Promising Sentencing Practice No. 8
Cognitive Behavioral Therapy

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By Judge Marion Edwards (Louisiana)

Overview
The use of Cognitive Behavioral Therapy has been recognized as a critical factor in reducing recidivism for repeat DWI offenders.80 Cognitive Behavioral Therapy focuses on changing thinking patterns and behaviors. It is based on the premise that if a repeat offender’s faulty thinking is not addressed, there is little likelihood of permanent change. Research has shown that the use of cognitive interventions can enhance outcomes by up to 50 percent; however, less than half of treatment programs for offenders report having a cognitive behavior component in their programs. Additional empirical studies need to be conducted to ascertain the efficacy of different programs; nevertheless, the programs outlined here appear to be promising.

What Is Cognitive Behavioral Therapy?
Cognitive Behavioral Therapy is an action-oriented form of psychosocial therapy, which assumes that faulty thinking patterns cause behavior that is counter-productive or that interferes with everyday living and also causes negative emotions. Treatment focuses on changing an individual’s thoughts or cognitive patterns in order to change his or her behavior and emotional state.

Application of Cognitive Behavioral Therapy to DWI Offenders
Cognitive Behavioral Therapy appears “to be the most effective treatment therapy for substance abusers . . . [Studies have] found that programs that included the cognitive component were more than twice as effective as programs that did not.”81 In Cognitive Behavioral Therapy, “alcohol and drug dependence are viewed as learned behaviors that are acquired through experience. If alcohol or a drug provides certain desired results (e.g., good feelings, reduced tensions, etc.) on repeated occasions, it may become the preferred way of achieving those results, particularly in the absence of other ways of meeting those desired ends. From this perspective, the primary tasks of treatment are to (1) identify the specific needs that alcohol and drugs are being used to meet, and (2) develop skills that provide alternative ways of meeting those needs.”82

The emphasis of Cognitive Behavioral Therapy is on teaching substance-abusing offenders core concepts of self-diagnosis, self-analysis, and self-management. Each of these concepts underlies the overall goal of assisting offenders to assume responsibility for their actions through techniques provided in therapy. The self-diagnosis phase emphasizes recognizing that problems exist, identifying feelings and situations that accompany the problems, and developing interpersonal issues. The goal of the self-analysis phase is to examine how the individual contributed to the problems, identify different solutions and the likely consequences, and identify thinking and situational factors that affect these problems. In the self-management phase, the individual uses the skills acquired in therapy (e.g., problem-solving, interpersonal skills training, and cognitive behavior modification) to address problems. The self-management phase also involves the use of support groups and reinforcement to equip the offender with the tools to prevent relapse.83

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Effectiveness of Cognitive Behavioral Therapy
A number of studies support the effectiveness of Cognitive Behavioral Therapy in treating alcohol abuse, including the following:

  • Alcohol abusers who received Cognitive Behavioral Therapy as a component of their treatment had better drinking-related outcomes than those who did not receive this therapy.84

  • A review of more than 24 randomized controlled trials found that Cognitive Behavioral Therapy was comparable to or more effective than other treatment for alcohol abuse.85

  • Cognitive Behavioral Therapy was found to be particularly effective in reducing the severity of relapse and in enhancing the durability of effects for substance abusers, including alcohol abusers.86

Cognitive Behavioral Therapy Programs
Four Cognitive Behavioral Therapy programs that have been used successfully by criminal justice agencies are: (1) Moral Reconation Therapy (MRT); (2) Thinking for a Change (TFAC); (3) Reasoning and Rehabilitation (R&R); and (4) Relapse Prevention Therapy (RPT). Each is discussed below. For a listing of other cognitive behavior programs used by criminal justice agencies, see “Cognitive-Behavioral Programs: A Resource Guide to Existing Services,” published by the National Institute of Corrections.

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Moral Reconation Therapy (MRT)
MRT is a cognitive behavior program that has been used to reduce the recidivism rate of repeat DWI offenders. It combines education, group and individual counseling, and structured exercises designed to alter how participants think and make judgments about what is right and wrong. It is designed to foster moral development in individuals who have proved to be resistant to treatment.

MRT was developed in the 1980s by Drs. Gregory L. Little and Kenneth D. Robinson. It was initially used extensively with alcohol and drug offenders at the Shelby County Correction Center (Memphis, Tennessee, is the county seat of Shelby County). It is now being used in more than 40 States. For example, it is part of the therapeutic program offered by the Anchorage Wellness Court to alcoholic misdemeanor defendants.87
An evaluation of the Shelby County MRT program for DWI offenders with an average of three DWI convictions found that offenders who participated in the program had fewer re-arrests than offenders who received no treatment and served jail time only. For program participants, the re-arrest rate for new DWI offenses within two years after release was 4 percent, compared to a re-arrest rate of 15 percent for non-participants.88 However, after this two-year period, the DWI recidivism rates for both groups are essentially the same.89 Despite the fact that the developers of MRT conducted these studies, independent researchers found that MRT “works in reducing the recidivism of offenders.”90

Thinking for a Change (TFAC)
TFAC is a cognitive behavior program for offenders developed by the National Institute of Corrections (NIC) in the U.S. Department of Justice. Since its introduction in 1997, over 30 agencies have become partners with NIC as host field test sites. These agencies include State correctional systems, local jails, community-based corrections programs, and probation and parole departments.

TFAC uses a combination of approaches to increase offenders’ awareness of self and others. It integrates cognitive restructuring, social skills, and problem solving. The program begins by teaching offenders an introspective process for examining their ways of thinking, feelings, beliefs, and attitudes. This process is reinforced throughout the program. Social skills training is provided as an alternative to antisocial behaviors. The program culminates by integrating the skills offenders have learned into steps for problem solving. Problem solving becomes the central approach offenders learn that enables them to work through difficult situations without engaging in criminal behavior.

Offenders learn how to report on situations that could lead to criminal behavior and to identify their thoughts, feelings, attitudes, and beliefs that might lead them to offending. They learn how to write and use a thinking report as a means of determining their awareness of their risky thinking that leads them into trouble. Within the social skills component of the program, offenders try using their newly-developed social skills in role-playing situations. After each role-play the group discusses and assesses how well the offender did in following the steps of the social skill being learned. Offenders apply problem-solving steps to problems in their own lives.

TFAC was developed to be appropriate for a wide range of offenders. Further information about TFAC is available on NIC’s website.91

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Reasoning and Rehabilitation (R&R)
The R&R program is a multifaceted cognitive-behavior program designed to teach juvenile and adult offenders cognitive skills and values. It was developed by Dr. Robert Ross of the University of Toronto, and by Canadian criminal justice practitioners Elizabeth Fabiano and Frank Porporino. It is widely used throughout the Canadian correctional system, as well as in a number of States in the United States. The developers created R&R as an educational, skills-based intervention that Ross has described as a “cognitive-behavioral program designed to teach offenders social cognitive skills and values which are essential for pro-social competence.”92 They designed the program to assist offenders in developing self-control, social skills, problem-solving abilities, and the ability to critically assess their thinking.93 The authors identified the following factors that appeared to lead to repetitive pattern of criminal behavior: (1) problems with impulsivity associated with poor verbal self-regulation; (2) impairment in means-end reasoning; (3) a concrete thinking style that impinges on the ability to appreciate the thoughts and feelings of others; (4) conceptual rigidity that inclines them to a repetitive pattern of self-defeating behavior; (5) poor interpersonal problem-solving skills; (6) egocentricity; (7) poor critical reasoning; and (8) a selfish perspective that tends to make them focus only on how their actions affect themselves instead of considering the effects of their actions on others.94 The authors created a program that consists of 35 two-hour sessions, which is an amalgam of content and techniques borrowed from a number of sources. The program is delivered two to four times per week to groups of 4 to 10 offenders.95 The program avoids didactic presentations and uses role playing, video-taped feedback, modeling, group discussion, games, and practical homework review to teach the skills.96

Relapse Prevention Therapy (RPT)
RPT is a behavioral self-control program designed to teach individuals who are trying to maintain changes in their behavior how to anticipate and cope with the problem of relapse. It was originally designed as a maintenance program for use following the treatment of alcohol or drug addition, but may also be used as a stand-alone treatment program. RPT combines behavioral and cognitive interventions in an overall approach that emphasizes self-management.

RPT intervention strategies consist of coping-skills training, cognitive therapy, and lifestyle modification. Coping-skills training is the cornerstone of RPT, teaching individuals strategies to understand relapse as a process, identify and cope effectively with high-risk situations, cope with urges and cravings, implement damage control procedures during a lapse to minimize its negative consequences, stay engaged in treatment even after a relapse, and learn how to create a more balanced lifestyle. A number of studies have shown that RPT is effective as a psychosocial treatment for alcohol and drug dependence.97

 

80 See Kadden, Ronald M., “Cognitive-Behavioral Approaches to Alcoholism Treatment,” Alcohol Health & Research World, Vol. 18, No. 4, pp. 279-285 (1994); Donovan, D.M., et al., “Prevention Skills for Alcohol-Involved Drivers,” Alcohol, Drugs and Driving, Vol. 6, pp. 169-188 (1990); Connors, G.J., et al., “Behavioral Treatment of Drunk-Driving Recidivists: Short-Term and Long-Term Effects,” Behavioral Psychotherapy, Vol. 14, pp. 34-45 (1986).
81 See Taxman, Faye S., “Unraveling ‘What Works’ for Offenders in Substance Abuse Treatment Services,” National Drug Court Institute Review, Vol. II, No. 2,
pp. 108-110 (1999).
82 See Kadden, Ronald M., “Cognitive-Behavior Therapy for Substance Dependence: Coping-Skills Training,” Illinois Department of Human Services’ Office of Alcoholism and Substance Abuse (2000).
83 See Taxman, supra, pp. 109-110.
84 See Longabauch, R., and J. Morgenstern, “Cognitive-Behavioral Coping-Skills Therapy for Alcohol Dependence,” Alcohol Research and Health, Vol. 23, pp. 78-85 (1999).
85 See Carroll, K.M., “Relapse Prevention as a Psychosocial Approach: A Review of Controlled Clinical Trials,” Experimental Clinical Psychopharmacology, Vol. 4,
pp. 46-54 (1996).
86 See Carroll, K.M., “A Cognitive-Behavioral Approach: Treating Cocaine Addiction,” U.S. Department of Health and Human Services, National Institutes of Health (2000).
87 See discussion under Promising Sentencing Practice No. 1, above.
88 See Little, Gregory L., et al., “Treating Drunk Drivers with Moral Reconation Therapy: A Two-Year Recidivism Study,” Psychological Reports, Vol. 66, pp. 1379-1387 (1990).
89 See Little, Gregory, L., “Cognitive-Behavioral Treatment of Offenders: A Comprehensive Review of MRT Outcome Research,” Addictive Behaviors Treatment Review, Vol. 2, No. 1, pp. 12-21 (2000).
90 Allen, Leana C., et al., “The Effectiveness of Cognitive Behavioral Treatment for Adult Offenders: A Methodological, Quality-Based Review,” International Journal of Offender Therapy and Comparative Criminology, Vol. 45, No. 4, p. 509 (2001).
91 Http://www.nicic.org.
92 Ross, R. R.,“The Reasoning and Rehabilitation Program for High-Risk Probationers and Prisoners,” in R. R. Ross, D. H. Antonowicz, & G. K. Dhaliwal (Eds.), Going Straight: Effective Delinquency Prevention and Offender Rehabilitation, p. 195 (1995).
93 Ross, R. R., Fabiano, E. A., & Ewles, C. D, “Reasoning and Rehabilitation,” International Journal of Offender Therapy and Comparative Criminology, Vol. 32, 29-36 (1988).
94 Gaes, Gerald et al., “Adult Correctional Treatment,” in Michael Tonry and Joan Petersilia (Eds.), Prisons, p. 375 (1999).
95 Id. at p. 376.
96 Id. For further information about R&R, see Ross, R., et al., “Reasoning and Rehabilitation,” International Journal of Offender Therapy and Comparative Criminology,” Vol. 32, pp. 29-35 (1988), and Van Voorhis, Patricia, et al., “The Georgia Cognitive Skills Experiment: A Replication of Reasoning and Rehabilitation,” Criminal Justice and Behavior, Vol. 31, No. 3, pp. 282-305 (2004).
97 See Irvin, J.E., et al., “Efficacy of Relapse Prevention: A Meta-Analytic Review,” Journal of Consulting and Clinical Psychology, Vol. 67, pp. 563-570 (1999); Parks, G.A. and G.A. Marlatt, “Relapse Prevention Therapy for Substance-Abusing Offenders: A Cognitive-Behavioral Approach in What Works: Strategic Solutions,” American Correctional Association, pp. 161-233 (1999).