Review of the Roots of Youth Violence: Literature Reviews

Volume 5

Rehabilitation Strategies5

What Is Rehabilitation?

Rehabilitation efforts are an attempt, through treatment or programming, to stop offenders from continuing to offend. Webster (2004) notes that “[r]ehabilitation is a crime prevention strategy rooted in the notion that offenders can change and lead crime-free lives in the community” (Webster, 2004: 115). While other preventative programs attempt to sway youth away from getting involved in violence and delinquency before they have done so, rehabilitation programs target youth who have already engaged in delinquent or violent behaviour. Rehabilitation is also known as tertiary crime prevention (Farrington and Welsh, 2007: 93). Rehabilitative programs can be provided within or as part of another criminal justice sanction, such as incarceration or probation, but this is not a requirement of rehabilitative programming (Lipsey and Cullen, 2007: 9).

The Great Debate

Rehabilitative treatment was a dominant response to criminal offending until concerns began to arise in the 1950s, 1960s and 1970s. Those opposed to rehabilitation questioned the use of discretion afforded to state officials in determining and delivering treatment as a sentence, versus its use as a method of control and discrimination (Cullen, 2007: 718). During this period, a number of evaluation studies also suggested that rehabilitative efforts were not working. This trend culminated in Dr. Robert Martinson’s famous (or infamous) 1974 publication on programming in correctional settings, which posed the question “does nothing work?” (Martinson, 1974: 48; also see Martinson, 1976: 180; and Lipton et al., 1975). Martinson’s “nothing works” hypothesis did not, however, terminate the debate surrounding rehabilitation. Critics jumped at the challenge to prove that rehabilitation strategies do have promise (for example, Palmer, 1975; Gendreau, 1981; Cullen, 2005). By 1979, Martinson himself reversed his original arguments and noted that positive effects have been shown to occur with a number of different treatment programs (Martinson, 1979: 244). In a re-analysis of the rehabilitation literature, he notes that

. . . startling [positive] results are found again and again in our study, for treatment programs as diverse as individual psychotherapy, group counseling, intensive supervision, and what we have called individual/help (aid, advice, counseling) (Martinson, 1979: 255).

Unfortunately, despite Martinson’s efforts to recant his initial conclusions, and despite the results of many other studies that clearly demonstrated the utility of rehabilitation approaches, an “anti-treatment” sentiment marked most correctional policy discussions throughout the 1980s. Nonetheless, the next two decades continued to turn out research that documented the many positive effects of rehabilitative treatment programs (for example, Gendreau and Ross, 1987; Cullen and Gendreau, 1989; Lab and Whitehead, 1988; Andrews et al., 1990; Lab and Whitehead, 1990). The most convincing of these studies have come in the form of sophisticated meta-analyses. These studies attempt to summarize the results of large numbers of previous evaluation studies and establish the overall “effect size” of rehabilitation on various outcome variables (including subsequent offending patterns):

First we got meta-analyses, then we had meta-analyses of meta-analyses. In short it was a campaign of ‘shock and awe’ that seemed to end the thirty-year reign of scepticism following Martinson’s flawed, over-exposed and exaggerated review (Ward and Maruna, 2007: 9).

Nonetheless, despite numerous empirically based rejections of the “nothing works” hypothesis, some policy-makers have continued to argue that rehabilitation efforts do not work and are soft on criminals. Such critics of the treatment approach frequently call for tougher sentences to deter or incapacitate criminals and for greater monitoring of criminal populations through the expansion of law enforcement capacity (Ward and Maruna, 2007: 10–12). Many of these individuals argue that governments should divert the monies they currently devote to rehabilitation programming into prison construction and policing. However, as outlined in this report, most criminological research strongly supports rehabilitation over both deterrence and incapacitation strategies (Cullen, 2007: 717). It can thus be said with confidence that there is a substantial body of empirical research that supports the notion that rehabilitative efforts can reduce violent and other criminal behaviour. The balance of this paper will be dedicated to this body of research.

This section of the report aims to review different types of rehabilitative programs within the basic framework of “what works” and “what doesn’t work.” It begins with a brief discussion of public opinion about rehabilitation. A review of the meta-analytic evaluation literature is then provided, followed by a description of some rehabilitation programs that have been shown to reduce recidivism. This section concludes with a summary of what works, what doesn’t work and what we need to know more about regarding rehabilitation efforts. Specific recommendations about the implementation of rehabilitation strategies are also reviewed. Please note that this review is most interested in rehabilitation programs that include strategies that target serious violent offenders – including young offenders – who have already been arrested and sentenced to a period of incarceration. However, the available research is not limited to serious and violent youthful offenders. Thus, wherever possible, effects for serious offenders will be explicitly identified.

Public Support for Rehabilitation

While public figures often highlight the public’s desire to “get tough” on crime, detailed questioning of citizens indicates that the public also supports the general principles of rehabilitation. American researchers have been aware of this trend for more than 20 years. Roberts (2004) reports that, during the late 1980s, 78 per cent of Americans felt that rehabilitation should be the primary goal when sentencing youth. Moreover, similar results were found earlier in the 1980s and again in the 1990s, indicating stability in public perceptions of rehabilitation (Roberts, 2004: 512). As Cullen (2005) notes, “although the public is punitive and offender treatment has been excoriated repeatedly, Americans still strongly support the view that efforts should be made to rehabilitate offenders” (Cullen, 2005: 12–13).

Importantly, the general public is particularly supportive of rehabilitation for young offenders. In a survey of Ontario residents, Varma (2000, as in Doob and Cesaroni, 2004: 9) found that respondents feel that the rehabilitation of young offenders is far more important than rehabilitation for adults. Moreover, the public feels that incapacitation and deterrence is less important for youth than it is for adults (Varma 2000, as in Doob and Cesaroni, 2004: 9). When asked to rate the importance of rehabilitation as a purpose of youth sentencing, a sample of approximately 500 Ontarians rated rehabilitation as 8.1, on average, on a scale of 1 to 10, with 1 signifying no importance and 10 signifying high importance (Doob, 2000: 329). A separate group of approximately 500 Ontarians was asked the same question with regard to adults and indicated 7.77 out of 10 (Doob, 2000: 329), which is still high, but not as strong as perceptions about rehabilitation for youth. This stands in stark contrast to a federal government that wants to “get tough” on youth crime. It is possible that the public appreciates the root causes of youth criminality and realizes that the vast majority of young offenders will ultimately return to the community. The public is aware that we can either address the needs of youthful offenders while they are serving sentences – or simply incarcerate them without treatment and hope that they will be deterred.

The question that emerges, however, is whether the public’s general faith in rehabilitation is warranted. The answer to this question will be determined next, by reviewing the empirical evidence on rehabilitative efforts.

What Do We Know About Rehabilitation?

The “what works” discourse essentially boils down to teasing out the factors and treatment programs that help reduce the recidivism of known offenders. Traditionally, therefore, the main goal and primary indicator of a successful rehabilitation program is whether program participants achieve a lower recidivism rate than non-participants do. However, talking about “what works” is not as straightforward as might be expected. There are thousands of existing evaluations on rehabilitative efforts (Wormith et al., 2007: 881) and it would be almost impossible to simply review each and every one of these reviews and decipher what the best practices are for youth. Meta-analytic studies help to overcome this daunting task by synthesizing the results of many studies at once.

Meta-analyses first select a sample of evaluation studies that meet certain methodological standards. Criteria for inclusion in a meta-analysis might include factors like sample size, pre-program and post-program outcomes, the presence of a control group, etc. A study selection process that focuses on methodological rigour and program characteristics ultimately makes it easier to summarize results and compare rehabilitative efforts across time and space. The subsequent process of coding information from individual studies is conducted much like the systematic coding of individual survey responses from a representative sample from the general population (see Howell, 2003: 198). The outcome variable in meta-analytic studies is called an “effect size,” which in the case of rehabilitation refers to whether (and how much) the treatment worked in reducing recidivism when compared with the control group that received no treatment. A larger effect size indicates that there was less recidivism among the treatment groups compared with the control groups. A negative effect size indicates a negative impact (i.e., more recidivism among the treatment groups when compared with control groups). Essentially, an effect size is the mean difference between the treatment and control groups (Aos et al., 2001: 38). The next section of this report reviews the findings from meta-analyses, beginning with three of the most influential meta-analyses to date, which continue to be widely cited in current literature (Cullen, 2007).

Evaluation of the Rehabilitation Paradigm Through Meta-analyses

Andrews et al., (1990) conducted a meta-analysis on correctional treatment evaluations using two samples of studies. The first sample included 45 studies of juvenile treatment that were published in professional journals between 1975 and 1984. The second sample included 35 additional studies that were conducted between the 1950s and 1989. The purpose of the second sample was to analyze the generalizability of the first sample, including the applicability of conclusions to adult correctional populations (Andrews et al., 1990: 377).

In looking at recidivism for various programs, Andrews et al. (1990) were also testing their model of “risk-need-responsivity” (RNR) in predicting effective treatment. The RNR model posits that applying the three principles of risk, need, and responsivity is imperative for effective treatment planning and delivery and hypothesized reductions in offender recidivism.

The “risk” principle refers to the notion that offenders who are at higher risk of reoffending should have greater levels of treatment devoted to them, whereas lower-risk offenders should receive lesser levels of treatment. (Andrews et al., 1990: 374). The “needs” principle refers to the notion that criminogenic needs should be targeted for change. Criminogenic needs are risk factors that are seen as dynamic or changeable. Examples of criminogenic needs include anti-social attitudes and feelings and negative peer associations. Static risk factors, such as prior criminal record, are obviously unchangeable (Andrews et al., 1990: 374–375). The “responsivity” principle refers to using methods of treatment that are capable of bringing about the desired changes in offenders and that are matched with the learning styles of offenders (Andrews et al., 1990: 375). This principle has been criticized by other authors for being circular, because the definition of the principle is essentially the desired outcome as well (change in the offender). However, Andrews et al. point to specific approaches, such as cognitive-behavioural and social learning techniques, that have been shown to bring about changes in behaviour (Lipsey and Cullen, 2007: 310).

To test the RNR model, studies included in the meta-analysis were categorized as belonging to one of four types. The first category refers to normal correctional sanctions without rehabilitative programming. The remaining three types included appropriate service, unspecified service and inappropriate service. “Appropriate” correctional service refers specifically to programs that incorporate the three RNR principles:

(1)delivery of service to higher risk cases, (2) targeting of criminogenic needs, and (3)use of styles and modes of treatment (e.g. cognitive and behavioural) that are matched with client need and learning styles (Andrews et al., 1990: 369).

“Inappropriate” correctional service, on the other hand, refers to programs that do not follow the three RNR principles and thus provide service to lower-risk cases, do not target criminogenic needs, and are unstructured (Andrews et al., 1990: 379). Finally, Andrews and his colleagues refer to “unspecified” correctional service as rehabilitative programs that cannot be categorized into either of the previous two types of treatment program (Andrews et al., 1990: 380).

Andrews et al. (1990: 382) found that type of treatment was the strongest predictor of subsequent offender behaviour.6 They reported that upon comparing “appropriate” service with “unspecified,” “inappropriate” service and non-treatment criminal sanctions, it was determined that, indeed, appropriate service yielded significantly higher reductions in recidivism than did either of the other three categories. Moreover, appropriate and unspecified treatment both showed significant reductions in recidivism when compared with criminal sanctions and inappropriate service. “Casual review of recidivism rates will reveal that, on average,” appropriate treatment was found to cut recidivism rates by 53 per cent (Andrews et al., 1990: 385). In other words, when recidivism rates for offenders who received “appropriate” treatment were compared with recidivism rates for offenders who received criminal sanctions, the rates of reoffending were cut by about half. Thus, for example, if for every offender who received criminal sanctions six would recidivate, then only three out of every ten offenders who received appropriate treatment would recidivate.

A few years later, Loeber and Farrington (1998) reported on the results of Mark W. Lipsey’s and David B. Wilson’s 1998 meta-analysis of 200 studies investigating the effectiveness of treatment interventions for serious and violent juvenile offenders (Loeber and Farrington, 1998: 18). Mark Lipsey is one of the leaders in meta-analytical studies and has been commended for continuing to publish numerous methodologically sound studies on rehabilitation (Cullen, 2005; Jones and Wyant, 2007; Ward and Maruna, 2007). Loeber and Farrington (1998) described seriously violent youth as those who had committed offences such as homicide, rape, robbery, aggravated assault and kidnapping. Serious non-violent offences were defined as burglary, motor vehicle theft, theft over $100, arson and drug trafficking. Youth who engaged in these offences were defined as serious and/or violent juveniles (SVJ) (Loeber and Farrington, 1998: 7). Conclusions were made about the effect sizes in reducing recidivism for both institutionalized and non-institutionalized youth. Although small, medium/moderate and large effect sizes were not defined by Loeber and Farrington (1998), Cohen (1988), in reference to Cohen’s d (difference between two means), defined small effect sizes as equal to 0.2, medium effect sizes as equal to 0.5 and large effect sizes as equal to 0.8. According to this definition, small effect sizes indicate a reduction in recidivism of up to 14.7 per cent compared with the control group; moderate effect sizes indicate up to a 33 per cent reduction of recidivism compared with the control group; and large effect sizes indicate up to a 47.4 per cent reduction in recidivism compared with the control group.

Among non-institutionalized youth, the authors found that positive rehabilitative effects were larger for youth who had mixed prior offences (including offences against persons), compared with youth who only had prior property offences (Loeber and Farrington, 1998: 18). For both institutionalized and non-institutionalized youth, there were larger positive treatment effects detected for longer treatment durations (i.e., longer programs), although fewer contact hours per week were associated with larger effect sizes among non-institutionalized youth (Loeber and Farrington, 1998: 18).

With regard to specific types of programs, Loeber and Farrington (1998) found that programs that used interpersonal skills training, behavioural approaches, individual counselling and drug abstinence programs yielded the largest effect sizes on reducing recidivism among non-institutionalized youth. For institutionalized youth, it was found that the largest effect sizes for reductions in recidivism occurred with interpersonal skills training, cognitive-behavioural programs and teaching family homes (Loeber and Farrington, 1998: 18). In addition, institutionalized programs yielded larger positive effects when program implementation was monitored, compared with when it was not; programs were older than two years; and programs used mental health personnel instead of criminal justice personnel to deliver the treatment (Loeber and Farrington, 1998: 18).

Among both non-institutionalized and institutionalized youth, moderate effect sizes in recidivism reductions were found in programs that offered multiple services. For non-institutionalized youth, restitution programs were also found to provide moderate effect sizes, while among institutionalized youth, moderate effect sizes were found in programs that offered community residential programs, group counselling, individual services, and guided group therapy (Loeber and Farrington, 1998: 18).

With respect to the best-case scenarios provided by this study, the reductions in recidivism were the same for institutionalized and non-institutionalized youth, yielding “reductions in recidivism from around .50 to .30, a substantial 40 per cent reduction” (Loeber and Farrington, 1998: 18). However, both Lipsey and Wilson (1998) and Andrews et al. (1990) found that treatment effects were generally larger in the community than within institutionalized settings (Lipsey and Cullen, 2007: 304). In essence, this means that when compared with community-based programs, institutionalized programs have been found to be less effective. Although Lipsey and Wilson (1998) and Andrews et al. (1990) both found that treatment effects were larger in the community than within institutionalized settings, they did not address why this could be the case. They did discuss whether this may have had something to do with differences between offenders in the two groups, differences in the treatment itself, or the inherent differences in the treatment environment (Lipsey and Cullen, 2007: 304).

Greenwood (2006) identifies three problems with residential treatment, with the first two aiding in understanding why treatment is less effective in these settings. Firstly, putting groups of serious offending youth together paves the way for them to support each other in delinquent behaviour. Secondly, residential programs often create an artificial environment, thus making it difficult for youth to apply what they learn in real-world situations. Lastly, residential treatment is expensive, costing “at least three times the cost of intensive nonresidential programs” (Greenwood, 2006: 88).

Returning to Loeber and Farrington (1998), for programs that did not work, they reported that among institutionalized youth, employment-related programs and drug abstinence programs all had little or no effect on recidivism. For non-institutionalized offenders, deterrence programs (e.g., boot camps), early release probation and parole, and some vocational programs all had little or no effect on recidivism. Wilderness challenge programs were found to “not work” for either institutionalized or non-institutionalized youth, and subsequent studies have actually found that wilderness programs are much less effective for serious and violent youth than for any other delinquent youth group (Howell, 2003: 141). Furthermore, other studies have supported the finding that some programs increase recidivism for non-institutionalized serious and violent youth, such as deterrence programs (e.g., boot camps, Scared Straight) and vocational programs that do not include education (Howell, 2003: 136; Lipsey and Cullen, 2007: 300).

A subsequent meta-analysis by Lipsey (1999) combined the results of over 200 studies on juvenile treatment programs in institutionalized settings and community-based settings. He found the largest effects on recidivism occurred with programs that “incorporated individual counselling, developed interpersonal skills, offered behavioural programs (e.g., family therapy), and included multiple services” (Jones and Wyant, 2007: 764-765). Youth who were exposed to interventions reported significantly lower recidivism rates. Further analysis of 83 interventions for institutionalized young offenders found that programs that helped build interpersonal skills and offered behavioural programs and multiple services continued to be effective in these settings as well as in community residential programs (Jones and Wyant, 2007: 765).

As in the 1998 study, Lipsey (1999) found that programs that were longer than six months, were provided by a non-justice provider, were properly implemented and had been in existence for more than two years all contributed to significantly reducing recidivism. Over all, the programs with the best program features could reduce recidivism to 40 per cent to 50 per cent of what it would be without programming (Lipsey, 1999, as cited in Jones and Wyant, 2007: 765). Hence, if recidivism were to occur for 50 per cent of offenders without treatment, then the best-case scenario for treatment effects would reduce this figure by up to half, or 25 per cent.

More recent meta-analyses have continued to echo findings similar to what has been reported by Andrews et al. (1990), Loeber and Farrington (1998) and Lipsey (1999) and offer more focused examinations of program characteristics such as program integrity, mandated versus voluntary participation, and offender characteristics. The findings on these types of factors are discussed next.

The need for treatment initiatives to maintain program integrity, or the delivering of programs as they were designed, seems like a common sense issue: if programs are not implemented according to their design, how can they be said to work? Factors such as resource scarcity and variation between treatment counsellors can contribute to the low integrity of treatment programs. There are a handful of meta-analyses that have looked into the relationship between program implementation and effect size and all have found that program implementation is strongly related to program effects on recidivism (Andrews and Dowden, 2005; Landenberger and Lipsey, 2005; Latimer, 2001, Lipsey and Wilson, 1998; Lösel and Schmucker, 2005 as cited in Lipsey and Cullen, 2007: 311). Recall that Loeber and Farrington (1998) reported larger effects when the program implementation was monitored in correctional settings. Some studies indicate that programs that are not implemented properly have the potential to do more harm (such as result in more violence) than no treatment at all (Webster, 2004). Hence, if a program cannot be delivered as designed due to financial or other constraints, it is best not to make modifications to try and keep it running.

When examining family interventions, one researcher discovered an important relationship between treatment effects and voluntary treatment. Latimer (2001) examined family interventions through a meta-analysis of 35 published and unpublished studies conducted between 1973 and 1999. While support for family interventions was no longer strong after controlling for methodological rigour (Latimer, 2001), Latimer did also find that more positive effects on recidivism occurred with treatment programs where participation was voluntary as opposed to mandated (Latimer, 2001). One explanation for this could be that more serious offenders are more likely to be forced into treatment; however, this would violate Andrews et al.’s “risk” principle, which has been supported in subsequent studies (Dowden and Andrews, 2000). An alternative explanation for the relationship between voluntary treatment and program success is that when offenders want to be in treatment, when they want to change, results are more easily attained. Interestingly, this implies that program effects can be influenced by offenders themselves – the same would be true for example, where offenders physically attend programs but do not participate (i.e., are not engaged), or if they drop out of a program before it is completed (also known as attrition). As Ward and Maruna (2007: 18–19) stress, “if participants themselves do not engage with or commit themselves to an intervention, the ‘treatment’ cannot really claim to be of much ‘help.’”

Expanding on the Dowden and Andrews (2000) study cited above, offender characteristics have been shown to have an impact on correctional program effectiveness through a meta-analysis of 35 studies7 that used violent recidivism as the outcome variable (Dowden and Andrews, 2000: 456). Specifically, in accordance with the RNR’s “risk” principle, higher-risk and violent offenders have shown larger reductions in recidivism than lower-risk offenders upon effective treatment. However, this finding did not reach statistical significance within the particular study (Dowden and Andrews, 2000: 460). The authors note that risk has generally been the weakest-supported aspect of the RNR model and that this could be due to problems in coding high- and low-risk offenders during meta-analysis since original studies tend to lack this information. Logically, it makes sense to think that larger reductions in recidivism would follow from treatment of higher-risk offenders compared with lower-risk offenders, considering that the expectation of higher-risk offenders is that they will commit more crime than lower-risk offenders will. Thus, the successful treatment of high-risk offenders would expectedly prevent more crimes than the successful treatment of low risk offenders would. In other words, higher-risk offenders “have more room for improvement from effective treatment” (Lipsey and Cullen, 2007). However, more research is needed to clarify the issue. One of the most important findings of Dowden and Andrews (2000) is that the results are consistent with the results found in Andrews et al. (1990) indicating that treatment that incorporated the principles of effective correctional treatment8 yielded the largest reductions in recidivism when compared with inappropriate service (Dowden and Andrews, 2000: 458). The difference, however, is that Andrews et al. (1990) used general recidivism as the outcome variable whereas Dowden and Andrews (2000) used violent recidivism as the outcome variable, thus indicating the generalizability of the RNR model to more specific conditions (violent recidivism) (460).

To conclude this section on the findings of meta-analyses, it is noteworthy that Lipsey and Cullen (2007) reviewed virtually all meta-analyses regarding correctional treatments and found that, when comparing those who received rehabilitative treatment with those who did not, “every one of these meta-analyses found mean effect sizes favourable to treatment and none found less than a 10 per cent average reduction in recidivism,” with most mean effect sizes showing reductions of recidivism of 20 per cent and the highest reductions going up to 40 per cent (Lipsey and Cullen, 2007: 303). Moreover, in meta-analyses of studies that compare sanctions (longer versus shorter sentences, more versus less), the best cases have shown moderate reductions in recidivism while the worst cases have shown increased recidivism as the result (Lipsey and Cullen, 2007: 314). Finally, the smallest mean reduction found among meta-analyses of rehabilitative treatments is larger than the greatest mean reduction in recidivism found in meta-analyses of criminal sanctions (Lipsey and Cullen, 2007: 314). What this implies is that rehabilitation “works,” and in comparison with conventional sanctions, it works a lot better.

The next section of this report will turn to some of the specific programs that have been shown to work within and outside of correctional settings.

As noted above, Lipsey and Cullen (2007) compared the effect sizes of numerous meta-analyses in their review. In order to do this, the authors created an index of meta-analyses that converted findings into a phi statistic and subsequently calculated reductions in recidivism as a percentage,9 which allowed for simple comparison (Lipsey and Cullen, 2007: 300). Please keep this in mind wherever this study is referred to below, as the figures may deviate slightly from what was noted by the original authors as a result of the systematic comparison by Lipsey and Cullen (2007).

Promising Programs

It is important to mention that different programs work for different types10 of offenders. For example, providing employment opportunities has been shown to work in reducing recidivism, but only for people who were more than 26 years old (Webster, 2004: 118). Recall that the focus of this report is treatment for serious and violent youth who have already been adjudicated. It is well beyond the scope of this report to review the vast literature on all individual programs that are currently in operation, but the following are some of the most promising due to rigorous evaluations. For clarity, programs have been broken down into those that have been tested in the community and those that have been tested in institutional settings, although the programs are not limited to these settings.

Promising Programs Within the Community

The three programs that will be discussed below have the following elements in common: “All three involve recruiting and motivating families to participate in the intervention, working with families to identify problems and develop solutions, and extensive monitoring of adherence to the model and intervention protocols” (Greenwood, 2006: 70). Moreover, they include oversight mechanisms that ensure programs are implemented accurately and consistently. Multi-systemic therapy and multidimensional foster care programs both use service coordinators who stay in touch with schools, parents, counsellors, etc. These are tested models that have been replicated in various sites.

Multi-systemic therapy and multidimensional treatment foster care programs “appear promising in the treatment of severely aggressive adolescents with chronic juvenile justice histories,” with reported decreases in arrest rates of 25 to 75 per cent lower than control groups over one-year to four-year follow-up periods, according to evaluation studies (Connor et al., 2006: 812), and the research is supportive of functional family therapy as well.

Multi-systemic Therapy

Scott Henggeler’s multi-systemic therapy (or MST) has received much attention for producing a model that not only “works” to reduce recidivism, but also is also continuously evaluated and has been successfully replicated in other areas.

The main goal of MST is to assist parents in dealing with their child’s behaviour problems. Examples of these problems include poor school performance and hanging around deviant peers. The program serves youth in both the social service and youth justice systems (Greenwood, 2006: 72). MST is usually administered in natural settings, such as the home or school or in the community. The duration of the treatment is four months, including 50 hours of time with a counsellor. In addition to the 50 contact hours, counsellors are on call for emergency service (Howell, 2003: 235).

MST works with the family to help parents with effective parenting and building social support networks. This approach encourages the extended family to participate, in addition to teachers, school administrators, “and other adults who interact with the youth” (Greenwood, 2006: 72).

The research done about the effects of MST is extensive. Three meta-analyses on MST have indicated reductions in recidivism ranging from 16 per cent to 46 per cent when compared with control groups (Aos et al., 2001; Curtis et al., 2004; Littell et al., 2005 as cited in Lipsey and Cullen, 2007: 308). Moreover,

MST is considered as one of the best practice programs as reported by the highly regarded Washington State Institute for Public Policy (WSIPP) and The Centre for the Study and Prevention of Violence at the University of Colorado (Leschied, 2007: 40).

It has also been named as a “model” therapy by the Surgeon General’s Report (Greenwood 2006: 70) in the United States. MST has been shown as an effective treatment for delinquency (Howell, 2003: 137), even for serious and violent youth.

First, MST targets for change the ‘empirically established determinants of serious antisocial behaviour’ (Henggeler, 1999: 3). Second, when intervening with youths, there is a reliance on the ‘integration of evidence-based techniques’ (Sheidow et al.’ 2003: 303). Third, there is a continuing commitment to evaluate MST programs to ensure quality control and to understand the factors that shape its effectiveness across types of problem behaviors and settings. In general, MST has enjoyed firm empirical support (Farrington and Welsh, 2002, 2003; Sheidow et al., 2003; cf. Littell, in press as cited in Cullen, 2005: 24).

Clearly then, support has been mounting for MST as an effective treatment program for delinquent youth, including violent youth. Evidence-based support has also been mounting for multidimensional treatment foster care, which will be discussed next.

Multidimensional Treatment Foster Care

Multidimensional Treatment Foster Care (MTFC) puts delinquent youth into a foster home, either by themselves or with one other adolescent. Foster parents are trained and use behavioural parenting techniques prior to taking a youth into the home (Eddy et al., 2004: 3). During the youth’s stay, foster parents engage in daily phone calls with a case manager and attend group meetings once a week that are run by a case manager (Greenwood, 2006: 72–73).

Youth are treated by an individual therapist while another therapist works with the natural parents. There are no group sessions and youth are discouraged from associating with delinquent peers (Eddy et al., 2004: 3). Program delivery is coordinated and overseen by case managers.

Studies have compared MTFC with treatment in a group home through random assignment and found that MTFC is effective in reducing subsequent arrests (Greenwood, 2006: 73). For example, Eddy et al. (2004) compared the violent recidivism of 42 male youth who were randomly assigned to group care (GC) with 37 male youth who were randomly assigned into MTFC between 1991 and 1995. Group care consisted of homes with six to 15 offenders living together. Although there was variation between the 11 homes studied, most youth participated in individual and group therapy as part of their program (Eddy et al., 2004: 3).

These youth were deemed serious and chronic offenders who fell into “the top 1 per cent of local juvenile offenders in terms of total arrests in the past 3 years” (Eddy et al., 2004: 3). Ages ranged from 12 to17, with an average age of 14.9 at the beginning of the program (Eddy et al., 2004: 4). There were no significant differences between the control and experimental groups in terms of demographics, offence type/history and a number of other factors (Eddy et al., 2004: 4).

Official criminal referrals (i.e., official records of assault, menacing, kidnapping, unlawful weapons use, robbery, rape, sexual abuse, attempted murder, and murder) were coupled with self-report data to obtain a measure of violent behaviour for a two-year follow-up period (Eddy et al., 2004: 4-5). Findings indicated that MTFC participants had significantly fewer criminal referrals for violence than youth who were in GC (21 per cent versus 38 per cent) according to official referrals and self-report data (Eddy et al., 2004: 5). Moreover, only five per cent of MTFC youth were referred for two or more violent offences, while 24 per cent of GC youth were referred for two or more violent offences (Eddy et al., 2004: 6). A subsequent study found similar program effects for girls (Leve and Chamberlain, 2005: 340). A meta-analysis of MTFC showed a 36 per cent reduction in recidivism when compared with the control groups (Aos et al., 2001 as cited in Lipsey and Cullen, 2007: 308).

Functional Family Therapy

In Functional Family Therapy (FFT), treatment is delivered to youth between the ages of 11 and 18 who have engaged in delinquency, violence or substance abuse (Greenwood, 2006: 70). Essentially, the program works on relationships between family members in order to improve the functioning of the family unit as a whole. FFT equips families with tools for problem-solving and effective parenting in addition to building family bonds.

Service delivery of FFT consists of a hierarchical structure whereby senior therapists/trainers supervise and monitor teams of four to eight other therapists (Greenwood, 2006: 72).

According to Greenwood (2006), FFT “is well documented and readily transportable” (Greenwood, 2006: 72). FFT has been demonstrated as effective in many trials over the last 25 years. Results have held in various settings and with services delivered by different types of therapists (Greenwood, 2006: 72). It was also named as a “model” therapy by the Surgeon General’s Report in the United States. Meta-analysis of FFT for juveniles indicated a 20 per cent reduction in recidivism compared with the control group (Aos et al., 2001 as cited in Lipsey and Cullen, 2007: 308). FFT is cheaper than MST, but not as intensive, and there is no on-call therapist. Both programs take about the same amount of time to complete (four months) (Greenwood, 2006: 72).

Promising Programs within Institutional Settings

Unfortunately, the research support for specific programs within correctional settings is lacking compared with community treatment programs. The institutional programs are not as well defined as MST, FFT, and MTFC, but types of treatment have been looked at, although they may vary in implementation from site to site. Even so, these programs, as cited in the literature (e.g., Webster, 2004: Howell, 2003; Greenwood, 2006), suggest that many of the known institutional programs are not what work best for youth, especially seriously delinquent youth. For example, vocational programs, as noted above, may not be ideal for youth. The same has been said for substance abuse programs within correctional settings for serious and/or violent youth (Lipsey, 1999), although these have shown positive results in other meta-analyses of effective youth and adult treatment (Lipsey and Cullen, 2007: 309). Interpersonal skills training has received support as an effective treatment component (Lipsey, 1999); however, there is little discussion of what this entails or whether it occurs as a program by itself. Thus, in the case of institutional treatment, there are general principles that have been identified as effective. These principles have been discussed above as part of the review of meta-analyses and will be summarized towards the end of this section of the report. However, there is agreement that “[b]ehavioural and social learning approaches faired better than non-behavioural approaches” to treatment in institutional settings (Dowden and Andrews, 2000: 459) and as a result, it is most appropriate to discuss one of these treatments here. Cognitive-behavioural therapy has been selected for discussion because it is one of the most well-defined forms of treatment in the literature and it is widely used on its own or as part of other treatments (such as MST, Moral Reconation Therapy (MRT) and the Reasoning and Rehabilitation program (Hubbard, 2007: 3)]. Moreover, this treatment is consistent with Andrews et al.’s (1990) concept of responsivity.

Cognitive-behavioural Therapy

Cognitive-behavioural therapy (CBT) is an approach that is used on its own or as part of another program. It uses

. . . exercises and instruction that are designed to alter the dysfunctional thinking patterns exhibited by many offenders [e.g., a focus on dominance in interpersonal relationships, feelings of entitlement, self-justification, displacement of blame and unrealistic expectations about consequences of antisocial behaviour (Walters 1990)] (Lipsey and Cullen, 2007: 302).

CBT helps people become aware of the existence of these dysfunctional thinking patterns, or “automatic negative thoughts, attitudes expectations and beliefs, and to understand how these negative thinking patterns contribute to unhealthy feelings and behaviours” (Wolfe, 2007: 66). As such, CBT focuses on one of the most robust correlates of crime, anti-social attitudes. Moreover, correctional staff can be trained to conduct CBT in a relatively short period of time (Hubbard, 2007: 6). Qualified staff help youth transform negative thoughts into positive ones, and with the emphasis on the connection between thoughts and behaviours, this helps change behaviour as well (Wolfe, 2007: 66). Some of the behavioural techniques used by CBT include role playing, reinforcement and modelling (Hubbard, 2007: 7). This can be related to the RNR model, since using a multitude of techniques is important to meeting the responsivity principle of the RNR model because it allows for a larger scope of varying learning needs/styles to be met for different offenders (Hubbard, 2007: 2).

Meta-analyses of CBT have indicated reductions in recidivism ranging from eight per cent to 32 per cent compared with control groups, although these studies generally include mixed samples of adults and juveniles (Lipsey and Cullen, 2007: 308). As noted above, programs that have included CBT have also fared well during evaluation research. However, it is clear that more research needs to be done on the type of programming that is implemented within correctional settings. This is but one of many research questions that remain to be answered by future research. The next section discusses some of the other questions that remain regarding rehabilitation efforts.

What Do We Need To Learn More About?

While the research on rehabilitation has come a long way over the last few decades to support the notion that “rehabilitation works,” a multitude of unanswered questions remain for future research to address. The following are some of the issues that are most pertinent to the advancement of effective rehabilitation.

Effects of Incarceration on Rehabilitation

Some authors suggest that the effects of prison may wipe out the effects of programming (Webster, 2004: 116). Although it has been contended here that effective treatment can be offered both within and outside the walls of a correctional facility, there is evidence that being imprisoned elicits negative effects. However, if it is decided that imprisonment is the most appropriate choice of punishment, it is suggested that rehabilitative efforts are a requirement in order to combat negative effects of prison.

On the one hand, continued efforts in rehabilitation are arguably an obligation by the state to ensure at a minimum – that offenders do not return to the community worse off than before conviction (Webster, 2004: 120).

As noted earlier, treatment within prison is better than prison with no treatment.

Interaction Effects

While most studies discuss the effects of particular programs or approaches, the literature is lacking on the topic of combinations of different programs. The reality is that most offenders receive multiple programs, especially during incarceration. It would be interesting to learn what the cumulative benefits and/or downfalls are to combining various types of programming.

“What Works” for Female Offenders?

Most of the rehabilitation studies on youth involve a male sample. Much like what is seen in the adult system, the lack of data on female youth is generally attributable to the small numbers of female youth, compared with males, who enter the youth justice system. Pertinent to the present context, it is important to remember that females are far less likely to engage in violent behaviour than males are. This makes it difficult to obtain a representative sample for research purposes. This in turn makes it difficult to bring forth female-specific conclusions regarding effective rehabilitation for female offenders. Therefore, researchers may need to consider new, creative methods for obtaining a reliable research study on female youth.

With such limited data available on programs for violent female youth, Goldstein et al. (2007) conducted a study on 12 girls who were randomly assigned to anger management or a “treatment as usual” condition. The study found that there was a positive effect (Goldstein et al., 2007: 1); however, the small sample precludes any decision-making based on this study. Consistent with the authors’ recommendations, a larger-scale study should be conducted to determine the potential of such programs. Other studies (for example, Dowden and Andrews, 2000; Hubbard, 2007; Lipsey, 1999) have supported the notion that the RNR model extends to female offenders as well, particularly the responsivity principle. Nonetheless, more research needs to be done to make robust conclusions for this particular group.

The Process of Change

One item of importance is the formation of an adequate theoretical grounding for rehabilitation. Research has started to uncover some of what works, but not why it works. Andrews et al.’s (1990) RNR model, while useful, has been criticized for lacking in a theoretical base, and for not providing enough guidance on what to actually do in order to address dynamic factors (Ward and Maruna, 2007: 51–65).

Blanchard (2001) examined the experiences of violent youth mandated to counselling sessions as a mode of rehabilitation. The sample of eight participants was obtained from the Department of Juvenile Services in southern Louisiana. This was a purposeful sample of male violent offenders between the ages of 12 and 18 who had various experiences in counselling. All participants were selected from an Intensive Supervision Program that included time in a detention facility (one to two weeks), followed by house arrest as part of probation. Participants must have committed at least one violent offence to be included in the study, such as simple assault, aggravated assault, sexual assault, gang fights, strong-arm robbery, or homicide. Participants also had to be reoffenders, meaning that they had committed at least one previous criminal or non-criminal offence. Individual and/or group counselling sessions occurred at least once per week throughout the entirety of the intensive supervision program (Blanchard, 2001: 36-41).

Blanchard found that participants generally found current counselling sessions to be more positive than previous experiences with counselling because of the relationship with program counsellors (Blanchard, 2001: 105–106). While this finding is not generalizable due to the incredibly small sample, it highlights the importance of studying the therapeutic relationship in terms of rehabilitation.

What do Offenders Want?

The voices of offenders are often left out of the “what works” debate. Studies that have actually consulted with known offenders have revealed that convicts are often not fond of rehabilitation or treatment efforts within the correctional environment – especially in the context of programs that emphasize personal risk or psychological perspectives (Ward and Maruna, 2007: 15). At the same time, many people who are or were in prison have expressed positive attitudes towards treatment strategies that focused on “self-change, empowerment, and desistance” (M. Kay Harris, 2005 as cited in Ward and Maruna, 2007: 15–16).

Consider the names of following types of correctional therapy: “cognitive-behavioural programming” and “reasoning and rehabilitation.” These are examples of terms that highlight the need to change an individual who is somehow “wrong” or “deficient” or “pathological.” Many offenders reject these negative labels. Thus, the negative connotations associated with many treatment programs can impact how they are received or interpreted by offenders and ultimately hinder program effectiveness. This notion is in line with research that suggests that effective rehabilitative treatment is most likely to occur when participation is voluntary (Latimer, 2001: 244).

In her qualitative study of 20 young men and women who had undergone rehabilitative treatment, Hoffman (2004) notes that all participants expressed that “the momentum and desire to change has to come from within” (Hoffman, 2004: 108). Thus, when designing programming and policy, it is important that the outcome is appealing for those whom we want to change. Perhaps consultation or collaboration with the people who are most directly affected by programming would help to create the most appropriate treatment services – services that are more consistent with the specific rehabilitation needs of individual offenders. Nothing that we try to do can be successful without their cooperation.

Research on Current Treatment Programs and Upcoming Treatment Models

As mentioned earlier in this report, there are many programs that have not received extensive evaluation. This is not to say that these programs do not have the potential to be promising, only that evaluation has yet to be completed. It is imperative that programs are evaluated with the utmost methodological rigour in order to ensure that youth are receiving optimal treatment and/or to make necessary adjustments. The process of evaluation and redesign was a key factor in the creation of the “promising programs” discussed above. For example, a program that needs more evaluation is the Good Lives Model of rehabilitation (GLM). It has much in common with Andrews et al.’s RNR model, but approaches treatment from a different viewpoint (Ward and Maruna, 2007: 172-173). It would be fair to say that the main difference is that the GLM presents treatment options as a glass half full instead of half empty. Whereas RNR looks to deficiencies and areas that essentially need to be repaired in individuals, GLM focuses on positive aspects and encourages change through a different lens. This and other appealing programs in the growing field of positive psychology should be the aim of future research.

Summary of What Works in Rehabilitation

According to the literature previously cited in this section of the report (Andrews and Dowden, 2005; Andrews et al., 1990; Cullen, 2005; Dowden and Andrews, 2000; Greenwood, 2006; Howell, 2003; Jones and Wyant, 2007; Landenberger and Lipsey, 2005; Latimer, 2001; Lipsey, 1999; Lipsey and Wilson, 1998; Lipsey and Cullen, 2007; Loeber and Farrington, 1998; Lösel and Schmucker, 2005; MacKenzie, 2002; Ward and Maruna, 2007; Webster, 2004), and other sections of the report (specifically deterrence and incarceration/incapacitation), there are some common themes that can be extrapolated in terms of what works for rehabilitation. The following is a summary of what works and what doesn’t in rehabilitation.

What is Effective:

What Doesn’t Work:

Guiding Questions for Future Research


The rehabilitation debate – arguments about whether or not rehabilitation works – has been the focus of rehabilitation research for more than 30 years. The research has undoubtedly supported the notion that, yes, rehabilitation does work. Moreover, it works better than doing nothing when youth are incarcerated and it works better than deterrence-based strategies. In other words, rehabilitation works better than many of the programs and ideals that are rampant in corrections to date. While deterrence-based strategies may appease the public’s “get tough” sentiment, they do not satisfy the public’s desire to rehabilitate offenders, especially their heightened desire to rehabilitate youth.

Classic meta-analytical studies have provided a foundation for contemporary researchers to build on and fill in the gaps in knowledge. Since the general questions about the effectiveness of rehabilitation have been answered, it is now time to turn to the particulars of rehabilitation to determine what the ideal circumstances are for effective treatment.

It is important to note that rehabilitation is not the only relevant crime prevention strategy. Preventing crime can begin much earlier than when there needs to be a response to offending youth. On the front end, prevention of offending behaviour can be accomplished by addressing communities and ensuring that the welfare of all Ontarians is provided for (health care, education, employment opportunities, equal treatment, etc.). On the back end, rehabilitation needs to address individual needs within the setting of “real life” or in the community. In both cases, this requires the cooperation of service providers such as mental health, corrections, enforcement and education. The programs discussed herein call for input from mental health professionals, academics, schools and families. Effective coordination across service sectors is imperative. “Research into service delivery needs to advance our understanding regarding what the most effective means are to provide such cross-sectoral services” (Leschied, 2007: 44).

Policy-makers must be mindful that rehabilitation efforts do not appear inconsistent or unfair in any way. There is fine balance between addressing the needs of a youthful offender and imposing sanctions that can be seen as disproportionately punitive. The Youth Criminal Justice Act prescribes that responses to youth crime must be proportionate in terms of the current offence (i.e., youth may not be punished more severely for being repeat offenders). This is a tough challenge. Collaboration between service providers may be able to help the youth justice system adhere to the principles of the Youth Criminal Justice Act by referring treatment decisions to other sectors.

Finally, the most important lesson learned from a review of the vast literature on rehabilitation is that the key to providing adequate service is to base interventions on evidence-based practices and continuously evaluate the effects of these treatments. It is recommended that when implementing a new program, funding be built in and dependent on a rigorous evaluation process that involves a pre-test/post-test research design and randomization wherever possible.11 Mandated evaluation strategies will enable program developers to understand what works and what doesn’t while changes can be made. Follow up studies are also needed in order to understand the long-term effects of rehabilitative treatment. From a policy perspective, evaluation requirements enable government funding agencies to understand whether or not they are spending their money wisely. To this end, programs can foster scientific support, instead of hype or rhetoric being used to “sell” specific programs. Most importantly, high-quality evaluation research will measure and contribute to assurances that treatment interventions are making a positive impact on the lives of youth – or provide good reason to amend programs that are not helping youth live up to their potential.


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5 This chapter was written with the assistance of Rhea Adhopia, MA, Centre of Criminology, University of Toronto.

6 Other variables included the sample of studies (recall that there were two samples), the justice system (juvenile vs. adult), the year of study publication, the quality of the design and the setting (community, institutional/residential) (Andrews et al., 1990: 380-381).

7 Note that in this meta-analysis, more than 70 per cent of the studies used contain an adult sample (Dowden and Andrews, 2000:456).

8 This includes the RNR principles plus an additional “human service” principle which refers to human service in contrast to sanctions with no services (Dowden and Andrews, 2000: 455).

9 This percentage assumed that the rate of recidivism for the average control group was 0.5 (Lipsey and Cullen, 2007: 300).

10 For example, age, gender, type and seriousness of offence, etc.


Volume 1. Findings, Analysis and Conclusions

Volume 2. Executive Summary

Volume 3. Community Perspectives Report

Volume 4. Research Papers

Volume 5. Literature Reviews