The Efficacy of Self-directed CBT Programing

The implementation of traditional group cognitive behavioral therapy (CBT) is accompanied by numerous challenges. Manualized cognitive behavioral therapy (MCBT) curriculum overcomes these challenges. A study sponsored by the National Institute of Justice (Duwe, 2017) found programs that increase prosocial support reduce recidivism and program costs. One of the clear advantages of the MCBT curricular approach is that it calls for the use of prosocial mentors. MCBT curriculum provides opportunities to incorporate the storytelling approach, a method which allows for the introspection needed for behavioral change (Hodge, 2002). MCBT curriculum also effectively supports difficult-to-serve populations such as those in rural settings (Timko et al., 2018). MCBT curriculum creates change by addressing the eight principles advocated by the National Institute of Corrections. Research has shown that self-guided CBT also helps treat mental health problems (Gellatly, 2007). This paper will discuss the MCBT approach, in general, as well as focus in on a specific sample MCBT curriculum that has been found effective by several organizations, including San Diego County Probation, Oklahoma Department of Corrections AP&P, Arizona State Parole, adult county probation departments in Texas, U.S. Probation and Pretrial districts and numerous misdemeanor courts located in OH, AZ, and UT. In a University of North Dakota research study, researchers used the sample MBCT curriculum and found it lead to reduced noncompliance, fewer revocations, and significantly fewer positive drug tests.

The benefits of cognitive behavioral therapy (CBT) in the treatment of justice-involved individuals have been well-documented (Feucht and Holt, 2016). At the same time, the implementation of traditional group CBT brings with it several challenges to reaching the potential of these methodologies. These challenges include:

> Limited interaction with prosocial mentors
> Time and costs needed to build facilitation and program capabilities
> Delays during CBT group formation/scheduling conflicts
> Need for travel (especially rural participants)
> Need for increased motivation and reduced resistance
> Need for greater interaction between participants and leaders

This paper examines how self-directed manualized cognitive behavioral therapy (MCBT) can overcome these challenges while maintaining and expanding the benefits of the group CBT approach. Toward that end, it will discuss the treatment innovations, statistically significant outcomes, complementary evidence-based research, and program efficacy of an unnamed sample MCBT curriculum. In conclusion, practical applications and scalability will be addressed.

Methodology of the Sample MCBT Curriculum

Following National Institute of Corrections (NIC) guidelines (NIC and Crime & Justice Institute, n.d.), the sample self-directed MCBT curriculum involves a prosocial mentor to assist the participant in completing the evidence-based cognitive courses that make up the curriculum. Each of the curriculum’s 17 adult available courses (and 8 juvenile courses) begins with vicarious stories about an individual facing the kinds of problems with which the participant is dealing. Next, the courses ask the participant to think about and understand the character’s situation. Finally, the courses require writing and self-reflection based on principles of cognitive behavioral therapy. Each course includes multiple stories and writing prompts, and application / skill building sections. Participants are required to check in with both prosocial mentors and their supervision officer or counselor throughout the use of the curriculum.

Benefits of a Flexible MCBT Curriculum

The MCBT curriculum modality differs from alternative group therapies in essential ways. First, it allows for the use of prosocial mentors rather than group settings. Working with these prosocial companions rather than other justice-involved individuals has proven beneficial in reducing recidivism.

This aligns with the results of a study sponsored by the National Institute of Justice. In his report, “The Use and Impact of Correctional Programming for Inmates on Pre- and Post-Release Outcomes,” Duwe (2017) stated: “Programming that increases prosocial sources of support warrants greater attention as a correctional intervention, not only because of its demonstrated efficacy in reducing recidivism, but also because of its potential cost effectiveness” (p. 21).

As discussed by the study’s authors, a prosocial approach is both effective (because of the positive coaching and external support it provides) and cost-effective. In the sample curriculum’s methodology, any at-risk individual can participate, and there is reduced need to train supervision officers or counselors to lead group classes. This modality is also highly scalable, widely available, and can be used during incarceration, after incarceration, or as an alternative to incarceration. It can also be used among historically difficult-to-serve populations including those in rural settings (Timko et al., 2018). In that study, researchers found that “services adapted to rural settings that target [criminogenic need] factors, such as telehealth and other technology-based resources, may hasten improvement on both [substance use and criminal activity] outcomes among drug users” (paragraph 1).

It should be noted that while the sample curriculum focuses primarily on individual courses completed with the help of prosocial mentors, MCBT curriculum has also been utilized successfully in group settings, particularly for high-risk populations.

The next essential way an MCBT curriculum differs from other modalities is its reliance on self-directed learning. The system gives justice-involved individuals more control over their own learning, challenging them to complete the material on their own. This motivates them to think of their own solutions for both the stories about others as well as their own life challenges. Moreover, justice-involved individuals appreciate this approach. As one participant in a study using the sample program shared, “‘this workbook should be given to every criminal, every drug user, every person stuck in neutral in life.’ Moreover, most participants indicated they would recommend this program to others” (McGrath, 2018, p. 4).

The third essential way this MCBT modality differs is the opportunity it provides to use a storytelling approach, which disarms participants’ objections to help them change the way they think. In “Utilizing Traditional Storytelling to Promote Wellness in American Indian Communities,” (Hodge et al., 2002), researchers found that: “The individual needs this type of introspection to assess, understand, and change his or her behavior. Thus, storytelling becomes a powerful adjunct to health education.”

Finally, MCBT curriculum differs in the opportunities it provides to incorporate technology to enhance treatment effectiveness. “Technology-based assessments and interventions are important therapeutic tools that clinicians can integrate into their work with clients” (Substance Abuse and Mental Health Services Administration, 2015, p. 3). Technology facilitates ongoing collaboration between referring professionals, justice-involved individuals, and other members of the support team. In the case of our sample curriculum, whether participants choose to take a course online or with a traditional workbook, the curriculum’s publisher provides specific feedback about the participation and completion of each referred client. This type of collaboration with referring professionals provides a platform for targeted feedback, follow-up, and skill training. It also improves the efficiency and effectiveness of their supervision meetings and interactions.

A Review of the Literature

Numerous studies and meta-analyses have shown the efficacy of CBT treatment, in general, to reduce recidivism, and researchers with the National Institute of Justice (Feucht and Holt, 2016) found that, “an analysis of programs and practices in CrimeSolutions.gov finds that cognitive behavioral therapy can deter crime, assist victims, and prevent recidivism” (paragraph 1). Researchers from the University of North Dakota had similar findings, stating that, “Cognitive behavioral therapy (CBT) has been gaining popularity as a treatment modality used by probation agencies. This is so much the case that CBT is specifically recommended within the EBP philosophy”(Gottschalk, & Mayzer, n.d., p. 5).

NIC and the Crime & Justice Institute (n.d.) advocate eight principles of effective intervention, as follows: assess actuarial risk/needs, enhance intrinsic motivation, target interventions, skill train with directed practice, increase positive reinforcement, engage ongoing support in natural communities, measure relevant processes/practices, and provide measurement feedback. The sample MCBT courses address each of these principles. For example, it assesses actuarial risk/needs by providing free onsite training to help staffers connect the curriculum with their agency’s risk assessment tools. It enhances intrinsic motivation using prosocial mentors and storytelling, which elicit internal values clarification. It targets interventions by addressing the most important criminogenic risks first, including criminal thinking and procriminal networks. It also focuses on skill training: each unit in each course concludes with a skill training and application section. Participant responses are sent directly to referring professionals, who can then target areas in which further skill building is needed. It increases positive reinforcement with prosocial mentoring, certificates of completion, and, in many cases, incentives from supervising agencies such as shortening the length of supervision. It engages ongoing support in natural communities because learning and changing takes place in the context of positive relationships in the home; instead of connecting participants to the system, this curriculum connects them to their communities, which is a much more sustainable approach. It measures relevant processes and practices with ongoing reports on both completion and recidivism rates, in addition to random internal reviews of completed courses to ensure program fidelity and inform content development. Finally, it provides measurement feedback by sharing reports and studies with referring agencies, providing monthly reports to program supervisors and providing instant digital access to participant status.

In addition to reviewing research about CBT in justice-involved populations and principles of effective intervention in recidivism prevention, several studies have examined self-directed interventions to treat mental health problems. In a 2007 meta-analysis (Gellatly et al., 2007), researchers compared 34 studies to “determine whether the content of self-help interventions, the study populations, or aspects of study design were the most important moderators.” They found that “only guided self-help remained significant in the multivariate analysis” (p. 1217).

In conclusion, research to date points toward cognitive behavioral therapeutic techniques, guided self-help, prosocial mentors, and adherence to well-defined principles of effective intervention as evidence-based practices that reduce recidivism.

Recidivism and Completion Rates of the Sample Curriculum

The sample MCBT curriculum is built on these evidence-based practices, and outcomes from its implementation in locations throughout the US uphold its veracity.

In a six-year period in eight US Probation districts (American Community Corrections Institute [ACCI], 2018) a total of 1137 participants were referred to the sample curriculum. 79.8% of participants completed the curriculum, and the overall revocation rate was 17.8%. The authors cite the following: “Through reviewing the handwritten and eLearning evaluations of those that completed, we have learned that approximately 82% of probationers gave a positive evaluation of their assigned cognitive [sample] course and appreciated an opportunity to learn and implement the cognitive life skills they learned with the help of a ‘coach’ they chose” (p. 2).

Over a 3-year period in Ohio (ACCI, 2018c), a total 649 participants were referred to the sample curriculum with an average 73% completion rate in three counties. The recidivism rate averaged 19%, but only 5 and 6%, respectively, in two of the referring counties.

In the Arizona program Wise Choice Alternatives, 1,336 participants were referred to the sample curriculum over a 14-month period. A total 92% completed the courses. Of those, the recidivism rate averaged 13%, with 100 participants being reported non-compliant and 150 being convicted of re-offense (ACCI, n.d.-c).

In a 21-month period among Community Supervision & Corrections Departments in Texas (ACCI, 2018b), 781 probationers were referred to a correspondence course version of the curriculum. A total 81.3% of participants completed the course, and researchers studied rates of completion and revocation. Revocation was found to be approximately 15% or less, depending on the year. “Overall results of the [sample] program administered in fifteen counties in the state of Texas indicate that results are positive,” (p. 22) according to researchers.

In San Diego County Probation (ACCI, 2018a) over a 12-month period, 60 probationers were referred to the sample MCBT curriculum and 51 completed it. Four were convicted of re-offenses and seven were found to be noncompliant with parole, resulting in a recidivism rate of 8%. Among the four who re-violated, only one returned to incarceration.

During a 28-month period with the Oklahoma Department of Corrections AP&P (ACCI, 2018d), 747 probationers were referred to the sample curriculum, with a completion rate of 86% and a recidivism rate of 5%.

In a 30-month period with Arizona State Parole (ACCI, n.d.-b), a total 2859 probationers were referred to the curriculum. A total 70% completed the course and, of those, the recidivism rate was 10%.

In an 8-year period in Bastrop County, Texas (ACCI, n.d.-a), the district attorney required all offenders to take the sample MCBT course. Of 1,778 referrals, 77% completed the course and 3.2% repeated the course (after having been reconvicted). This 3.2% recidivism rate was lower than the department’s projected 6-8% recidivism rate. “Together, all results directly indicate that this form of cognitive restructuring can drastically reduce recidivism rates,” researchers stated (p. 1).

University of North Dakota MCBT Research Experiment

In a comprehensive report by University of North Dakota researchers (Gottschalk & Mayzer, n.d.), researchers used the sample MCBT curriculum to study evidence-based practices in Federal Probation. Researchers used the following outcome measures: sum of revocations, sum of non-compliance counts (technical violations), sum of new arrests, and sum of positive drug tests during supervision. Of the 346 offenders in a USPPS-ND database over a 4-year period, 101 began the MBCT treatment and 89 completed the course. A total 245 offenders received no treatment. On average, participants had moderately high or high risk scores and were predominantly male and of Native American descent. A subset of participants was analyzed using additional outcome measures — specifically, the Texas Christian University Criminal Thinking Scales (TCU Institute of Behavioral Research, n.d.). These outcomes focus on six cognitive domains: entitlement, justification, power orientation, cold-heartedness, criminal rationalization, and personal irresponsibility.

Initially, many of the outcome measures found no statistical significance between the general population and the group that completed the sample MCBT course, but after correcting for certain variables, the “MCBT program was significantly associated with fewer noncompliance reports per year of supervision” (Gottschalk & Mayzer, p. 19). “Among Native Americans who completed the program, there were significantly fewer revocations (.27 versus .96), significantly fewer noncompliance counts (2.77 versus 5.54), and significantly fewer positive drug tests (.20 versus .37) per year of supervision” (p. 17).

Outcomes using the TCU-CTS showed improvement among participants who completed the course. Researchers reported that, “significant reductions in criminal thinking were found for three of the six TCU-CTS subscales: entitlement, justification, and personal irresponsibility. Although changes on the other three scales (power orientation, cold heartedness, and criminal rationalization) did not reach statistical significance, they followed the same general trend — with average post-test scores lower than average pre-test scores” (Gottschalk & Mayzer, n.d., p. 28).

Overall, researchers drew broad conclusions: “The analyses conducted herein provide some reason to believe that the MCBT program used by the North Dakota District may hold promise for reducing criminal thought patterns among offenders as well as improving their consequent behavior” (Gottschalk & Mayzer, n.d., p. 30).

Further Research Needed

Much of the research on the sample MCBT curriculum focused on simple program completion and recidivism reduction and, therefore, lacked rigorous scientific controls, including comparisons to recidivism rates experienced by non-program participants. As stated by the authors of the North Dakota study (Gottschalk & Mayzer, n.d.), larger sample sizes, a comprehensive plan that integrates curriculum implementation, random assignment, the use of subgroups and evaluation, thorough pre- and post-analyses of intervention behaviors and a database created specifically for evaluation purposes would also be tremendously valuable.

Conclusions and Practical Applications of Self-directed CBT Curriculum

The success of MCBT curriculum shows statistically and substantively significant effects following program completion in regard to recidivism reduction. The research also shows improvement in the cognitive-behavioral realm, including statistically significant improvements in criminal thinking on the Texas Christian University Criminal Thinking Scales.

Looking forward, MCBT curriculum has many practical applications, particularly for justice-involved individuals determined to be at low risk or for individuals who do not perform well in groups and those who have transportation or scheduling conflicts. Another ideal application for this curriculum is an after-care approach for clients who have been through an intensive CBT group course and could benefit from additional reinforcement. This curriculum has also proven successful in group settings, particularly for high-risk incarcerated individuals.

Self-directed CBT curriculum is also effective outside a classroom setting, particularly for populations that can otherwise be difficult to reach, such as rural populations, day reporting centers, after-care populations, and populations supervised by parole officers. Often, caseloads for these officers are enormous, and departments lack the time and resources to offer group courses. In addition, with the sample MCBT’s prosocial companion aspect, justice-involved individuals can take responsibility for the coursework on their own time and at their own expense.

About the Author

Trevor Lloyd is the President and CEO of ACCI (American Community Corrections Institute). Having earned a master’s degree in industrial/organizational psychology, he has spent the last decade developing evidence-based lifeskills courses and programs that increase outcomes for correctional agencies and schools nationwide. He frequently trains and consults with county and state agencies, with a focus on increasing public safety and decreasing recidivism. He can be contacted at tlloyd@accilifeskills.com.

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