In 1974, Robert
Martinson published a now-classic text concluding that he was unable to find
evidence of the effectiveness of rehabilitative efforts for people involved in
the criminal-justice system. Although a section of his essay was titled, “Does
nothing work?” it became known as the “nothing works” doctrine. Despite the
fact that Martinson himself essentially admitted he had been wrong (Martinson,
1979), the nothing works doctrine held sway for many years until Canadian
criminologists such as Paul Gendreau introduced the “something works” doctrine
(meaning that it was clear that rehabilitative efforts could work, even if the
exact mechanisms remained unclear), and eventually the “what works” doctrine
that followed (e.g., Gendreau & Ross, 1987).
What works in
treatment seems clear enough, but is it really? The principles of effective
correctional rehabilitation (i.e. risk, need, and responsivity) state that we
should provide more intensive treatments to those who pose the highest risk,
focus on empirically supported treatment goals, and use empirically supported
techniques (e.g., CBT). The responsivity
principle further states that we should match treatment to the individual characteristics
of each client (e.g., cognitive ability, culture, mental health needs,
motivation).
From such simple
principles many controversies can emerge and great minds can disagree. For
example, one client who has sexually offended against children might benefit
from treatment addressing interpersonal skills in such a way that sex with
children is unnecessary and undesirable because of the client’s ability to form
intimate relationships with adults. Another client might reap minimal benefits
from such treatment, because it is the combination of sexual interest in
children and a suite of beliefs supporting abuse that contributes more to his
risk. As Tony Ward recently pointed out (Yates, Prescott, & Ward, 2010), absent an
explanatory means for understanding risk factors, they may simply be markers
for further investigation and understanding in programs that seek to reduce
risk and build capacities.
There is no
question that the principles of risk, need, and responsivity are vital
contributors to “what works” in treatment. However, a robust research
literature both inside and outside our field points to the fact that who the
professional is can be a vital contributor to building responsivity and beyond.
As a result, we are proposing a “who works doctrine” alongside the what works
doctrine. The name is intended to be provocative and only slightly
tongue-in-cheek, and intended as a homage to those brilliant researchers who
came before us. To illustrate the importance of thinking in terms of “who
works” in addition to what works, it may be helpful to review influential
developments of the past.
In 1979, Edward
Bordin proposed a model of the therapeutic alliance that involved agreement on
the nature of the therapeutic relationship, and agreement on the goals and
tasks of treatment. Subsequent research by Jon Norcross and others would also
highlight the importance of having therapy take place in the context of strong
client preferences (Norcross, 2011). These four areas: agreement on the nature
of the relationship, goals, tasks, and values form the basis of a critical
element of treatment. Over a thousand studies have pointed to the contribution
of the alliance to successful therapy outcomes. Recent research has highlighted
the importance of clinicians getting feedback from their clients in these areas
(e.g., Lambert, 2010; Prescott & Miller, 2015). In fact, one can argue that
attention to the alliance is amongst the most evidence-based therapeutic
activities there is. Without it, targeting criminogenic needs is useless, and a
greater waste of resources for those at highest risk (since they presumably
receive the most treatment).
Likewise, Bill
Marshall’s classic 2005 summary of research that he conducted with others
points to the qualities of the most effective professionals (Marshall, 2005).
They are warm, empathic, rewarding, and directive (in the sense of being able
to guide people and processes. However, much of our field remains influenced by
early texts and professionals who advocated a more overtly confrontational
approach (e.g., Salter, 1988). Indeed, a 2008 meta-analysis by Karen Parhar and
her colleagues found that the more coercive the treatment experience, the less
likely it is to be effective (Parhar, Wormith, Derzken, & Beauregard,
2008). Most recently, Theresa Gannon and Tony Ward published an important paper
titled, “Where has all the psychology gone?” that illustrated how far
correctional programs can stray from what – and who – works in helping people
in the legal system to rebuild their lives (Gannon & Ward, 2014).
Elsewhere in the
psychotherapy literature, there is evidence that there is a greater difference
in success between therapists practicing within a model than there is between
models themselves (Wampold & Imel, 2015). Likewise, there is considerable
evidence that the most effective practitioners in any endeavor tend to spend
more time engaging in activities meant to improve their skills and outcomes (Ericsson,
XXX). It is important to separate deliberate practice aimed at improvement from
simply practicing a lot. More hours doing the same thing can be just that –
doing more of the same. This is particularly crucial when one considers
research finding that therapists often overestimate their effectiveness (e.g.,
Beech & Fordham, 1997; Walfish, McAlister, O’Donnell, & Lambert, 2012).
However, in some
quarters, our field is paying less attention to therapeutic variables and
focusing on cutting costs by engaging in a very high level of manualization at
the expense of a deeper and more meaningful treatment experience (Albright,
2015). There is no reason to believe this will work. For example, Janice
Marques and her colleagues found in a randomized clinical trial that there was
no difference in re-offense rates between those who did and didn’t complete
abuse-specific treatment, although those who “got it” and meaningfully
completed their treatment goals really did re-offend at lower rates, although
these individuals received no further study. It is therefore not difficult to
see how over-manualization (e.g., highly scripted rather than individualized)
can easily result in problems adhering to the responsivity principle.
What works in
treatment? We propose it is time for a return to a greater attention to factors
related to specific responsivity and
to draw on the existing psychotherapy research. Areas of focus can include:
·
A return to thinking of our
programs as delivering therapy and not simply treatment
·
Greater attention to the
professional self-development of therapists
·
Increased recognition that society’s
attempts to use punishment-only approaches are almost entirely ineffective,
while the right therapy and right supervision can make an impact on re-offense
rates, community safety, and client well-being.
·
A greater awareness of the role
of adverse experiences in the lives of clients and a greater fine-tuning of
therapy in order to help clients understand how adverse events have shaped
their lives and provide avenues for growing beyond the effects of these
experiences.
·
Greater attention to what is
important in clients’ lives (e.g., drawing on the Good Lives Model; Ward
citation).
In many environments,
this will involve a return to viewing therapists as the professionals and
experts that they are. After all, the very definition of evidence-based
practice includes clinical expertise as well as best available research and in
accordance with client characteristics.
David
S. Prescott, LISCW & Gwenda M. Willis, PhD
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