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Assessing Treatment
Readiness in Violent
Offenders
Journal of Interpersonal
Violence
Volume 24 Number 4
April 2009 618-635
2009 Sage Publications
10.1177/0886260508317200
http://jiv.sagepub.com
hosted at
http://online.sagepub.com
Andrew Day
University of South Australia
Kevin Howells
Nottingham University and University of South Australia
Sharon Casey
University of South Australia
Tony Ward
Victoria University
Jemma C. Chambers
University of South Australia
Astrid Birgden
Deakin University
he enormous social and economic costs associated with violent offending are such that the development and delivery of programs to reduce
the occurrence of violent crime has become a priority area for many governments. Although there is some evidence to suggest that violent crime in
some countries may be slowly decreasing (e.g., Moffatt & Poynton, 2006),
the number of offenders imprisoned for violent offenses has risen steadily
over the past few years. Australian statistics, for example, show that nearly
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619
half of the sentenced prison population has been convicted of crimes of violence, with nearly one in two (47%) having the most serious offense involving violence or the threat of violence, including offenses such as acts intended
to cause injury (14%), robbery/extortion (12%), sexual assault and related
offenses (11%), and homicide and related offenses (10%; Australian Bureau
of Statistics, 2004). Although it is difficult to obtain a true base rate for violent reoffending, the available data indicate that at least 20% of convicted
offenders will go on to commit further violent offenses after release from custody (Dowden & Serin, 2001), making the treatment and rehabilitation of
known offenders a particularly important area for service development.
Anger-management and violence-reduction programs aimed specifically
at this population have proliferated in recent years, despite a relatively limited evidence base from which to draw any conclusions about program
effectiveness. In the just published meta-analysis, Polaschek and Collie
(2004) identified only nine violent offender program evaluations that they
considered to be of sufficient methodological rigor to warrant inclusion. Of
these, only four studies reported rates of violent recidivism. More recently,
Polaschek, Wilson, and Townsend (2005) reported positive outcomes from
a New Zealand program, with 32% of the treatment group being reconvicted for a violent offense after release as compared to 63% of a matched
comparison group (matched on the basis of relevant characteristics such as
offense type and sentence). For those treated participants who were reconvicted, survival analysis revealed that the mean number of days to violent
reoffense was more than double that for the comparison group.
A particularly important issue in violent offender treatment concerns the
assessment and selection of appropriate candidates for treatment. Although
it is generally accepted that programs should target the higher risk offenders
(Andrews & Bonta, 2003), violent offenders are not a particularly homogeneous group in terms of their treatment needs (see Davey, Day, & Howells,
2005). There is a widely acknowledged need for individualized assessment
Authors Note: The authors would like to thank all the program participants who generously
gave their time to participate in this research for no personal benefit: Katherine Hawkins and
Rebecca Penrose, who assisted with data collection and entry, and particularly to program
facilitators from violence programs in the different states: Cherice Cieplucha, Julie Malone (New
South Wales), Linda De Haan, Piers Yates-Round, Lucy Cunningham, Shelly Hicks (Western
Australia), Steven Wright, Ann-Marie Martin (South Australia), and Annie Thomas (Victoria).
This research was supported by an Australian Research Council Research Grant in collaboration
with Corrections Victoria. The views expressed in this article are those of the authors and do not
necessarily reflect those of Corrections Victoria or other agencies. Correspondence concerning
this article should be addressed to Andrew Day, School of Psychology, North Terrace, Adelaide,
5000 South Australia; e-mail: Andrew.day@unisa .edu.au.
620
and case formulation before treatment is offered to reduce the rates of inappropriate referral to treatment (e.g., Daffern, Howells, & Ogloff, 2007;
Wong & Gordon, 2004). Inappropriate referral can lead to low rates of
engagement in treatment and even program noncompletion or dropout.
Rates of attrition in many correctional programs appear to be quite high,
and Dowden and Serins (2001) findings that those who dropped out from
a Canadian correctional service program for violent offenders had the highest rate of violent reoffending (40%, compared with untreated [17%] and
treated [5%] groups) are a cause for much concern (see also McMurran &
Theodosi, 2004). That is not to say that high-risk offenders who are assessed
as likely to drop out of programs should not be offered treatment; rather,
they may require additional interventions designed to prepare them to
receive the type of intervention delivered in violent offender treatment (see
Day, Bryan, Davey, & Casey, 2006).
One potential way to minimize rates of attrition is to assess participants
before they enter the programs in terms of their ability to engage in a meaningful way with the program facilitators, materials, and other participants.
Howells and Day (2003) have suggested that many violent offenders will
struggle to do this, identifying a number of potential impediments that form
significant barriers to therapeutic engagement (including, for example, the
likelihood of comorbidity with other problems and the inferences that violent
people tend to make about the nature of their problems, such as I am right and
my reaction just or It is better to express anger than control it). In short, they
argued that many violent offenders are simply not ready for treatment.
It would therefore appear to be important to find ways of reliably predicting those offenders who will have difficulties engaging in treatment and, as a
consequence, be at increased risk of not completing programs. In this article
we report on the validation of a brief self-report measure that assesses treatment readiness in those offenders who are referred to violent offender treatment programs. In a recent study, Casey, Day, Howells, and Ward (2007)
described the psychometric properties of a new scale designed to measure
treatment readiness in offenders referred to cognitive skills programs. The
Corrections Victoria Treatment Readiness Questionnaire (CVTRQ) was internally consistent and displayed high levels of discriminant and convergent
validity and, from a practical perspective, provided a brief and easily administered measure, given that it has been designed to be used by staff with no specific professional qualifications. Importantly, scores on this measure were
shown to be positively correlated with therapeutic engagement, giving evidence of predictive validity.
621
Items from the CVTRQ were derived from a theoretical model of offender
treatment readiness articulated by Ward, Day, Howells, and Birgden (2004),
which, it is suggested, represents a conceptual advance on other models of
readiness that draw solely on the transtheoretical model (TTM) of change
(see Wong & Gordon, 2004 for an application of the transtheoretical model
with violent offenders), given the limited support for the application of this
model with offender populations (see Casey, Day, & Howells, 2005). This
study examines the extent to which an offense-specific adaptation of treatment readiness questionnaire of Casey et al. (2007) is a valid and reliable
measure, which can be used to predict engagement in those attending violent offender treatment. The study builds on the previous work in three
ways. First, a brief semistructured readiness interview was given to participants prior to entering the program. The purpose of this was to establish
whether a face-to-face interview provides a better predictor of treatment
engagement than a self-report measure, given the suggestion that interviews
may provide a more reliable method of assessment with offender populations (Serin & Kennedy, 1997). Second, the measure was readministered at
the end of the program to establish whether levels of readiness changed
over the course of the program. If readiness does change over time, then the
measure may have the potential to be also used as a measure of change in
interventions designed to promote treatment readiness prior to program participation (see Day et al., 2006). Finally, data were collected on therapeutic
engagement not only at the midpoint of the program but also on completion
of the program. In addition, data regarding participant satisfaction with the
program were also collected at the end of program to provide an additional
outcome measure and to determine whether participants identified as being
higher in treatment readiness would report higher levels of treatment satisfaction. This allows for an examination of the extent to which the measure
predicts not only engagement but also treatment performance.
Method
Participants
Participants in the study were 96 convicted male offenders referred to a
semi-intensive or intensive violence (more than 100 hours) intervention
programs delivered in four Australian states (Victoria n = 48, Western
Australia n = 26, New South Wales n = 16, South Australia n = 6). These
programs aim to promote an understanding of violent offending, identify and
622
Materials
Participants in the program completed the following measures.
Violence Treatment Readiness Questionnaire (VTRQ). The VTRQ is a
20-item self-report questionnaire that assesses readiness to participate in and
engage with a violence program. The questionnaire is an adapted version of
the CVTRQ (Casey et al., 2007), with item wording changed to reflect violence rather than offending in general (e.g., I have not offended for some
time now was replaced with I have not acted violently for some time now).
The measure is reproduced in the appendix. Items in the CVTRQ can be
grouped into four components (attitudes and motivation, emotional reactions, offending beliefs, and efficacy) that map onto the Multifactor Offender
Readiness Model (MORM; Ward et al., 2004). Responses are made on a
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625
control, volition, and choice. Responses to each statement are made using
a true/false format, with each true response scored as 0 and each false
scored as 1. Higher scores indicate a greater level of perceived coercion.
Treatment engagement. A measure of treatment engagement was constructed using the protocol developed by Casey et al. (2007), which involved
factor analysis of three measures: the Penn Helping Alliance Rating Scale
(PHA; Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983), a
measure of two types of alliance relating to the clients experience of the therapist and the clients sense of collaborative working; the Working Alliance
Inventory-Client Short-Form (WAI-C SF; Horvath & Greenberg, 1989;
Tracey & Kokotovic, 1989), a 12-item self-report measure of working
alliance, that consists of three subscales: goals, tasks, and bond; and the Group
Cohesion Scale (GCS; adapted from Riggs, Warka, Babas, Betancourt, &
Hooker, 1994), an 11-item self-report questionnaire designed to assess the
degree to which individuals believe in the shared efficacy of a group and the
ability of that group to achieve particular outcomes (see Bandura, 1977).
Responses to each of these measures are made on Likert-type scales from
strongly disagree to strongly agree. The subsequent 17-item measure, the
Treatment Engagement Scale (TES), comprised three subscales that incorporate client perceptions of and confidence in the treatment process and the
extent to which a therapeutic alliance is established. The Alliance factor (eight
items) describes the participantfacilitator relationship (e.g., The facilitators
and I trust one another); the Group Process factor (four items) describes participant beliefs about the efficacy of the group in terms of achieving treatment
goals (e.g., Some members of this group do not participate well); and the
Confidence factor (five items) reflects participant self-confidence in terms of
changing their offending behavior (e.g., I feel now that I am understanding my
problem with violence and can deal with it myself). Items were summed, following reverse scoring of negatively keyed items, to provide a total score of
treatment engagement with higher scores reflecting greater engagement.
Casey et al. reported strong internal consistency reliability ( = .90) for this
measure of engagement. The 17-item scale as developed by Casey et al. was
used to assess treatment engagement in the present study.
Therapy satisfaction. This 12-item scale (Oei & Green, 2004) asks questions relating to how participants felt about the therapy and the therapists in
the group program they attended (e.g., I am satisfied with the quality of
the therapy I received, My needs were met by the program, and The therapist was not negative or critical toward me). Items are rated on a 5-point
Likert-type scale from 1 (strongly disagree) to 5 (strongly agree). Items
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626
Procedure
Participants completed the battery of questionnaires at three points in the
program delivery. The VTRQ and VTRI were administered at the preprogram stage, together with the measures of convergent validity (SEQ, RCQ,
STRS) and discriminant validity (PDS, PCS). Measures of predictive validity (Working Alliance Inventory-Client Short-Form, Penn Helping Alliance
Rating Scale, and Group Cohesion Scale) were collected at the midprogram
stages and, together with the VTRQ, again at the postprogram stage. All
measures were given out in treatment groups and placed in a sealed envelope for posting back to the researchers. The scoring and analysis was conducted blind in so far as those conducting the analyses were not aware of
participants scores on the readiness measure.
Results
Preliminary Analyses
Prior to undertaking analyses, invalid self-report protocols were identified by applying the test manual cutoff scores for the impression management subscale of the PDS. No cases were identified as above the upper
cutoff scores (>12, faking good); using the lower cutoff (<1, faking bad),
five cases (6.3%) were identified. These five cases were removed, leaving
a total sample of 87 for subsequent analyses.
Descriptive Statistics
Descriptive statistics and internal consistency reliabilities for all measures
used in the evaluation (following deletion of invalid self-reports) are provided in
Table 1. Internal consistency reliability for the VTRQ at both pre- and posttest
was acceptable, although marginally lower than that found by Casey et al. (2007)
for the CVTRQ (.83). Mean scores on the PDS (Paulhus, 1998) were higher than
those reported by Paulhus for a prison population (8.44 vs. 7.50).
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Table 1
Descriptive Statistics for the Violence Treatment Readiness
Measure (Pre- and Posttest), Treatment Readiness Interview,
Loza-Fanous Self-Efficacy Questionnaire, Readiness
to Change Questionnaire, Serin Treatment Readiness Scale,
Paulhus Deception Scale, McArthur Perceived Coercion Scale,
Penn Helping Alliance Scale, Group Cohesion Scale,
and Treatment Engagement Scale (pre- and posttests)
Variables
Violence Treatment Readiness Measure (Preprogram)
Violence Treatment Readiness Measure (Postprogram)
Treatment Readiness Interview
Loza-Fanous Self-Efficacy Questionnaire
Readiness to Change Questionnaire
Serin Treatment Readiness Scale
Processes of Change Questionnaire
Paulhus Deception Scale
McArthur Perceived Coercion Scale
Working Alliance Inventory-Client Short Form
Penn Helping Alliance Rating Scale
Group Cohesion Scale
Treatment Engagement Scale (Midprogram)
Treatment Engagement Scale (Postprogram)
Therapy satisfaction
SD
Range
73.65
77.90
12.39
23.83
45.17
42.55
28.96
8.44
2.53
62.13
44.22
7.56
70.43
75.34
50.37
7.80
8.76
4.96
5.42
5.48
5.48
7.06
5.26
1.74
9.44
4.62
.95
10.81
11.13
7.17
55-95
53-99
4-23
12-40
27-59
29-55
11-49
1-23
0-6
19-84
23-55
4-10
33-93
51-93
29-60
.72
.76
.63
.81
.71
.79
.75
.81
.63
.91
.91
.65
.91
.92
.94
Predictive Validity
Predictive validity, which refers to the association between a measure
and some theoretically related outcome or criterion, was examined by
exploring the relationship between scores on the VTRQ and the composite
628
Table 2
Bivariate Correlations Between Violence Treatment
Readiness Questionnaire, Treatment Readiness Interview,
Loza-Fanous Self-Efficacy Scale, Readiness to Change
Questionnaire, Process of Change Questionnaire, Serin
Treatment Readiness Scale, and McArthur Perceived
Coercion Scale, Paulhus Deception Scale
Item
1. Treatment Readiness
Questionnaire
2. Treatment Readiness
Interview
3. Self-Efficacy
4. Readiness to Change
5. Processes of Change
6. Serin Treatment Readiness
7. Perceived Coercion
8. Paulhus Deception Scale
ns
1.00
.27 ns 1.00
.26* .37* 1.00
.55*** .35*
.15 ns 1.00
.51*** .27 ns .32**
.45*** 1.00
***
ns
***
.51
.29
.48
.62*** .47*** 1.00
.37**
.08 ns .30* .16 ns .16 ns .55*** 1.00
.03ns
.06 ns .26*
.07 ns .34**
.17 ns .03 ns 1.00
p > .05. *p < .05. **p < .01. ***p < .001.
measure of midprogram treatment engagement (TES). The significant positive association between treatment readiness scores and treatment engagement, r(53) = .46, p < .001, supports the predictive validity of the VTRQ.
By comparison, the only measure of convergent validity significantly
related to midprogram treatment engagement was that which measured
self-efficacy, that is, SEQ, r(53) = .28, p < .05; neither the RCQ, r(53) =
.19, p > .05 nor the STRS, r(53) = .24, p > .05, were found to be significantly associated with scores on the measure of treatment engagement
(TES). Consistent with the underlying principles of the MORM (Ward
et al., 2004), midprogram scores of treatment engagement, as measured by
the TES, r(41) = .53, p < .001, were significantly positively associated
with scores on the therapy satisfaction scale.
629
r(38) = .27, p > .05, the association was nonetheless in the desired direction and approached significance (p = .09). Furthermore, whereas scores on
the self-report measure were moderately and significantly related to scores
on the measure of treatment engagement, r(53) = .40, p < .01, the relationship between scores on the semistructured interview and treatment
engagement was nonsignificant, r(26) = .04, p > .05.
Discussion
In this article we have reported on the validation of a self-report measure
designed to assess treatment readiness in those offenders referred to semiintensive and intensive violent offender rehabilitation programs. The measure,
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630
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offenders, with the data collected in this study revealing that 6% of participants displayed a tendency to fake bad. It may be, given the possibility
of favorable parole decisions being associated with attendance at programs
that offenders seek to persuade assessors that they are indeed in need of
treatment. It should be noted that all measures used in the validation study
were self-report in nature that can raise questions about the veracity of participant responses. Although the authors acknowledge this possibility, the
relationship between scores on the readiness interview and two of the convergent validity measures (the RCQ; Rollnick et al., 1992 and SEQ; LozaFanous, 2004) were in the same direction as the self-report measure of
treatment readiness.
The results of this study also suggest that treatment readiness does increase
over the course of participation in programs. It is perhaps not surprising by the
end of treatment that participants are able to demonstrate changes in their attitudes and motivation, emotional reactions to their offenses, offending beliefs,
and efficacy; however, the data suggest that the VTRQ may have an additional
use as a measure of change in interventions designed to increase problem
awareness and motivation prior to entry in structured treatment programs.
Although the sample size in this study was insufficient to allow for confirmatory factor analysis, the four readiness subscales identified by Casey et al.
(2007) offer a clinically useful method of assessing which facets of readiness
may need to be addressed to improve readiness in particular individuals.
Although readiness did increase over the course of the intervention, it
was interesting to note that levels of therapeutic engagement (as measured
by the TES) also increased between the midprogram and postprogram points
of assessment. This suggests that for violent offenders the therapeutic alliance
continues to develop over the course of the program, in contrast to other
treatments where the alliance may develop relatively early on and then
remain stable. This finding illustrates the potential difficulties that violent
offenders experience in engaging in therapeutic change, and highlights the
need for facilitators to be sensitive to process issues throughout the treatment process. In addition, we note the strong positive correlation between
midprogram levels of treatment engagement and therapy satisfaction. This
finding underscores the importance of establishing the therapeutic alliance
early in the treatment process.
In conclusion, these results suggest that the VTRQ measure may assist
those who assess offenders with histories of violence for rehabilitation in
decision making around program eligibility and suitability. It may also
inform the design of interventions to improve treatment readiness in those
offenders who are unable to engage in violent offender treatment.
632
17.
18.
19.
20.
8.
9.
10.
11.
12.
13.
14.
15.
16.
1.
2.
3.
4.
5.
6.
7.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Strongly
Disagree
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Disagree
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Unsure
Appendix
The Violence Treatment Readiness Questionnaire (VTRQ)
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Agree
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Strongly
Agree
633
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Andrew Day works in the School of Psychology at the University of South Australia. He is
interested in clinical forensic psychology research and practice, and has worked both in the
United Kingdom and Australia.
Kevin Howells is from the Peaks Academic and Research Unit, Nottinghamshire Healthcare
Trust and University of Nottingham. He also works at the Centre for Applied Psychological
Research, University of South Australia.
Sharon Casey is Programme Director of the Forensic Psychology Masters Programme at the
University of South Australia.
Tony Ward is currently a professor of clinical psychology at Victoria University of
Wellington, New Zealand. His research focuses on rehabilitation issues and models, cognitive
635
processes in offenders, and the offense process in sex offenders. His most recent book is
Rehabilitation: Beyond the Risk Paradigm, Routledge (2007, coauthored with Shadd Maruna).
Jemma C. Chambers completed her PhD at the University of Melbourne in 2006. She currently works in the United Kingdom.
Astrid Birgden is a forensic psychologist who develops offender rehabilitation services, particularly regarding sexual offenders and intellectually disabled offenders. She is currently
Director of a drug treatment prison in Sydney, Australia.