang-affiliated offenders also scored higher on measures of risk for
recidivism and engaged in violent and other criminal behaviors more frequently during
the follow-up. In another study, Chu et al. (2015) found that gang affiliation in youth was
associated with increased criminal recidivism as well as an exaggeration of various
criminogenic needs. The 4 ‘L’s are Lack of happiness and stability in relationships, such
as family and marriage. Lack of Education, employment, and achievement: Studies of
prisoners who participated in prison-based education or vocational prison programs
show that they are less likely to recidivate upon release than non-participants because
they tended to have higher employment rates (see Wilson et al., 2000). Lack of
prosocial leisure: ‘Idle times make idle hands’ is an old but accurate adage. Involvement
in pro-social activities reduces delinquency in youth. The Lifestyle of alcohol, drugs, and
substance abuse: The prevalence of alcohol and drug use is four times higher among
offenders than in the general population (Substance Abuse and Mental Health Services
Administration, 2011). To reduce criminal risk, treatment providers must provide
services that target (i.e., aim to reduce) these risk factors.

Not surprisingly given the broad acceptance of the importance of incorporating

the principles of RNR into correctional interventions, treatment providers consider
issues of criminal risk to be important treatment considerations (Bewley & Morgan,
2011), and they tend to provide interventions that target areas of prominent criminal
risk (see Morgan et al., 2012). However, when intervening with incarcerated
offenders with mental illness, treatment providers consider issues of mental illness
recovery (such as psychosocial rehabilitation) as more important than treatments
targeting issues of criminal risk and needs (Bewley & Morgan, 2011). Given
the overwhelming evidence (see Andrews & Bonta, 2010, and Gendreau et al.,
for a thorough review of this evidence) demonstrating the benefits of RNR, we submit
that interventions aimed at reducing criminal activity must be grounded in the primary
risk factors of antisocial cognitions, antisocial associates, family and/or relationship
circumstances, school and/or work functioning, leisure and/or recreational pursuits, and
substance abuse. Failure to do so is analogous to a physician treating persons with
heart disease at risk for cardiac arrest without prescribing medications to reduce blood
pressure as well as providing or recommending interventions aimed at improving stress
management, diet, exercise, and other positive lifestyle changes.

Cognitive Behavioral Theory, as reviewed by Gendreau, Goggin, and Smith,

correctional interventions are more effective when they are grounded in CBT. One form
of psychotherapy stands out in the criminal justice system. Cognitive behavioral therapy
reduces recidivism in both juveniles and adults. The therapy assumes that most people
can become conscious of their own thoughts and behaviors and then make positive
changes to them. A person's thoughts are often the result of experience, and behavior is
often influenced and prompted by these thoughts. In addition, thoughts may sometimes
become distorted and fail to reflect reality accurately. Cognitive behavioral therapy has
been found to be effective with juvenile and adult offenders; substance-abusing and
violent offenders; and probationers, prisoners, and parolees. It is effective in various
criminal justice settings, both in institutions and in the community, and addresses a host
of problems associated with criminal behavior. For instance, in most cognitive
behavioral therapy programs, offenders improve their social skills, means-ends problem
solving, critical reasoning, moral reasoning, cognitive style, self-control, impulse
management, and self-efficacy" (NIJ Journal No. 265, April 2010, p. 22).

The most prominently researched cognitive-behavioral program for offenders is the

reasoning and rehabilitation (R&R) program, which was developed and implemented
with federal prisoners in Canada in the 1980s (Ross, Fabiano, & Ewles, 1988). R&R
utilizes a cognitive-behavioral approach and is delivered in a structured format over 36
two-hour sessions with groups of 6 to 12 offenders. The program utilizes an interactive
approach, with multiple techniques of presentation. Role plays, games, cognitive
exercises, and discussions are used to stimulate participation and improve reasoning
skills (Robinson & Proporino 2004). The program aims to decrease criminality (i.e., the
program focuses on criminalness) by addressing the cognitive distortions and thinking
styles associated with criminal behavior. The curriculum covers the specific topics of
self-control, interpersonal problem-solving skills, social perspective-taking, critical
reasoning, cognitive style, and values (Robinson & Proporino, 2004). A significant
amount of time is spent addressing cognitive rigidity and problem-solving skills.
Offenders are taught to think more systematically and analyze various solutions and
outcomes before acting. Research on R&R with offenders has shown the program to be
an effective means of reducing recidivism (Pearson, Lipton, Cleland, & Yee, 2002;
Proporino & Robinson, 1995), and offenders demonstrated improvement in their
criminal attitudes, criminal identification, and cognitive reasoning (Fabiano, Robinson, &
Proporino, 1990). Notably, a meta-analytic review by Landenberger and Lipsey (2005)
found that R&R was as effective as any other cognitive-behavioral intervention for the
treatment of criminal offenders. Further meta-analytic reviews of R&R demonstrated
reductions in recidivism, on average, of 14% when compared to control groups and it
was equally as effective with incarcerated offenders as with offenders in the community
(Tong & Farrington, 2006, 2008).

Beyond demonstrating the effectiveness of R&R, Landenberger and Lipsey’s (2005)

meta-analysis examined therapeutic elements of cognitive-behavioral interventions for
adult and juvenile offenders. Treatment elements included in this review were cognitive
restructuring, interpersonal problem-solving skills, social skills, anger control, moral
reasoning, victim impact, substance abuse, behavioral modification, and relapse
prevention skills. Interpersonal problem-solving and anger management had a positive
statistically significant effect on recidivism outcomes of these CBT elements. Two areas,
victim impact, and behavioral modification had a negative effect on recidivism
outcomes. This finding is particularly notable given the large number of correctional
interventions that aim to increase victim impact, which intuitively seems to be a
reasonable therapeutic strategy, but evidence suggests otherwise.

Simple Treatment Heuristics, given inmates’ below-average educational attainment

(Harlow, 2003) and intellectual functioning (Birmingham, Mason, & Grubin, 1996;
Herrnstein & Murray, 1994), it is important to present therapeutic constructs and
information in as simple a manner as possible (Morgan, Kroner, & Mills, 2006).
Specifically, Morgan et al. recommended that learning heuristics be developed in a
manner that is consistent with the offenders’ everyday behaviors. For example, when
educating offenders about the negative influences and risks of having criminal
associates (see Mills, Jones, & Kroner, 2005), treatment participants are instructed to
rate relationships utilizing a common everyday metaphor: a stoplight. A red light is
universally recognized as a stop signal, and offenders can label their criminal and
nonproductive associates accordingly. A yellow light is recognized as a warning of a
pending red light (or a caution signal), and offenders can label their associates who
engage in some antisocial and nonproductive behavior accordingly. A green light is
universally recognized as positive (a go), and offenders can label their prosocial
associates accordingly. Although a very simple concept, this learning heuristic allows
inmates to evaluate their life situation from a perspective that is common to them; thus,
they spend their time evaluating their situation (working to reduce risk) and not learning
a complicated learning strategy or technique.

Homework, the best interventions, and treatment programs are more effective with
incarcerated offenders when they are able to incorporate what they have learned into
their everyday environment. Out-of-treatment homework is one process that allows this
to happen, and, not surprisingly, meta-analytic reviews with offenders have found that
homework outside of the treatment setting significantly improves outcomes (Morgan &
Flora, 2002; Morgan et al., 2012). In fact, the evidence supporting the use of homework
in offender treatment is sufficiently strong to suggest that it is essential for achieving
maximum therapeutic benefit with offenders (McDonald & Morgan, 2012; Morgan et al.,
2006). Two guidelines should inform therapists’ use of homework: (1) homework
exercises should be simple and structured to facilitate the use of learned skills and
behaviors, not challenge offenders’ learning of skills and knowledge (i.e., homework is
not a test of retention or learning); and (2) homework should be applicable but
stimulating enough to sustain offenders’ interest. It is commonly recognized that
offenders are impulsive and easily bored (see Zamble & Quinsey, 1997); consequently,
homework needs to be simplified but interesting. For example, watching a
predetermined movie to identify instances of criminal thinking that led to antisocial
behavior will be much more stimulating to offenders than a bibliotherapy assignment
designed to educate offenders about the negative impact of their thinking on their
behavior. Obviously, homework will be effective only if it is completed. McDonald and
Morgan (2012) identified two promising strategies for enhancing homework compliance.
Although future research needs to examine these preliminary findings in greater detail,
strategies of public commitment (i.e., having offenders publicly commit, in the treatment
group, for example, to completing homework assignments; Freeman & Rosenfield,
2002) and task modeling (i.e., providing in-session modeling or rehearsal; Kazantzis &
Lampropoulos, 2002) are promising strategies for increasing homework compliance.

Structure, given that CBT is a structured therapy that has proven effective with
offenders, it should be of no surprise that structured interventions produce more
favorable outcomes for offenders than non-structured interventions (Leak, 1980;
Morgan & Flora, 2002). The structure most commonly takes one of two forms. The
structure can be incorporated into the therapeutic process by the addition of specific
(structured) learning activities. These are typically skill-based activities that help
offenders develop specific skills or abilities. Alternatively, the structure can be
incorporated into the therapeutic process so that the treatment specifies who will do
what and how. For example, psychoeducational processes can be regularly integrated
into an intervention to facilitate learning and acquiring new information. Regardless of
how the structure is integrated into the therapeutic process, it is clear that a structured
approach produces superior results when compared to non-structured processes such
as psychodynamic approaches (Andrews et al., 1990).

Intensiveness, services for offenders are most effective when they are intensive.
Specifically, appropriately intensive services occupy a significant portion of the
offender’s time (between 40% and 70%) and are of significant duration (between 3 and
12 months; Gendreau, 1996b). The more intensive therapeutic services are (i.e., of
longer treatment duration), the better the outcomes when working with offenders
(Lipsey, 1989, as cited in Andrews & Bonta, 2010). Along similar lines, the greater the
treatment dosage, the better the outcomes (see Aytes, Olsen, Zakrajsek, Murray, &
Ireson, 2001; Bourgon & Armstrong, 2005; Fisher, Beech, & Browne, 2000; Gossop,
Marsden, Stewart, & Rolfe, 1999; Lipton, 1995; Westhuis, Gwaltney, & Hayaski, 2001;
Wexler, Falkin, & Lipton, 1990). In fact, it has been found that, for every month an
offender spends in treatment, a 4% decrease in recidivism can be expected (Burdon et
al., 2004).

Therapist Cultural Competence, although not yet an evidence-based practice in

corrections, greater effort must be devoted to employing culturally competent therapists
and developing culturally sensitive interventions. Programs such as that developed by
Polaschek and Dixon (2001), which specifically integrates culturally based practices into
a treatment program for violent offenders, are the exception rather than the rule. Given
the racial disparity in prisons across the world, it is no longer acceptable for treatment
providers to overlook issues of diversity and employ treatment materials that lack ethnic
minority case material (e.g., images, and vignettes). Cultural competence in correctional
settings needs to extend beyond individual offender characteristics and include
competence for working within the prison culture. Many correctional institutions maintain
a machismo facade whereby everyone, including professional staff, is tough and tough
on inmates. This is counterproductive for behavioral change and inconsistent with the
principle of responsivity in RNR. On the contrary, the evidence is compelling (see
Andrews & Bonta, 2010; Gendreau, 1996a, 1996b) that interpersonally sensitive
therapists working from a service-oriented perspective produce better outcomes with
offenders.
 INTERVENTION FOR INTELLECTUAL DISABILITY OFFENDERS

Offenders with intellectual disabilities (IDs) can have a high occurrence of

antisocial/aggressive disorders (Lund, 1990). Although these offenders have cognitive
deficits, the literature has repeatedly shown interventions to be effective (Taylor, 2010).
Specifically, research has shown that cognitive-behavioral techniques are particularly
effective when addressing treatment targets with this population of offenders (Barron,
Hassiotis, & Banes, 2002). As with other offenders, structured interventions delivered in
a consistent and reliable fashion with appropriate staff-to-offender ratios are important
for treatment success.

An article reviews the development and evaluation of treatment programmes for

offenders with intellectual and developmental disabilities (ID). Prevalence studies have
shown that a significant percentage of individuals in the criminal justice system have ID
and that around 50% of those individuals, if untreated, will go on to re-offend. Over the
past 15–20 years, adaptations have been made to assessments that are relevant to
offending issues. These include assessments for anger and aggression, a range of
psychiatric symptoms, sexual offending and criminal thinking. Generally, the results
have been positive, with assessments showing good reliability, internal consistency and
the integrity of the factor structures. Adaptations to treatment methods include
simplification of communication and the methods of cognitive therapy, alterations in the
use of recording and assessment techniques and promoting motivation in participants.
A review of a range of treatment interventions showed that successful case studies
have been reported in the fields of anger and violence, inappropriate sexual behaviour,
fire-raising and social problem-solving/criminal thinking. Controlled trials have produced
robust results in showing the effectiveness of programmes for anger and violence.

Another meta-analysis has shown common interventions such as behavioral

approaches, cognitive–behavioral therapy (CBT), and psychodynamic psychotherapy.
Nagel & Leiper, in their survey of interventions used by clinical psychologists in the UK,
found that 80% of respondents stated that they used behavioral interventions through
staff, 35% reported that they used CBT techniques and 17% reported that they were
using psychodynamic methods. Prout & Nowak-Drabik, in their meta-analysis of a small
number of studies covering a wide range of psychotherapeutic approaches, found that
such interventions only result in a moderate amount of change, and are only moderately
effective. Their conclusion was that a range of psychotherapeutic interventions should
be considered as part of the overall treatment plan for people with intellectual
disabilities.

People with an intellectual disability (ID) are a marginalized and vulnerable group. The
available research suggests an association between ID and criminal offending; this has
served to propel public fear and reinforce perceptions of the need for social distance.
However, the evidence from which these conclusions have been drawn remains far
from definitive, with significant methodological limitations marring what are arguably
tentative conclusions. A related area that has received much less scientific attention is
criminal victimization, despite a compelling argument that specific deficits in
interpersonal functioning and cognitive capability potentially increase exposure to
dangerous situations, therefore contributing to the likelihood of criminal victimization.

The functional deficits evident in ID suggest that people with ID may also be likely to
offend. This sentiment has a long tradition, attracting consistent research attention over
the years; with studies claiming that people with ID are overrepresented among
individuals processed by the criminal justice system. The estimated prevalence of
offending in people with intellectual disabilities ranges from two to ten percent and
varies depending on the population and methods utilized. There is much variation within
prison populations, with estimates ranging from less than 2% to as high as 30%, yet
there is little agreement on a standardized conceptual definition of what criminal
offending is across these studies. A recent systematic review, pooling results from ten
studies and including a total of 11,969 prisoners concluded that typically 0.5% to 1.5%
of prisoners are diagnosed with intellectual disabilities. Estimating offending prevalence
with prison populations is problematic as many individuals with ID have been diverted
into the community or forensic services rather than prison, so there may be an
underestimation of the true prevalence using this method.

Court appearances and police contacts provide an alternative means of establishing

prevalence and are more sensitive, as these records more adequately capture the
extent of contact people have with the criminal justice system. The available literature at
this interface estimates that around 1 in 10 people with ID will come into contact with the
police or courts as a perpetrator of the crime. These rates are substantially different
from those in the general population, with males with ID being three times more likely
than males in the general public to have a prior conviction, while females have been
found to be four times more likely to have a prior conviction. Interestingly, this figure
was more pronounced for violent offenses, with males four times higher and females 25
times higher, therefore potentially suggesting a significant vulnerability to violent
offending among people with ID.

Some evidence suggests that people with ID are susceptible to the perpetration of
specific crimes, such as sexual offenses. Further, there are additional factors that
potentially complicate the hypothesized link between ID and offending, with findings
revealing that complexities such as childhood neglect, physical health problems, mental
health problems, and perinatal adversity are particularly common among offenders with
ID. There is also some suggestion that offenders with ID may be less effective at
evading police and more visible as perpetrators and this is the reason for increased
prevalence rates.

The relationship between crime perpetration and ID and mental illness, which is highly
comorbid with ID, has received empirical scrutiny. Hodgins and others estimated that
the presence of mental illness increased five times in psychiatric inpatients compared to
those with ID who had not been admitted for mental health treatment. Additionally,
Vanny found that nearly half of those people with ID who were referred to court had a
mental illness, thereby suggesting a more complex group who may be at increased risk
of criminal offending.
Most services for people with intellectual disabilities employ nurses or psychologists
with specialized skills in behavioral interventions who are able to deliver such
treatments. These models can be adapted and applied to the full range of people with
intellectual disabilities. Some critics, however, question the benefits of the behavioral
approach as it often fails to address the emotional context of the behavior, and therefore
its sustained benefit is questionable.

There have been efforts to assess the effectiveness of the different components of
behavioral interventions. For example, a meta-analysis showed that pre-treatment
functional analysis and respondent contingent procedures were significantly more
effective than other procedures. Hassiotis et al assessed both the efficacy and cost-
effectiveness of a service-led intervention over a longer follow-up period. Overall, it
appears that there is not much evidence of the cost-effectiveness of different
components of intervention packages.

Cognitive–behavioral therapy is widely used in mainstream services and has a good

evidence base in terms of both short- and long-term efficacy. In the intellectual disability
population, much of the research on CBT has come from forensic secure units and has
shown it to be effective for conditions such as depression, anxiety, anger management,
and sex offending, with literature on anger management appearing to have the strongest
evidence base. There are two RCTs for the use of CBT in anger management. The first
trial was conducted in secure settings and revealed a significant reduction in self-
reported outcome measures. The second trial was conducted in the community and
revealed a reduction in anger as reported by both the participant and the carer. Despite
a number of available research studies in this area, the quality of studies remains poor
with the exception of a few. Additionally, most of the trials on CBT have multi-
component packages making it difficult to establish the effectiveness of each
component.

The use of CBT relies significantly on language, which can limit its utility when there are
communication difficulties. Although a number of initiatives have been taken to improve
access, it has not been possible to develop standardized approaches to the application
of CBT in the intellectually disabled population. Sturmey, in a review paper, pointed out
the fact that the extent to which CBT can be used in an intellectual disability population
is not clear and therefore, unlike behavioral interventions, CBT has not yet become an
integral part of service delivery in many areas. The question that still remains to be
answered is whether CBT can be provided for people who have limited intellectual
abilities.

Psychodynamic therapy is still at an early stage of development in people with

intellectual disabilities. The literature suggests that psychodynamic psychotherapy can
lead to a reduction of psychological symptoms and result in improved self-esteem in this
population. There have been efforts to use psychodynamic interpretations to explore the
experiences of people with intellectual disabilities. However, research in this area is
restricted to a few case reports and case series. In common with all of the interventions
discussed here, the use of psychodynamic therapy is limited by any co-existing
communication deficits, which makes it difficult to understand the dynamic constructs of
the individuals concerned. Furthermore, assessing the effectiveness of the intervention
may be difficult to differentiate from the benefits the individuals may have had from the
humanistic element of the contact.

Effective understanding of offenders with IDs is essential to providing effective

correctional interventions. A significant barrier to engaging these clients is the
overlap between mental illness and ID. Issues of mental illness among offenders
with IDs often go undetected (undiagnosed, untreated) for one of the following
reasons (Taylor, Lindsay, & Willner, 2008): two distinct groups of professionals typically
provide services for those with IDs and those with mental illness. There is an absence
of good tools for assessing mental health concerns among those with IDs. Poor
differential diagnosis may occur when symptoms of IDs are attributed to mental health
concerns and mental health issues are attributed to intellectual deficits.
 SUMMARY

The umbrella term “mental disability” is used to include psychiatric disabilities and
intellectual disabilities. Psychiatric disabilities may be major (e.g. schizophrenia and
bipolar disorder) or more minor mental health problems, often referred to as
psychosocial problems (e.g. mild anxiety disorders). Intellectual disabilities are defined
as “a condition of arrested or incomplete development of the mind characterized by
impairment of skills and overall intelligence in areas such as cognition, language, and
motor or social abilities”.

States parties to the Convention on the Rights of Persons with Disabilities must ensure
that the existence of a disability shall in no case justify a deprivation of liberty (art. 14,
para. 1 (b)); and recognize the equal right of persons with disabilities to live in the
community, including by ensuring that persons with disabilities have access to a range
of in-home, residential and other community support services, including personal
assistance necessary to support living and inclusion in the community (art. 19, para.
(b)). The Nelson Mandela Rules stipulate that persons who are found to be not
criminally responsible, or who are later diagnosed with severe mental disabilities and/or
health conditions, for whom staying in prison would mean an exacerbation of their
condition, must not be detained in prisons; and arrangements must be made to transfer
them to mental health facilities as soon as possible (rule 109, para. 1).

Given the particularly harmful effect of imprisonment on persons with mental disabilities,
they should be diverted from the criminal justice system as much as possible. Diversion
programs and referral mechanisms should ensure that offenders receive adequate
treatment in specialized mental health facilities or in the community. However, in many
low-income countries, such facilities or community-based resources are simply not
available or accessible to offenders. By default, therefore, prisoners with mental
disabilities may end up in prison without proper care or attention. In prison, persons with
mental disabilities are at increased risk of being abused and victimized by other
prisoners, and sometimes also by prison staff. As such persons are often punished for
behavior that they are not able to control, the Nelson Mandela Rules stipulate that
prison authorities must not sanction any conduct of a prisoner that is considered to be
the direct result of his or her mental illness or intellectual disability (rule 39, para. 3). The
Nelson Mandela Rules also prohibit the imposition of solitary confinement in the case of
prisoners with mental or physical disabilities when their conditions would be
exacerbated by such measures (rule 45, para. 2).

A competent diagnosis of mental disabilities and subsequent treatment or other

interventions require that a careful (psychiatric) assessment be conducted by a qualified
mental health professional. The Nelson Mandela Rules require the prison healthcare
service to include sufficient expertise in psychology and psychiatry (rule 25, para. 2).
Unfortunately, the services of mental health professionals are not always available in
prisons. In the absence of qualified mental health professionals, at the very least, other
healthcare professionals and regular prison personnel should be trained to identify
symptoms of psychological or emotional distress and to recognize the signs and
symptoms of mental disabilities.

Upon being released into the community, prisoners with mental disabilities are likely to
encounter some unique problems. They sometimes experience extreme social isolation
and often encounter considerable difficulties in finding suitable accommodation and
securing employment. Many of them will require further medical or therapeutic services,
as well as practical assistance (e.g. in financial management). These factors, in
combination with the risk of non-compliance with treatment orders, require the
development of a community-based treatment model of continuing care that addresses
the risks, needs, and vulnerabilities of this group. The Nelson Mandela Rules point to
the need for arrangements to be made, in cooperation with the appropriate agencies, to
ensure if necessary the continuation of psychiatric treatment after release and the
provision of social-psychiatric aftercare (rule 110). This includes multidisciplinary case
management for psychiatric treatment and social services (e.g. housing, food, help with
disability benefits, and vocational training).
Offenders with mental health disorders are often affected by co-occurring substance
use disorders. Evaluations of enhanced treatment programs for offenders with mental
disabilities who have substance use problems, for example, have shown that: (a)
integrated treatment and care for mental health and substance disorders constitute the
recommended approach to addressing health disorders and improving the quality of life
of people affected by these often comorbid disorders; (b) comprehensive models of
treatment and care provide diverse evidence-based treatment options in a continuum of
care that are tailored to the needs of the person with a mental health and/or substance
use disorder; and (c) like any other health intervention, treatment of substance use
disorders is aimed at the highest attainable level of health. In addition, substance use
disorders often follow the course of chronic and relapsing disorders. In this regard, while
abstinence from illicit substance use is the final goal of treatment, reduced substance
use, improved quality of life, and reduction of the negative health and social
consequences of substance use are also important treatment outcomes. Offenders
participating in treatment programs that accept only complete abstinence as a positive
treatment outcome often have problems fully complying with the conditions of such
treatment.

The core components of interventions designed to assist prisoners with mental

disabilities in successfully re-entering the community include: stabilizing the offender’s
illness as a matter of priority and appropriate administration of medication, enhancing
their independent functioning, maintaining internal and external controls so as to
minimize the likelihood that the offender will act violently and commit new offenses,
establishing a liaison between treatment staff and the justice system, providing structure
in the offender’s daily life, using authority appropriately, managing the offender’s
violence and impulses, integrating treatment and case management, securing
therapeutic living arrangements where necessary and working with the offender’s family
to determine if it is a reliable source of support for the offender.

The findings just described—that offenders with mental disorder present with criminal
risk factors similar to non–mentally ill inmates and that treatments that integrate both
mental health and correctional rehabilitative efforts produce favorable outcomes
compared to interventions that do either alone—support the opinion of Hodgins et al.
(2007), who noted that offenders with mental disorder present unique challenges that
require service providers to treat both psychiatric symptoms and criminal propensity and
risk. That is, interventions for offenders with mental disorders should aim to decrease
psychiatric hospitalization days as well as time spent incarcerated while simultaneously
working to improve quality of life(e.g., increased number of functional days). Desistance
and mental health recovery (recovery here does not refer to remission but to achieving
a return to independence as a result of self-management of illness producing an
improved quality of life) are the ultimate goals.
 POST TEST

1. Give at least 5 evidence-based practices for intervening with incarcerated

offenders.
2. It is a legal term that describes individuals who have offended and experienced a
diagnosed severe psychological disorder.
3. It is the most influential model for the assessment of offenders.
4. This program aims to decrease criminality by addressing the cognitive distortions
and thinking styles associated with criminal behavior.
5. It is one of the promising strategies for enhancing homework compliance by
providing in-session modeling and rehearsal.
6. It refers to individuals who have a significant impairment of intelligence and social
function.
7. Give at least 5 primary factors of criminal risk.
8. It refers to individuals experiencing disorders such as antisocial.
9. These are the ultimate goals for the interventions given to offenders with mental
illness.
10. It is one of the principles in RNR that assess criminogenic needs and target them
in treatment.
 POST TEST
ANSWER KEY

1. Give at least 5 evidence-based practices for intervening with incarcerated

offenders.

Ans.

•Targeting factors associated with criminal risk

•Grounding interventions in cognitive-behavioral theory (CBT)

•Using simple treatment heuristics

•Incorporating homework into the therapeutic process

•Using structure to facilitate learning

•Intensifying services

•Therapist’s cultural competence

2. It is a legal term that describes individuals who have offended and experienced a
diagnosed severe psychological disorder.

Ans. Mentally Disordered Offender

3. It is the most influential model for the assessment of offenders.

Ans. Risk-Needs-Responsivity

4. This program aims to decrease criminality by addressing the cognitive distortions

and thinking styles associated with criminal behavior.

Ans. Reasoning and Rehabilitation (R&R) Program

5. It is one of the promising strategies for enhancing homework compliance by
providing in-session modeling and rehearsal.

Ans. Task Modeling

6. It refers to individuals who have a significant impairment of intelligence and social

function.

Ans. Learning Disabilities

7. Give at least 5 primary factors of criminal risk.

Ans.

•History of antisocial behavior

• Antisocial personality pattern

• Antisocial cognitions

• Antisocial associates

• Family and/or relationship circumstances

• School and/or work functioning

• Leisure and/or recreational pursuits

• Substance abuse

8. It refers to individuals experiencing disorders such as antisocial.

Ans. Personality Disorder

9. These are the ultimate goals for the interventions given to offenders with mental
illness.

Ans. Desistance and Mental Health Recovery

10. It is one of the principles in RNR that assess criminogenic needs and target them
in treatment.

Ans. Needs Principle

 REFERENCES

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646847/
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https://nicic.gov/projects/cognitive-behavioral-therapy
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