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Copyright ? 2006-2013 Scientific Research Publishing Inc. All rights reserved.
2011. Vol.2, No.2, 122-131
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.22020
Treatment Alternatives for Mentally Disordered Offenders:
A Literature Review
Joshua J. Knabb, Robert K. Welsh, Marjorie L. Graham-Howard
Azusa Pacific University, Azusa, USA
Received October 7th, 2010; revised January 16th, 2011; accepted January 17th, 2011.
Over the last few decades, a considerable amount of research has been devoted to mentally disordered offenders
(MDOs), with both theoretical and empirically validated treatments permeating the literature. Due to the recent
onslaught of treatment options for MDOs, a synthesis of this literature seems immediately relevant to the field of
forensic psychology. The authors review the current status of the treatment literature for both sentenced and
nonsentenced MDOs in both inpatient and outpatient settings. An exhaustive search of the available literature on
MDO treatment options was conducted. Ten treatment modalities, both theoretical and empirically validated,
were summarized, including their theoretical underpinnings, interventions, empirical support, and strengths and
weaknesses. Issues surrounding f utu re research are a lso discussed.
Keywords: Mentally Disorder ed Offender, Empirically Validated Treatment, Evidence Based Treatment,
The moniker “evidence based” has become synonymous with
the acceptable standard of psychological care in facilities that
maintain and treat mentally disordered offenders (MDOs). De-
spite the widespread recognition of evidence based treatments,
there is a shocking lack of empirical research on which psy-
chological treatments work best for this complex population.
This major gap in the research is particularly troubling given
the large number of MDOs in correctional and forensic facili-
ties throughout the world. In 2004, one of the authors set out to
conduct a meta-analysis on evidence based treatments for
MDOs, and found only a handful of research studies suitable
for quantitative analysis (Welsh, Ashby, Glassmire, Love,
Tavegia, & Warke, 2004). Most of the existing studies were
either poorly controlled, did not report sufficient statistical
information to conduct a meta-analysis, or did not adequately
define the treatment or treatment population. Nevertheless,
three treatments were identified that had a weak to moderate
evidence base—behavioral therapy, cognitive therapy, and
therapeutic community. Since then, there has been additional
research conducted on interventions for MDOs, and new prom-
ising treatments have emerged. Thus, we provide an updated
review of the aforementioned treatments, and discuss new and
emerging treatments that hold particular promise for MDOs.
Mentally Disordered Offenders
Mentally disordered offenders (MDOs)—defined broadly in
this article as individuals with a serious Axis I mental disorder
or Axis II personality disorder being treated in an inpatient or
outpatient correctional or forensic facility—are an exceedingly
complex population to conceptualize and treat. Such individuals
present for treatment with a dizzying array of target concerns,
including psychiatric diagnoses, substance abuse histories,
unique offense characteristics, and high risk and potentially
dangerous behavior (Rice & Harris, 1997).
The treatment needs of MDOs are largely governed by their
legal status, which statutorily defines their goals for treatment.
For example, the treatment needs of an insanity acquittee are
notably different from a defendant receiving competency resto-
ration treatment—the chief concern for the court in the insanity
acquittee is suitability for outpatient treatment and risk man-
agement, whereas the goal for the defendant remanded for
competency restoration is trial competency. Mentally disor-
dered offenders also have treatment needs that are related to
their offense characteristics—a patient in treatment for domes-
tic violence will have different treatment needs than a patient
who is a serial arsonist. Finally, the treatment goals for MDOs
will differ with respect to their broad range of psychiatric di-
agnoses—the review conducted by Welsh and colleagues (2004)
yielded widely discrepant psychiatric diagnoses among MDOs.
As an example, an acutely psychotic patient will have different
treatment needs than a depressed patient with a substance abuse
In spite of this heterogeneity, many forensic institutions
adopt evidence based treatments for MDOs that are validated
on other populations (see, e.g., Hodel & West, 2003; Hoffman
& Kluttig, 2006), leaving forensic psychologists unsure about
which treatments are appropriate for MDOs (Rice & Harris,
1997). A comprehensive literature review, therefore, is cur-
rently necessary to provide forensic clinicians with an under-
standing of what is available in the field. In our article, we at-
tempted to accomplish this objective in four ways. First, each
MDO treatment was summarized, including theoretical under-
pinnings and interventions. Second, the empirical support of
each treatment was reviewed to better understand current re-
search in the field. Third, the strengths and weaknesses of each
treatment were discussed. Finally, directions for future research
J. J. KNABB ET AL. 123
A review of the literature was conducted to locate the avail-
able treatment options for MDOs. In our search for research, we
took a liberal approach, defining MDOs as individuals who
have a serious Axis I mental disorder or Axis II personality
disorder and are being treated in the context of an inpatient or
outpatient correctional or forensic facility. We found that much
of the European and Canadian literature classified personality
disorders under the MDO rubric. Thus, our goal was to cast a
net as widely as possible to include treatments that are used
worldwide with individuals who are classified as MDOs.
However, we fully realize that including personality disorders
might potentially capture the vast amount of correctional treat-
ment literature in which the participants are primarily diag-
nosed with antisocial personality disorder. Because of the
breadth of this existing literature, we intentionally excluded
empirical research focused solely on criminal populations di-
agnosed with antisocial personality disorder. In a similar vein,
we did not include treatment literature that focuses exclusively
on sex offender treatment, substance abuse treatment, or com-
petency restoration treatment—these areas are adequately cov-
ered in other literature reviews.
We located treatments through several electronic databases
of journal articles, including PsycINFO, ProQuest, and the
Social Sciences Citation Index, as well as journals, abstracts,
and reference sections of review articles. Treatments were in-
cluded if they offered a clear and specific treatment option with
detailed interventions for MDOs. Both empirically validated
and theoretical treatments were identified and included in the
present review. Unpublished papers and doctoral dissertations
In the following section, we provided an overview of the ten
treatments located within the MDO literature, specifically fo-
cusing on the theoretical underpinnings, interventions, empiri-
cal support, and strengths and weaknesses of each treatment.
According to Spiegler (1983), behavioral therapy focuses
solely on behaviors that can be directly observed, emphasizing
psycho-education, self-control skills, and action. There are a
plethora of behavior therapies, including positive reinforcement,
modeling, cognitive restructuring, shaping, systematic desensi-
tization, and stimulus control (Spiegler, 1983). Overall, behav-
ior therapists are interested in changing overt behavior, and
tend to de-emphasize internal processes (Spiegler, 1983).
Behavioral therapy applied to MDOs can take on many
forms, including social skills training, social learning programs,
and token economy programs (Rice, 1983). As an example,
both Rice and Chaplin (1979) and Rice (1983) describe social
skills training programs for MDOs that include behavior re-
hearsal, modeling, coaching, instructions, feedback from group
members and therapists, and homework assignments. A com-
mon focus among these programs seems to be the improvement
of interpersonal skills.
Goodness and Renfro (2002) implemented a social learning
program at a maximum-security forensic unit, which included
applying social learning principles to staff-patient interactions
and observing patient activities to identify both interaction
problems and useful dangerousness management strategies.
Furthermore, modeling, reinforcement, shaping, overlearning,
and generalization were utilized in the program, with tokens
used to increase pro-social behaviors (Goodness & Renfro,
Regarding token economy programs, Rice, Quinsey, and
Houghton (1990) suggest they should be designed to shape
offender behavior so as to increase pro-social behavior and
decrease antisocial behavior. One of the characteristics of token
economies is for patients to be rewarded, or reinforced, when
they exhibit good behavior by increasing their privileges (Rice
et al., 1990). Conversely, fines may be administered when pa-
tients misbehave, taking the form of decreased privileges (Rice
et al., 1990). Ultimately, token economy programs rely on posi-
tive and negative reinforcement to promote change among of-
In terms of the treatment efficacy of behavioral therapy with
MDO populations, numerous studies have demonstrated its
utility in teaching social skills (Rice, 1983; MacKain & Strev-
eler, 1990). Moreover, evidence based treatment manuals for
MDOs have emerged that emphasize problem solving skills
(Ross, Fabiano, & Ewles, 1988). Although many studies have
examined the efficacy of behavioral interventions for MDOs, to
the authors’ knowledge, no meta-analyses have been conducted.
Further research is needed in order to understand the overall
efficacy of behavioral interventions for MDOs.
When examining the strengths of behavioral therapy for
MDOs, it becomes immediately clear that a focus on the be-
havior of offenders is important. With this being the case, one
of the strong suits of behavioral therapy is its focus on tangible
and concrete behavioral changes through interventions such as
social skills training and token economies. Antisocial behavior
must be changed in order for MDOs to better deal with conflict
in society. With a focus on measurable behaviors, behavioral
therapy allows clinicians the opportunity to see progress, and
research can be conducted that clearly measures its efficacy. To
date, behavioral therapy is one of the most researched MDO
treatment options (see Rice, 1983; MacKain & Streveler, 1990),
which improves its position among the established MDO inter-
Among the weaknesses of behavioral therapy is that it has
been mainly applied to civil populations—only in the last few
decades has behavioral therapy emerged as an intervention for
MDOs. As such, the heterogeneity of MDO populations is not
addressed as thoroughly as with some of the other forms of
MDO treatment (e.g., therapeutic community, assertive com-
munity treatment). And although behavioral therapy focuses on
salient offender issues such as social skills and problem solving,
it may lack a more comprehensive approach in that it fails to
address idiosyncratic demographic variables such as type of
criminal act committed and disorder. Nevertheless, overall,
behavioral therapy appears to be a solid intervention with
well-established efficacy for MDO populations.
Cognitive Behavioral Therapy
According to Steiman and Dobson (2002), cognitive behav-
ioral therapy (CBT) is a blanket term for both cognitive and
J. J. KNABB ET AL.
behavioral interventions. These therapies share an understand-
ing that cognitions, or thoughts, play a central role in the etiol-
ogy, maintenance, and treatment of mental illness (Steiman &
Dobson, 2002). Steiman and Dobson explain that cognitive
restructuring, coping skills therapies, and problem solving
therapies all fall under the heading of CBT. Ultimately, the
differing CBT interventions vary mainly in their focus on cog-
nitive versus behavioral elements of treatment (Steiman &
Cognitive behavioral therapy is a widely used form of treat-
ment for MDOs. In fact, numerous meta-analyses of CBT for
MDOs have emerged over the last few decades (see, e.g., Lip-
ton, Pearson, Cleland, & Yee, 2002). What is more, CBT has
been used for a wide variety of offender dysfunctions, including
anger management for violent offenders (Renwick, Black, &
Ramm, 1997), and coping skills for personality disordered of-
fenders (Clarke & Ndegwa, 2006). Lipton, Pearson, Cleland,
and Yee (2002) highlight that CBT is especially useful in ad-
dressing recidivistic behavior—MDOs, according to CBT, have
learned unacceptable behaviors and have failed to develop im-
portant cognitive skills (Lipton et al., 2002). Among the tech-
niques used by CBT for MDOs are problem solving training,
social skills training, and pro-social modeling with positive
reinforcement (Lipton et al., 2002).
Jones and Hollin (2004) employed a manualized CBT train-
ing program for MDOs that focused on the cognitive, arousal,
and behavioral elements of anger. Specifically, the program
involved arousal reduction techniques, cognitive restructuring,
and behavioral skills to respond to cues that previously brought
on an aggressive response. Timmerman and Emmelkamp (2005)
describe a CBT program for MDOs that incorporated behav-
ioral modification principles such as reinforcement, shaping,
modeling, and giving time outs, along with cognitive principles
such as challenging distorted thoughts.
Specific to CBT for MDOs seems to be the amalgamation of
both cognitive (e.g., disputing distorted beliefs, improving cog-
nitive skills) and behavioral (e.g., reinforcement, social learning
theory) principles. Although many of the programs adhering to
a CBT approach offer program-specific, individually tailored
approaches, the fundamental principles of CBT seem to be
practiced by most programs that use CBT interventions for
Empirically validated research with CBT for MDOs has been
consistent in recent years (Hodel & West, 2003; Timmerman &
Emmelkamp, 2005). Multiple studies have shown that CBT is
efficacious in terms of improved cognitive skills (Hodel &
West, 2003) and a reduction in psychopathological symptoms
(Timmerman & Emmelkamp, 2005). Additionally, manualized
cognitive skills programs have recently been compared to un-
derstand the efficacy of CBT for MDOs (Blud & Travers,
2001). Although meta-analyses have been conducted with CBT
(Lipton, Pearson, Cleland, & Yee, 2002), more specific re-
search needs to be conducted in order to better understand the
heterogeneous needs of MDO populations.
Among the strengths of CBT is its focus on both the cogni-
tive and behavioral components of the offender. CBT offers
offenders the ability to ameliorate coping skills and address
anger management issues, and provides pro-social modeling
and problem solving skills training. Matters surrounding anger,
coping, and adaptive and positive social behavior must be ad-
dressed with MDOs. CBT adequately tackles these issues, and
helps the offender use effective tools to dispute distorted beliefs
and embrace acceptable behavior in an attempt to reduce re-
cidivism. In addition, CBT for MDOs is empirically supported
in the literature (Hodel & West, 2003), and familiar among
various psychological fields and populations. Overall, CBT
provides offenders with tangible and effective tools to address
the multiple layers of dysfunction they must ameliorate in order
to rehabilitate and prevent recidivism.
Some of the weaknesses of CBT for MDOs surround its lack
of a focus on the heterogeneous needs of offenders. Particularly,
CBT fails to address issues surrounding the specific type of
offense and disorder. For example, although Hodel and West
(2003) implemented a cognitive training program for mentally
ill offenders with schizophrenia, the specific criminal act com-
mitted was not addressed or focused on. As another example,
Fleck, Thompson, and Narroway (2001) employed a problem
solving skills training program for MDOs that neglected to
address the specific crime committed (e.g., arson, sexual of-
fense, murder, armed robbery, grievous bodily harm, and bur-
glary). Along with specific criminal act committed, disorders
commonly fail to be a focus of attention within the MDO lit-
erature (see Timmerman & Emmelkamp, 2005). Instead, MDOs
tend to be lumped together regardless of type of disorder or
criminal act committed. Since it is still relatively unknown
what the relationship between offense and disorder is, more
specific interventions tailored to the idiosyncratic needs of
MDO populations must be developed in order to address their
Cognitive Ana l yti c Ther apy
According to Pollock and Stowell-Smith (2006), cognitive
analytic therapy (CAT) combines concepts from psychoanalytic,
cognitive, and personal construct theory, and is a relational
form of therapy. Central to CAT are self-processes, which are
an internalized system of self-other relationship patterns (Ryle
& Fawkes, 2007). Early negative interpersonal events can lead
to a negative system of self-other relationship patterns, which
CAT calls reciprocal role procedures (RRPs) (Ryle & Fawkes,
2007). Fundamentally, the goal of CAT is to change these
negative self-other relationship patterns into more positive in-
ternalized experi ences.
The application of CAT to offenders can be traced back to
the 1990s, when CAT therapists first suggested that the actions
of MDOs stem from RRPs (Pollock & Stowell-Smith, 2006).
The CAT therapeutic process for offenders involves three major
phases. First, within the reformation phase, the therapist gets a
detailed client history (Pollock & Stowell-Smith, 2006). Also in
this phase, a reformation letter is created, which is written by
the therapist to communicate his or her beliefs about the inter-
nal and external processes of the offender and serves as an
agreement about the work to be done (Pollock & Stowell-Smith,
2006). Ultimately, the letter helps to communicate to the patient
his or symptoms, pattern of relating, and difficulties (Pollock &
Belshaw, 1998). Second, within the recognition phase, the
therapist and client go over central themes and agree on home-
work assignments between sessions (Pollock & Stowell-Smith,
2006). Third, within the revision phase, the therapist helps the
client to improve his or her thinking, feeling, and behaving
(Pollock & Stowell-Smith, 2006). Lastly, termination is worked
J. J. KNABB ET AL. 125
towards in the CAT treatment process (Pollock & Stow-
Pollock and Belshaw (1998) note that interventions used for
offenders include the analysis of transference and counter-
transference in order to effectively manage the potential for
harm. In addition, helping the offender to identify with the vic-
tim (e.g., helplessness, vulnerability) is crucial with certain
types of offenders such as murderers (Pollock & Belshaw,
Multiple studies have examined the efficacy of CAT in fo-
rensic populations (Cowmeadow, 1994; Duignan & Mitzman,
1994; Golynkina & Ryle, 2000; Pollock & Belshaw, 1998).
Unfortunately, these studies were either case studies or lacked
controlled samples. And although some of these studies re-
ported a significant reduction in symptoms (Duignan & Mitz-
man, 1994), the empirical validation of CAT through a con-
trolled study is still lacking. In essence, CAT is successful with
general psychotherapy, but has not been empirically supported
in the forensic literature (Pollock & Stowell-Smith, 2006).
When looking at the strengths of CAT, it becomes immedi-
ately apparent that the conceptualization process emerges as a
strong point. Heuristics such as reciprocal role procedures
(RRPs) allow the clinician to better understand the intrapsychic
process and structure of the offender in an attempt to identify
the etiology of dysfunction. In addition, CAT focuses on the
relationship between offender and victim, which promotes em-
pathy and addresses issues surrounding the prevention of re-
cidivism. Overall, the interpersonal dimension of CAT sets it
apart from some of the other MDO treatments, and better helps
offenders relate to others in new and positive ways.
Some of the weaknesses of CAT for MDOs include its lack
of empirical validation. Although case studies and theoretical
articles have materialized (see Pollock & Belshaw, 1998), em-
pirically validated CAT interventions for MDOs are still needed.
Also, although CAT addresses the interpersonal component of
criminal behavior, it fails to emphasize the heterogeneous needs
of MDOs. Moreover, usable coping skills appear to be lacking
with CAT applied to MDOs. Offenders may benefit from tan-
gible interventions that can be carried over with them into the
real world. Overall, CAT offers more of an interpersonal ex-
perience, combined with insight, than it does specific tools
offenders can use to dispute distorted beliefs and decrease
Dialectical Behavior Therapy
Dialectical behavior therapy was originally developed as an
intervention for women with borderline personality disorder,
and has since been applied to other treatment populations
(Robins & Chapman, 2004). According to Fruzzetti (2002), the
goal of DBT is to help clients create a life worth living accord-
ing to their own values, which is done by aligning the stages of
treatment with the stages of the disorder.
In recent years, DBT has been applied to forensic popula-
tions, addressing the high frequency of antisocial behavior
among males (Evershed, Tennant, & Boomer, 2003; Wix,
2003). DBT for MDOs also focuses on staff burnout, as well as
involuntary and restricted institutional and legal demands
(Evershed et al., 2003; Wix, 2003).
With regard to treatment, DBT helps patients to monitor
symptoms, behavior, anger, and suicidal thoughts, providing
tools to manage behaviors such as alcohol and drug use or
self-injury (Wix, 2003). Throughout treatment, the therapist
builds and maintains a positive, interpersonal, validating, and
collaborative relationship with the offender (Wix, 2003), help-
ing the patient to develop new skills, address motivational ob-
stacles, and generalize the skills to daily living (Robins &
Chapman, 2004). Also, the therapist must simultaneously con-
front, comfort, and validate the offender (Wix, 2003). Skills
training sessions are held weekly, which focus on the four DBT
skill domains, including distress tolerance, interpersonal effec-
tiveness, emotion regulation, and mindfulness (Wix, 2003).
Robins and Chapman (2004) explain that DBT has been
modified for forensic populations to include behavioral targets
such as interpersonal violence and homicide. Furthermore,
DBT has been adjusted to incorporate testing skills acquisition
of antisocial offenders with exams and role-play quizzes (Rob-
ins & Chapman, 2004). McCann, Ball, and Ivanoff (2000) ar-
gue that the DBT for forensic populations differs significantly
from the original DBT model in that the patients have multiple
problems and violent behaviors.
Low, Jones, and Duggan (2001) applied DBT to forensic pa-
tients in the United Kingdom to reduce self-harm behavior (N =
10). Each MDO was required to attend one skills training ses-
sion and one individual therapy session every week. Overall,
results indicated a significant reduction in self-harm behaviors
from the pre-therapy to post-therapy periods (Low et al., 2001).
Evershed, Tennant, and Boomer (2003) applied DBT to a group
of forensic males (N = 8) in the United Kingdom, measuring
both violent and parasuicidal behaviors. The DBT program
required weekly individual and skills group sessions. Results
indicated no significant difference in pre-treatment and post-
treatment violent behavior (Evershed et al., 2003).
DBT research with MDO populations appears to be minimal
at best (Evershed, Tennant, & Boomer, 2003; Low, Jones, &
Duggan, 2001). Although DBT has been shown to be effica-
cious with borderline women (Linehan, Armstrong, Suarez, &
Allmon, 1991), it has rarely demonstrated its efficacy with
MDO populations. Authors such as Robins and Chapman (2004)
have suggested that DBT has been sufficiently modified for
applicability with forensic populations; still, to date, very few
outcome studies have emerged. Further research is needed to
ascertain the effectiveness of DBT for MDOs.
Among the strengths of DBT for MDOs is its focus on be-
havior and the promotion of more effective coping strategies.
The ability to effectively cope with stressors is an important
component to offender rehabilitation. Also, DBT for offenders
focuses on treating life-threatening behavior—this is crucial in
reducing the prevalence of destructive behavior within forensic
settings. Most importantly, DBT for MDOs teaches how to
monitor symptoms, behavior, suicidal thoughts, and anger,
allowing offenders to manage their own behavior more effec-
tively, which helps to reduce rates of recidivism.
Some of the weaknesses of DBT for MDOs include its lack
of a focus on specific MDO populations. For example, Wix
(2003) implemented a DBT program for MDOs in a forensic
unit, but failed to address their specific disorders. Instead, Wix
applied DBT to many different offender disorders (e.g., psy-
chotic, bipolar, major depressive, personality). In addition, the
specific criminal acts committed were not addressed. Another
weakness of DBT centers on its lack of empirical validation.
J. J. KNABB ET AL.
Only a handful of studies have addressed the efficacy of DBT
for MDOs. Further research is needed to better understand the
role that DBT plays in reducing recidivistic and maladaptive
behavior among offenders.
Therapeuti c C o mmunity
According to Lipton, Pearson, Cleland, and Yee (2002),
therapeutic community (TC) is a community-based residence
with professional staff. McMurran, Egan, and Ahmadi (1998)
suggest that TC is based upon the idea that certain people ex-
perience problems because they cannot relate to society.
Therapeutic community, therefore, attempts to ameliorate this
interpersonal deficit by creating a community in which resi-
dents stay about 9 to 18 months (McMurran et al., 1998).
With regard to TC for offenders, Ogloff, Wong, and Green-
wood (1990) describe TC as an environment wherein offenders
can learn to take responsibility for their behaviors through posi-
tive interactions with peers and staff. One of the main charac-
teristics of TC is the use of work in the community. Kennard
(2004) explains that TC serves as a “living-learning situation”
for residents to learn alongside other residents and staff—the
residents of TC are involved in the administration, food prepa-
ration, and maintenance of the facility. Additionally, TCs are
organized in a hierarchical fashion, with a clear chain of com-
mand—newer residents usually start with a lower status and
have to move up in rankings (Kennard, 2004). The main inter-
vention in TC is the daily group meeting (Ogloff, Wong, &
Greenwood, 1990), with the group functioning as a place for
therapy and the development of unit rules. Over time, a group
culture develops, acting as a positive experience for the resi-
dents, who provide support, feedback, affirmation, and instruc-
tion to one another (Lipton et al., 2002; Ogloff et al., 1990).
Van Stelle and Moberg (2004) carried out a TC program for
dually diagnosed forensic patients with substance abuse and
mental health disorders (N = 212). The program had two
phases—the orientation phase and four two-month residential
treatment program phases. Offenders participated in community
meetings, treatment groups, and social activities each weekday
during the treatment phases. Also, each offender participated in
mental illness and substance abuse treatment groups, individual
sessions with staff, social activities, daily living skills groups,
and health, anger management, and relapse prevention groups
(Van Stelle & Moberg, 2004).
Ogloff, Wong, and Greenwood (1990) employed a TC treat-
ment program for male offenders (N = 80) that included nurses,
a social worker, a psychologist, and a psychiatrist. The treat-
ment involved a large therapeutic group, which met on week-
days for two hours (Ogloff et al., 1990). During the group, the
patients were encouraged to share their personal problems with
patients and staff, and constructive confrontations between
members were supported (Ogloff et al., 1990). In addition,
smaller groups were used to focus on specific problems and
goals (Ogloff et al., 1990).
To date, only a handful of empirical studies have been con-
ducted on TC for MDOs (Greeven & De Ruiter, 2004; Messina,
Burdon, Hagopian, & Prendergast, 2004; Ogloff, Wong, &
Greenwood, 1990; Peters, LeVasseur, & Chandler, 2004; Rice,
Harris, & Cormier, 1992). Although promising, further research
is needed to evaluate the efficacy of TC programs for mentally
Strengths of TC applied to MDOs include its real world feel
and applicability. TC allows offenders the opportunity to ex-
perience an environment in which they can learn to take re-
sponsibility for their behaviors. It is essential for offenders to
learn how to positively interact with their environment in a way
that will reduce the likelihood of recidivism. TC applied to
MDOs allows for positive peer group influences, which may
help offenders learn to better deal with stressful life circum-
stances and social situations. Ultimately, TC does an effective
job of addressing the larger issues (e.g., positively interacting
with society, healthy confrontation) that the offender must face
Weaknesses of TC include its minimal amount of empirical
validation. Furthermore, although TC has addressed specific
types of disorders such as co-occurring disorders (e.g., mental
illness and chemical abuse), and has yielded promising results
in reducing criminal activity (see McKendrick, Sullivan, Banks,
& Sacks, 2006), further research is needed to better understand
more specific offender populations. Moreover, although TC
provides offenders with a healthy real world experience, it does
not emphasize specific tools to address criminal behavior.
Whereas other forms of treatment such as CBT provide usable
tools to offenders, TC offers more of a corrective experience
through interactions with others.
Assertive Community Treatment
Lamberti, Weisman, and Faden (2004) maintain that asser-
tive community treatment (ACT) was developed to help those
with chronic mental illness who are at risk of hospitalization or
homelessness function in their communities. Parker (2004)
describes ACT as a community treatment team of mental health
professionals that is responsible for the care of patients with
severe psychiatric illnesses in their home environments, with
the ACT team functioning like an inpatient treatment team—
regular team meetings, a multidisciplinary staff, team responsi-
bility, direct services, continuous availability, and a low cli-
ent-to-staff ratio. Udechuku, Olver, and Hallam (2005) suggest
that the main features of ACT include low caseloads (8 to 12
patients per worker), multidisciplinary teams, less than 20%
part-time staff, 24-hour availability, and input from a psychia-
In recent years, authors have applied ACT to MDO popula-
tions (Lamberti, Weisman, & Faden, 2004; Parker, 2004). In
2004, Lamberti and colleagues located 16 national programs
that apply ACT to MDOs in an attempt to prevent recurring
arrest and incarceration. Overall, ACT for MDOs seems to
function in the same way as it does for mentally disordered
With regard to ACT research, only a handful of studies have
examined ACT with forensic populations (Lamberti, Weisman,
& Faden, 2004; Parker, 2004). Although Parker (2004) found
that ACT with a forensic population showed promising results,
a control group was absent. Instead, most studies have focused
on ACT with mentally ill civil populations (Burns & Santos,
Among the strengths of ACT applied to MDOs is its focus on
meeting the needs of the offender wherever he or she is located
with mobile services. Moreover, ACT provides around the
clock mental health services, which is one of its key strengths.
Finally, ACT helps to reduce recidivism by offering a compre-
J. J. KNABB ET AL. 127
hensive form of treatment, meeting the needs of the offender in
the community by way of a multidisciplinary team.
One of the weaknesses of ACT for MDOs pertains to its lack
of empirical validation, with Parker (2004) noting that, to date,
there have been only three published reports on ACT for foren-
sic populations. Although ACT offers services in a way that
other forms of treatment do not, it lacks clear efficacious re-
search to substantiate its utility in reducing recidivism. Addi-
tionally, ACT rese mbles more of a case management team than
a form of treatment guided by a clear theoretical orientation.
With this being the case, ACT lacks the specific interventions
and therapeutic tools that other MDO treatments offer. Ulti-
mately, ACT applied to MDOs appears to be a relatively new
phenomenon within the forensic literature. Additional ACT
programs for MDOs must be examined in order to better under-
stand its usefulness in rehabilitating offenders and reducing
Auld, Hyman, and Rudzinski (2005) suggest that the under-
lying assumption of psychoanalytic therapy is that individuals
suffer from neurosis because of conflict and repression. Ame-
liorating this conflict involves reducing the strength of drives,
strengthening defensives, and undoing repression (Auld et al.,
2005). Overall, psychoanalytic therapy involves uncovering
unconscious mental processes, identifying transference, free
associating, and using interpretation as the central curative
ingredient (Auld et al., 2005).
According to Hoffman and Kluttig (2006), the recent empha-
sis on empirically validated treatments for MDOs has reduced
the prevalence of psychoanalytic approaches in forensic set-
tings. Hoffman and Kluttig assert that manualized treatments
have made it easier to measure treatment progress, with psy-
choanalytic approaches being “stifled” because of their lack of
a systematic, manualized approach. Still, Hoffman and Kluttig
(2006) maintain that group psychoanalysis overlaps considera-
bly with therapeutic community treatments—among both in-
terventions, the offender must interact with the whole commu-
nity in order to change. In addition, Hoffman and Kluttig argue
that team members focus on transference issues in an attempt to
understand the inner world of offenders.
One of the goals of psychoanalysis with MDOs is to help
them to view their criminal acts as overstepping boundaries,
which involves assisting the offenders in having an accurate
picture of themselves, their interactions with others, and with
their current life situations (Hoffman & Kluttig, 2006). Also,
the offender internalizes his or her positive, supportive experi-
ence with the therapist so as to ameliorate the shame of his or
her painful affect (Hoffman & Kluttig, 2006). Moreover, the
therapist helps the client to recognize triggers for violence or
assault, which reduces the likelihood of recidivism (Hoffman &
Kluttig, 2006). Finally, Adler (1982) suggests that Winnicott’s
holding environment, which simply refers to a place of safety
originally experienced within the caregiver-infant dyad, can be
applied to offenders, who may use the correctional system as a
form of containment they cannot find elsewhere.
With regard to research, there appears to be no empirical
studies done on psychoanalytic interventions with MDOs. In-
stead, manualized treatments have replaced psychoanalysis
(Hoffman & Kluttig, 2006). Although no empirical studies exist
with psychoanalytic therapy for MDOs, psychoanalytic therapy
has added to and strengthened empirically validated MDO
treatments such as TC and CBT (Hoffman & Kluttig, 2006).
Overall, psychoanalytic concepts such as the holding environ-
ment and countertransference can be effectively applied to
work with forensic patients in order to promote change.
Among the strengths of psychoanalytic therapy for MDOs is
its conceptualization of offenders. Conceptualizing offenders in
terms of impulsiveness and destructiveness, both psychoana-
lytic terms, allows the clinician to better interpret and under-
stand MDOs. Additionally, concepts such as Winnicott’s hold-
ing environment provide clinicians with an awareness of the
type of environment that may need to be created for a success-
ful therapeutic encounter with the MDO. Moreover, focusing
on the inner world of the offender may allow for additional
insight that can help to promote change. Finally, understanding
and addressing transference and countertransference issues that
take place within the therapeutic relationship may be beneficial
for both the MDO and therapist.
Weaknesses of psychoanalytic theory applied to MDOs in-
clude its lack of a standardized, structured intervention that can
be applied with confidence to MDO populations. Although
psychoanalytic concepts allow for an understanding of MDOs,
they fall short in terms of their efficaciousness. While other
forms of MDO interventions such as CBT have manualized
treatments (Blud & Travers, 2001), psychoanalytic therapy
tends to offer only theory. Although Hoffman and Kluttig
(2006) assert that psychoanalytic therapy should be reconsid-
ered in treating forensic populations, it simply lacks the em-
pirical validation and convenience that other treatment options
According to Holmes (2001), six domains of attachment the-
ory exist—the secure base, describing the caregiver who the
child returns to when upset; exploration and enjoyment, which
highlights the reciprocal quality of the secure base; loss, which
emphasizes the psychological distress the child experiences
when either loss or threat of loss is evident; internal working
models, which describe the internal representations of the in-
teraction between self and others; and reflexive function and
narrative competence, which refers to the ability to talk about
the self and self-difficulties. These six areas are used in clinical
work to conceptualize the client and promote change, all
through the lens of attachment patterns (Holmes, 2001).
Rich (2006) suggests that, to date, attachment theory has
solely focused on causal pathways of, and contributing factors
to, criminality. Thus, as of yet, a comprehensive form of at-
tachment therapy for MDOs has not been developed (Rich,
2006). Nevertheless, poor childhood attachment experiences
serve as a risk factor, defining the developmental trajectory that
points to antisocial behavior later in adulthood (Rich, 2006).
Regarding treatment, Rich (2006) explains that working with
offenders means seeing them through the lens of attachment
theory, including the mental images of self and others and be-
liefs about social interactions. Renn (2002) identifies several
phases of attachment treatment—the initial assessment, which
involves viewing the offender through an attachment heuristic,
and the therapeutic intervention, which consists of ameliorating
the internal working model of the offender. Included in this
J. J. KNABB ET AL.
phase is the disclosure of childhood trauma, which may be
cathartic for the offender (Renn, 2002). Overall, Rich (2006)
suggests that forensic clinicians use attachment theory as a
framework for treatment, rather than solely as the treatment
In terms of empirical research for attachment therapy for
MDOs, to date, studies have not examined attachment theory
directly as a therapeutic agent. Rather, current studies in the
literature have focused on attachment representations of of-
fenders (Timmerman & Emmelkamp, 2006; Van Ijzendoorn,
Feldbrugge, Derks, De Ruiter, Verhagen, et al., 1997). Al-
though these studies help to elucidate the correlation between
attachment representations and criminality, additional studies
are still needed that examine the efficacy of attachment therapy
in reducing violent behavior and recidivism.
Some of the strengths of attachment theory applied to MDOs
include its ability to conceptualize the relationships of the of-
fender via internal working models. This internal working
model acts as a template for the offender, which helps the clini-
cian to better understand potentially maladaptive and rigid ways
that the offender interacts with his or her environment. In addi-
tion, understanding negative early childhood experiences al-
lows the clinician to better comprehend why the offender re-
lates to others in unhelpful ways. For example, poor early
childhood experiences may prevent the offender from attaching
to others in adulthood. In sum, attachment theory provides a
framework for the clinician to conceptualize the interpersonal
functioning of the MDO.
Although attachment theory offers a lens through which the
clinician can view violent behavior, it falls short as a compre-
hensive and applicable form of treatment. Unfortunately, within
the field of MDO treatments, attachment theory has only been
applied theoretically (see Rich, 2006). As a result, research on
the efficacy and applicability of attachment therapy to MDOs
must be conducted.
Art therapy has been applied to many different populations
and used together with a vast number of theoretical orientations
(Rubin, 2001). Case and Dalley (2006) explain that art therapy
involves the use of different art media for clients to express and
work through the problems and concerns that initiated therapy,
with the client and therapist making sense of the artwork to-
gether. Sometimes, clients can express themselves through
mediums such as artwork in ways they cannot with traditional
talk therapy (Case & Dalley, 2006). Many art therapies involve
two poles, including creative production and expressive com-
munication (Feder & Feder, 1981).
In prison settings, Case and Dalley (2006) suggest that art
therapy can be difficult due to ongoing violent behavior. Still,
art therapy in prisons can offer the space to think and reflect,
helping offenders to express angry and violent feelings in a safe
way (Case & Dalley, 2006). In recent years, art therapy has also
been applied to MDO fields (Liebmann, 1998; Smeijsters &
Cleven, 2006; Teasdale, 1997). Teasdale suggests that art ther-
apy can be added to group therapy for personality disordered
offenders so as to gain insight into emotional experiences and
improve communication skills.
Smeijsters and Cleven (2006) highlight that the goals of art
therapy with MDOs are self-expression, improving coping
skills, breaking through defenses, exploring the offending be-
havior, insight into the thoughts, feelings and actions that pre-
cipitated the offense, increasing self-control, and developing
empathy for the victim. Furthermore, the offender can express
feelings to others, and work through painful childhood experi-
To date, research is non-existent on art therapy for MDOs.
Although multiple studies have examined the efficacy of art
therapy for offenders (Riches, 1998), no studies are in the lit-
erature that measure the efficacy of art therapy for MDOs. Thus,
original research is essential in order to better understand the
efficacy of art th era py applied to MD Os.
One of the strengths of art therapy is its ability to help the
MDO express him- or herself nonverbally. To be sure, offend-
ers may lack the verbal skills necessary to express painful ex-
periences. Art therapy, therefore, provides the offender with a
nonverbal outlet in order to express intrapsychic experiences.
Moreover, art therapy may allow MDOs to work through diffi-
cult childhood experiences. Poor early childhood encounters
may prevent the MDO from relating to his or her social envi-
ronment in a healthy and adaptive manner. Finally, art therapy
may help offenders to break through defenses and cope with
Among the weaknesses of art therapy applied to MDOs is its
lack of empirical validation. Moreover, although art therapy
may be beneficial as an adjunct to other forms of therapy, it
does not appear to have the weight to stand on its own as an
intervention for reducing recidivistic and violent behavior. Ul-
timately, art therapy appears to be an excellent form of
self-expression, but does not address some of the more
deep-seated problems that must be addressed in working with
MDOs, such as antisocial behavior, substance abuse, and lack
of impulse control.
According to Wilson (1990), music therapy in a hospital or
community program environment typically involves chorus,
band, or chamber groups. Newer forms of music therapy, how-
ever, include creative movement, discussion groups, guided
imagery, sports, and arts and crafts (Wilson, 1990). Wilson
stresses that music therapist interventions are goal-oriented,
emphasizing the psychological, behavioral, and social needs of
clients. Unkefer (1990) lists music performing, music psycho-
therapy, music and movement, music combined with other
expressive arts, recreational music, and music and relaxation as
different music therapies for mental illness. Moreover, Feder
and Feder (1981) suggest that music therapy helps to improve
interpersonal relationships, promotes self-development, and
induces physiological responses.
In the last decade, multiple articles have emerged that focus
on music therapy for MDOs (Hakvoort, 2002; Reed, 2002;
Smeijsters & Cleven, 2005). Reed (2002) applied music ther-
apy to MDOs in a state hospital setting, which involved playing
instruments, listening to music, and singing. According to Reed,
music therapy goals for MDOs may include increasing adaptive
behavior, enhancing coping skills, increasing self-esteem, and
eliminating maladaptive behaviors. One of the main interven-
tions is music listening groups (e.g., rock, soul, gospel), which
involves listening to music for 60 to 90 minutes, and helps cli-
ents to increase their motivation to participate in groups and to
J. J. KNABB ET AL. 129
improve self-expression (Reed, 2002).
Recently, Hakvoort (2002) combined music therapy with an
anger management program in an effort to reduce anger in fo-
rensic offenders. Hakvoort suggests that music allows offenders
to express their anger in a controlled environment, with the goal
of minimizing violent behaviors and reducing recidivism. With
music therapy, the music therapist must alter the treatment to
the specific offender and tailor the treatment to a specific prob-
lem area, which helps to explore the behavior and emotions that
are associated with the anger (Hakvoort, 2002). Furthermore,
there must be a confrontation that takes place within the musi-
cal environment, which may involve contrasting, intervening,
splitting, and shifting (Hakvoort, 2002). Ultimately, Hakvoort
emphasizes that a balance between containment and confronta-
tion is maintained in working with offenders.
With regard to the efficacy of music therapy for MDOs, no
empirical studies appear to exist in the literature. And although
multiple studies have applied music therapy to MDOs (Cooke
& Cooke, 1982; Hakvoort, 2002; Reed, 2002; Smeijsters &
Cleven, 2002), these authors relied on case studies rather than
empirical support. Further research is needed to address the
efficacy of music therapy for MDOs.
In terms of its strengths, music therapy offers the MDO an
alternative to more traditional therapeutic interventions, and
may help offenders to express themselves through avenues
other than talk therapy. In addition, music therapy may help the
offender to better relate to others through common interests
such as music. Also, music may be cathartic, offering an emo-
tional response other forms of therapy may not be able to pro-
vide. Moreover, music may be soothing and calming, which
may help offenders to explore anger and frustration in more
appropriate ways. Finally, music therapy may provide offenders
with a safe way to cope with stressors.
Music therapy applied to MDOs has severa l limitations. Fi rst,
music therapy lacks empirical validation as an efficacious
treatment for MDOs. Instead, most music therapy literature on
MDOs appears to be theoretical, and its use with MDOs seems
to be extracted from other populations. Overall, it is currently
unclear whether music can reduce the likelihood of recidivism
and maladaptive behavior among MDOs. Further research on
music therapy applied to specific MDO populations is essential
in order to understand its effect on reducing criminogenic be-
havior and am eliorating mental ill ne ss.
This article attempted to review all of the treatment options
in the forensic psychology literature on MDOs in order to pro-
vide practitioners with a cursory treatment guide. The ten
treatment options located were summarized to better understand
their applicability to MDOs. Also, each treatment was reviewed
in terms of empirical research to obtain a clearer understanding
of what is currently available in the field of forensic psychology.
Lastly, strengths and weakne sses were disc ussed to be tter gr asp
the suitability of each treatment for this heterogeneous popula-
Of the ten treatment options found in the literature, only five
are empirically validated with MDO populations (i.e., behav-
ioral therapy, cognitive behavioral therapy, dialectical behavior
therapy, assertive community treatment, therapeutic commu-
nity). The remaining five treatment options for MDOs are
theoretical in nature. In addition, only two treatments discussed
(i.e., therapeutic community, assertive community treatment)
are tailored to the specific needs of MDOs. Other treatments
(i.e., cognitive behavioral therapy, behavioral therapy, dialecti-
cal behavior therapy, cognitive analytic therapy), although ef-
ficacious and useful, are borrowed from other populations. The
remaining treatments (i.e., music therapy, art therapy, analytical
therapy, attachment theory) seem to be primarily theoretical,
and also tend to be borrowed from other populations.
Although several studies have been conducted on the five
empirically validated treatment options for MDOs, only a
handful of these studies have emerged with adequately con-
trolled samples (Rice, 1983; Rice & Chaplan, 1979). Rather,
many MDO treatment studies either employ case studies to
support their claims (Ryle & Fawkes, 2007), or rely on theo-
retical conceptualizations (Pollock & Belshaw, 1998). Further
research is needed with sufficient control groups and empirical
validation in order to better understand the efficacy of MDO
treatments. Furthermore, four of the reviewed treatments appear
to be relatively new interventions for MDOs. Specifically, cog-
nitive analytic therapy, dialectical behavior therapy, assertive
community treatment, and attachment theory have only recently
emerged as treatments for offenders with mental illness. It re-
mains to be seen just how useful these treatments will be for
MDOs. Further research is also necessary to empirically under-
stand these burgeoning interventions.
While the field of MDO treatment has grown exponentially
in the last few decades, additional work is needed to better un-
derstand the efficacious nature of the differing treatment op-
tions for MDOs and strive towards the overarching goal of
reducing recidivism. Since MDOs are a complex popula-
tion—forensic clinicians must consider the disorder, criminal
act committed, and location of treatment—emerging treatments
must address the vast assortment of treatment variables.
Rice and Harris (1997), in their comprehensive review of
treatment considerations for MDOs, conclude that effective
interventions must reduce the likelihood of future violent epi-
sodes and ameliorate mental illness. Rice and Harris also high-
light several clinical problems that regularly occur with MDOs,
including aggression, criminal tendencies, institutional man-
agement, lagging life skills, substance abuse, social isolation,
and psychotic and mood symptoms. New and innovative MDO
treatments must take these variables into consideration, and
draw from the strengths of existing treatments. For example,
behavioral therapy, cognitive behavioral therapy, cognitive
analytic therapy, dialectical behavior therapy, therapeutic
community, psychoanalytic therapy, and attachment therapy all
emphasize pro-social behaviors and interpersonal success,
whether through social skills training, problem solving skills,
internalizing new reciprocal role procedures, interpersonal ef-
fectiveness skills, corrective emotional experiences, or amelio-
rating internal working models of relationships. In addition,
most of the existing MDO treatments heavily emphasize im-
proving mental illness, whether through positive reinforcement,
cognitive restructuring, emotion regulation skills, or nonverbal
forms of self-expression to achieve catharsis. Finally, many of
the existing MDO treatments, in one way or another, address
common clinical problems highlighted by Rice and Harris
(1997). For instance, music and art therapies help offenders to
J. J. KNABB ET AL.
express anger in healthy ways so as to reduce the prevalence of
aggressive outbursts; therapeutic communities give offenders a
chance to learn new life skills, reduce criminal behavior in a
real world environment, and socially engage with other mem-
bers of their community; assertive community treatment
de-institutionalizes offenders by bringing services to them in
their own home environments; and cognitive behavioral and
dialectical behavior therapies provide clients with skills to cope
with psychotic and mood symptoms. In sum, future treatments
must combine the strengths of existing interventions, address
the plethora of MDO treatment variables and clinical concerns
(Rice & Harris, 1997), and measure their efficacy via random-
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