Wirksamkeit und Kosteneffizienz von forensischen

Wirksamkeit und Kosteneffizienz von forensischen

Wirksamkeit und Kosteneffizienz von forensischen Therapien
Prof. Dr. Jérôme Endrass Anzahl angeordneter Therapien in der Schweiz 1984-­‐2010 (BfS)
1400 1200 1000 800 600 400 200 0 Fragen
•  Welche Interven?onen können das Rückfallrisiko senken? •  Welche Therapieformen schneiden besonders gut ab? •  Welche Therapien sind kosteneffizient? •  Unterstützt die Bevölkerung Therapieprogramme für StraPäter? Wirkt Abschreckung?
Petrosino, 2003 Abschreckung: Bootcamp und „Scared Straight“
Ergebnisse von Scared Straight (Petrosino 2003)
Frickenauer (1982) 5.5 Michigan (1967) 3.8 Lewis (1983) 2.1 GERP (1979) 1.5 Vreeland (1981) 1.5 Orchowsky (1981) 1.1 Yarborough (1979) 1.1 0 1 2 3 4 5 6 Wirkt Therapie?
Journal of Consulting and Clinical Psychology
2006, Vol. 74, No. 3, 482– 488
Copyright 2006 by the American Psychological Association
0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.3.482
Randomized Trial of Treatment for Children With Sexual Behavior
Problems: Ten-Year Follow-Up
Melissa Y. Carpentier
Oklahoma State University
Jane F. Silovsky and Mark Chaffin
University of Oklahoma Health Sciences Center
This study prospectively follows 135 children 5–12 years of age with sexual behavior problems from a
randomized trial comparing a 12-session group cognitive– behavioral therapy (CBT) with group play
therapy and follows 156 general clinic children with nonsexual behavior problems. Ten-year follow-up
data on future juvenile and adult arrests and child welfare perpetration reports were collected. The CBT
group had significantly fewer future sex offenses than the play therapy group (2% vs. 10%) and did not
differ from the general clinic comparison (3%), supporting the use of short-term CBT. There were no
group differences in nonsexual offenses (21%). The findings do not support assumptions about persistent
or difficult to modify risk and raise questions about policies and practices founded on this assumption.
Keywords: sexual behavior problems, sexual offenses, children, recidivism, treatment
Juvenile justice, child welfare, and mental health systems have
devoted increasing attention to aggressive, victimizing, or highly
inappropriate sexual behavior by preadolescent children (Araji,
1997; Baker, Schneiderman, & Parker, 2002; Chaffin, Letourneau,
& Silovsky, 2002). Sexual behavior problems (SBP) do not represent a syndrome or diagnosable condition, but rather a set of
behaviors. Although definitions of childhood SBP vary and persistent and developmentally atypical self-focused behaviors may
be included in the definition, the dominant focus has been on
children 12 years of age and under with intrusive sexual behaviors,
usually directed at other and often younger children.
Increased attention has been fueled by concerns over sexual
aggression and child sexual abuse in general, and by efforts to
intervene early in what has been perceived as a progressive be-
have noted that up to one half of adult sex offenders report a
childhood or adolescent onset for their abusive sexual behaviors or
interests and that early onset cases have particularly high numbers
of offenses and victims (Abel et al., 1987; Hanson & Slater, 1988;
Marshall, Barbaree, & Eccles, 1991). Although retrospective data
do not accurately portray prospective risk, these findings have
been interpreted as cause for long-term concern, and children with
SBP have been viewed as posing a unique and potentially longterm risk to children in the community. For example, some state
child welfare systems have promulgated special tracking systems
for registering, segregating, and handling children identified as
having SBP. Children with SBP may be segregated within facilities and limited to specialized SBP units. Because preadolescent
Randomisiertes Kontrollgruppen-­‐Design (CarpenTer et al., 2006)
Design Ergebnisse •  RCT: N=135 mit “sexual behavior problem” (SBP) – Alter: 8-­‐9 Jahre. •  Kontrollgruppe: N=156 ohne SBP •  2 Behandlungsgruppen: 12% •  Kogni?ve Verhaltenstherapie (KVT) vs. Spieltherapie (ST) •  Zwei unterschiedliche Therapeuten •  10 Jahre follow-­‐up 10% 10% 8% 6% 4% 2% 3% 2% 0% KVT ST Kontrolle Journal of Consulting and Clinical Psychology
2009, Vol. 77, No. 1, 26 –37
© 2009 American Psychological Association
0022-006X/09/$12.00 DOI: 10.1037/a0013035
A Randomized Clinical Trial of Multisystemic Therapy With Juvenile
Sexual Offenders: Effects on Youth Social Ecology and Criminal Activity
Charles M. Borduin
Cindy M. Schaeffer
University of Missouri
Medical University of South Carolina
Naamith Heiblum
University of Missouri
A randomized clinical trial evaluated the efficacy of multisystemic therapy (MST) versus usual community services (UCS) for 48 juvenile sexual offenders at high risk of committing additional serious
crimes. Results from multiagent assessment batteries conducted before and after treatment showed that
MST was more effective than UCS in improving key family, peer, and academic correlates of juvenile
sexual offending and in ameliorating adjustment problems in individual family members. Moreover,
results from an 8.9-year follow-up of rearrest and incarceration data (obtained when participants were on
average 22.9 years of age) showed that MST participants had lower recidivism rates than did UCS
participants for sexual (8% vs. 46%, respectively) and nonsexual (29% vs. 58%, respectively) crimes. In
addition, MST participants had 70% fewer arrests for all crimes and spent 80% fewer days confined in
detention facilities than did their counterparts who received UCS. The clinical and policy implications of
these findings are discussed.
Keywords: juvenile sexual offender, multisystemic therapy, MST, cognitive-behavioral therapy, randomized clinical trial
Public concern about sex crimes is very high and has led to state
and federal mandates for harsher sentences and other sanctions
such as mandatory notification policies and sexual offender registries. Although arrests for sexual offenses are relatively rare,
accounting for less than 1% of all arrests (U.S. Department of
Justice, 2006), these crimes are among the most devastating to
victims (Chapman, Dube, & Anda, 2007; Letourneau, Resnick,
Kilpatrick, Saunders, & Best, 1996). Moreover, the societal costs
of sexual offending are substantial. Indeed, in the United States,
the estimated total annual cost to the public treasury for sexual
(Pastore & Maguire, 2007; U.S. Department of Justice, 2006). This
arrest statistic is especially disturbing when one considers that the
ratio of self-reported to adjudicated sexual crimes by juveniles is
approximately 25:1 (Elliott, 1995). There is also evidence that
about one half of all adult sexual offenders commit their first
sexual offense during adolescence (Zolondek, Abel, Northey, &
Jordan, 2001) and that juvenile sexual offenders are more likely
than juvenile nonsexual offenders and nonoffending adolescents to
sexually reoffend as adults (Hagan, Gust-Brey, Cho, & Dow,
2001). Accordingly, juvenile sexual offenders are important to
Randomisiertes Kontrollgruppen-­‐Design (Borduin et al., 2009)
Design Ergebnisse •  RCT: N=48 mit “sexual offenders at high risk” – Alter: 14 Jahre. •  2 Behandlungsgruppen: 50% •  Mul?systemische Behandlung (MST) •  Kogni?ve Verhaltenstherapie (KVT) •  9 Jahre follow-­‐up 46% 45% 40% 35% 30% 25% 20% 15% 8% 10% 5% 0% KVT MST Journal of Consulting and Clinical Psychology
2011, Vol. 79, No. 5, 643– 652
© 2011 American Psychological Association
0022-006X/11/$12.00 DOI: 10.1037/a0024862
Effects of Multisystemic Therapy Through Midlife: A 21.9-Year
Follow-Up to a Randomized Clinical Trial With Serious and Violent
Juvenile Offenders
Aaron M. Sawyer and Charles M. Borduin
University of Missouri
Objective: Although current evidence suggests that the positive effects of multisystemic therapy (MST)
on serious crime reach as far as young adulthood, the longer term impact of MST on criminal and
noncriminal outcomes in midlife has not been evaluated. In the present study, the authors examined a
broad range of criminal and civil court outcomes for serious and violent juvenile offenders who
participated on average 21.9 (range ! 18.3–23.8) years earlier in a clinical trial of MST (C. M. Borduin
et al., 1995). Method: Participants were 176 individuals who were originally randomized to MST or
individual therapy (IT) during adolescence and averaged 3.9 arrests for felonies prior to treatment. Arrest,
incarceration, and civil suit data were obtained in middle adulthood when participants were on average
37.3 years old. Results: Intent-to-treat analyses showed that felony recidivism rates were significantly
lower for MST participants than for IT participants (34.8% vs. 54.8%, respectively) and that the
frequency of misdemeanor offending was 5.0 times lower for MST participants. In addition, the odds of
involvement in family-related civil suits during adulthood were twice as high for IT participants as for
MST participants. Conclusions: The present study represents the longest follow-up to date of an MST
clinical trial and demonstrates that the positive impact of an evidence-based youth treatment such as MST
can last well into adulthood. Implications of the authors’ findings for policymakers and service providers
are discussed.
Keywords: juvenile offenders, randomized clinical trial, multisystemic therapy, MST, evidence-based
treatment
Serious and violent juvenile offenders continue to commit
crimes well into adulthood (Laub & Sampson, 2001) and are at risk
for a wide range of long-term negative outcomes, including low
educational attainment, physical and mental health problems, and
interpersonal and financial difficulties (Farrington, Ttofi, & Coid,
2009; Shepherd, Farrington, & Potts, 2004). Moreover, criminal
offenses, whether committed by juveniles or adults, have harmful
effects on victims, the families of victims and perpetrators, and the
larger community (e.g., Poehlmann, Dallaire, Loper, & Shear,
converted into dollar amounts and combined with criminal justice
system costs (e.g., incarceration), the total economic impact of a
single lifetime of crime ranges from $1.3 to $1.5 million (Foster,
Jones, & the Conduct Problems Prevention Research Group,
2006). Thus, there is a critical need for treatments that can prevent
or attenuate persistent criminal activity among serious juvenile
offenders.
Historically, mental health and juvenile justice services have
had little success in ameliorating the serious antisocial behavior of
Randomisiertes Kontrollgruppen-­‐Design (Sawyer & Borduin, 2011)
Design Ergebnisse •  RCT: N=176 mit “serious and violent juvenile offenders” – Alter: 15 Jahre. •  2 Behandlungsgruppen: 60% •  Mul?systemische Behandlung (MST) •  Kogni?ve Verhaltenstherapie (KVT) •  22 Jahre follow-­‐up 55% 50% 40% 35% 30% 20% 10% 0% KVT MST Article
Evaluating Three Treatments for Borderline Personality
Disorder: A Multiwave Study
John F. Clarkin, Ph.D.
Kenneth N. Levy, Ph.D.
Mark F. Lenzenweger, Ph.D.
Otto F. Kernberg, M.D.
Objective: The authors examined three
yearlong outpatient treatments for borderline personality disorder: dialectical
behavior therapy, transference-focused
psychotherapy, and a dynamic supportive
treatment.
Method: Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to transference-focused psychotherapy, dialectical
behavior therapy, or supportive treatment and received medication when indicated. Prior to treatment and at 4-month
intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety,
depression, and social adjustment in a
multiwave study design.
Results: Individual growth curve analysis revealed that patients in all three
treatment groups showed significant positive change in depression, anxiety, global
functioning, and social adjustment across
1 year of treatment. Both transferencefocused psychotherapy and dialectical
behavior therapy were significantly associated with improvement in suicidality.
Only transference-focused psychotherapy
and supportive treatment were associated with improvement in anger. Transference-focused psychotherapy and supportive treatment were each associated
with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of
change in irritability and verbal and direct assault.
Conclusions: Patients with borderline
personality disorder respond to structured treatments in an outpatient setting
with change in multiple domains of outcome. A structured dynamic treatment,
transference-focused psychotherapy was
associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment
were associated with fewer changes. Future research is needed to examine the
specific mechanisms of change in these
treatments beyond common structures.
(Am J Psychiatry 2007; 164:922–928)
I
mpulsivity, diminished nonaffective constraint, negative affectivity, and emotional dysregulation are core characteristics of borderline personality disorder (1–3). The
prevalence of borderline personality disorder in the community is approximately 1.3% to 1.4% (4, 5). This chronic
sons (14) and has demonstrated superiority over treatment as usual (unpublished data by KN Levy et al. available from the authors).
A necessary and first step in illuminating effective treatments for borderline personality disorder is to show that a
Randomisiertes Kontrollgruppen-­‐Design (Clarkin et al., 2007)
Design •  RCT: N=83 Pa?enten mit Borderline-­‐
PS •  3 Behandlungsgruppen: •  Transference-­‐Focused-­‐Psychotherapy (TFP) •  Dialek?sche Verhaltenstherapie (DBT) •  Stützende Psychotherapie (ST) Ergebnisse 50 45 Verbal Assault Direct Assault 40 35 30 25 20 15 10 5 0 TFP DBT ST Annu. Rev. Law. Soc. Sci. 2007.3:297-320. Downloaded from www.annualreviews.org
by Universitat Zurich- Hauptbibliothek Irchel on 10/14/11. For personal use only.
The Effectiveness of
Correctional Rehabilitation:
A Review of Systematic
Reviews
Mark W. Lipsey1 and Francis T. Cullen2
1
Institute for Public Policy Studies, Vanderbilt University,
Nashville, Tennessee 37212; email: [email protected]
2
Division of Criminal Justice, University of Cincinnati, Cincinnati, Ohio 45226-0389;
email: [email protected]
Annu. Rev. Law Soc. Sci. 2007. 3:297–320
Key Words
First published online as a Review in Advance on
July 5, 2007
treatment, deterrence, sanctions, offenders, meta-analysis
The Annual Review of Law and Social Science is
online at http://lawsocsci.annualreviews.org
This article’s doi:
10.1146/annurev.lawsocsci.3.081806.112833
c 2007 by Annual Reviews.
Copyright !
All rights reserved
1550-3585/07/1201-0297$20.00
Abstract
The effects of correctional interventions on recidivism have important public safety implications when offenders are released from probation or prison. Hundreds of studies have been conducted on those
effects, some investigating punitive approaches and some investigating rehabilitation treatments. Systematic reviews (meta-analyses)
of those studies, while varying greatly in coverage and technique,
display remarkable consistency in their overall findings. Supervision
and sanctions, at best, show modest mean reductions in recidivism
Wirksamkeit von Psychotherapien –Auswahl (Lipsey und Cullen, 2007)
RNR (Andrews, 1990) -­‐60% SOT (Retzel, 2006) -­‐46% -­‐36% SOT (Gallagher, 1999) -­‐32% KVT (Wilson, 2005) -­‐30% Rückfallpräven?on (Dowden, 2003) SOT (Hanson, 2002) -­‐28% KVT (Pearson, 2002) -­‐28% SOT (Lösel, 1995) -­‐26% SOT (Hall, 1995) -­‐24% -­‐22% KVT (Landenberger, 2005) -­‐8% KVT (Tong, 2006) -­‐70% -­‐60% -­‐50% -­‐40% -­‐30% -­‐20% -­‐10% 0% Wirksamkeit von Therapien (Lipsey & Cullen, 2007)
•  Therapeu?sche Interven?on sind effizienter als abschreckende/
puni?ve Interven?onen •  Effizienz therapeu?scher Interven?onen: •  1 Meta-­‐Analyse: Nega?ver Effekt •  2 Meta-­‐Analysen: Kein Effekt •  56 Meta-­‐Analysen: Posi?ver Effekt •  Therapien bei Jugendlichen sind effizienter •  Die Studienqualität hat keinen Einfluss auf das Ergebnis Kriminalitätskosten
Gemessen am Bru_o-­‐Inlandprodukt
•  Schätzung der Technischen Universität Darmstadt •  Kriminalitätskosten entsprechen zwischen 4% und 7% des Bruuoinlandsprodukts der jeweiligen Länder. •  Deutschland: 5% des Bruuoinlandsprodukts (Entorf 2007)]. Geschätzte jährliche Kriminalitätskosten
EU 869 USA 840 182 Deutschland Frankreich 137 Vereinigtes Königreich 127 91 Kanada Niederlande 40 Schweiz 33 21 Österreich 0 100 200 300 400 500 Kosten (Mia USD) 600 700 800 900 1000 Medizinische Versorgung von Opfern
•  Schätzungen aus den USA (90er Jahre): •  Jährlich 450 Miliarden USD durch Kriminalität verursachten direkte Opferkosten. •  Die medizinische Behandlung der Opfer von Gewaltdelikten macht 3% aller Gesundheitskosten. •  Die Kosten für die Behandlung psychischer Störungen bei Opfern entsprechen 10-­‐20% der Gesamtkosten für die Behandlung psychischer Störungen (Miller et al. 1996). Was sind Kriminalitätskosten?
•  Durch Kriminalität ausgelöste Kosten, die beglichen werden müssen -­‐ eine bewusste und freiwillige Entscheidung für Kostenübernahme (im Sinne einer Inves??on) ist nicht möglich. •  unmi-elbare und leicht zu iden5fizierende Folgekosten (wie beispielsweise Kosten die sich aus der medizinischen Behandlung der Opfer oder der ins?tu?onellen Unterbringung des Täter ergeben), •  schwerer zu iden5fizierende Kosten (wie z.B. die Auswirkungen von SexualstraPaten auf Bürger, die unweit vom Tatort leben und als Folge auf eine Deliktserie ihr Verhalten anpassen -­‐ z.B. häufiger Taxi fahren, einen Selbstverteidigungskurs besuchen und an ihrem Wohnort Alarmalagen und zusätzliche Schlösser einbauen lassen). 17.25 18 16 MILLIONEN MILLIONEN 20 0.5 0.4 14 0.4 12 0.3 10 0.3 8 0.2 6.16 6 0.2 4 0.1 2 0.448 0.5 0.335 0.151 0.145 0.048 0.1 0 0.058 0.0 Tötungsdelikt Vergewal?gung bouom-­‐up top-­‐down Raub Schwere Körperverletzung Kosten krimineller Karrieren
Philadelphia Kohortenstudie (Cohen 1998)
•  Bis zum Alter von 26 Jahren hauen 6'157 der 27'186 Personen aus der Geburtskohorte wenigstens einmal einen Kontakt mit der Polizei. •  4% der Popula?on (beziehungsweise 16% derjenigen mit mindestens einem Polizeikontakt) waren für 51% aller Polizeikontakte verantwortlich. •  Intensiv-­‐Tätern hauen durchschniulich 10.5 Polizeikontakte bis zum 26. Lebensjahr. •  Nicht jedes Delikt führt zu einem Polizeikontakt => Schätzwert für die Anzahl von Delikten, die durchschniulich begangen werden, bis es zu einem Kontakt mit der Polizei kommt. •  Basierend auf den Ergebnissen empirischer Untersuchungen sind Cohen et al. davon ausgegangen, dass die durchschniulich 10.5 Polizeikontakte für 134 bis 150 Delikte stehen. Career offenders – Philadelphia Kohortenstudie (Cohen et al., 2009) 25 20 15 ANZAHL DELIKTE 10 5 0 <8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 ALTER IN JAHREN Jährliche Kosten verursacht durch Intensiv-­‐
Täter (Cohen et al., 2009)
USD 350'000 USD 300'000 USD 250'000 USD 200'000 USD 150'000 USD 100'000 USD 50'000 USD 0 9 10 11 12 13 14 15 16 17 18 ALTER WTP 19 20 21 22 23 24 25 26 MILLIONEN Effekt (Kosten-­‐Vermeidung von Kosten) bei Beendigung krimineller Karrieren von Intensiv-­‐
Tätern(Cohen et al., 2009)
USD 5 USD 4 USD 3 USD 2 USD 1 USD -­‐ 8 10 12 14 16 18 20 ALTER 22 24 26 28 30 Kosten-­‐Nutzen-­‐Analyse Erwachsene Strahäter (Aos, 2006)
Strafvollzug: Berufsausbildung 13.74 Bewährungshilfe: Engmaschige Betreuung 11.56 Strafvollzug: Aus-­‐ und Weiterbildung 10.67 Strafvollzug: Kogni?v-­‐behaviorale Therapie 10.30 Ambulant: Drogentherapie 10.05 Strafvollzug: Arbeitstä?gkeit Strafvollzug: Drogentherapie 9.44 7.84 Drogengerichte für Erwachsene 4.77 Berufsausbildung on the job (am Arbeitsplatz) 4.36 0.00 20.00 40.00 60.00 80.00 Tausende Kosten-­‐Nutzen-­‐Analyse Jugendliche Strahäter (Aos, 2006)
Mul?systemische Pflegefamilientherapie 77.80 Diversion 40.62 Familienintegrierte Übergangsbegleitung 40.55 Funk?onelle Familientherapie 31.82 Mul?systemische Therapie 18.21 Aggressons-­‐Management-­‐Training Jugendgerichte 14.66 9.21 SexualstraPäter-­‐Therapie für Jugendliche 7.83 Wiedergutmachungsprogramme 7.07 Berreichsübergreifende Koordina?onsprogramme 5.19 Drogengerichte für Jugendliche 4.62 0.00 20.00 40.00 60.00 80.00 Gesellschahliche Akzeptanz
Wieviel sind Amerikaner bereit für Therapie bei Jugendlichen zu zahlen? Cost-­‐benefit (Nagin et al., 2006)
BereitschaP (Mio USD) 500 Kosten (Mio USD) 468 450 387 400 350 300 250 200 150 100 100 50 20 0 Therapie Längere Strafen Fragen
•  Welche Interven?onen können das Rückfallrisiko senken? •  Welche Therapieformen schneiden besonders gut ab? •  Welche Therapien sind kosteneffizient? •  Unterstützt die Bevölkerung Therapieprogramme für StraPäter? Fragen -­‐ Antworten
•  Welche Interven?onen können das Rückfallrisiko senken? •  Therapeu?sche Massnahmen können das Rückfallrisiko senken. •  Abschreckende Interven?onen erhöhen das Rückfallrisiko. •  Rein sichernde Interven?onen sind eher neutral – leicht schädigend. •  Welche Therapieformen schneiden besonders gut ab? •  MST und MSFCT schneiden in RCTs besonders gut ab. •  Welche Therapien sind kosteneffizient? •  Selbst Therapien, die nur einen geringe Rückfallsenkung erzielen können kosteneffizient sein. •  Besonders effizient: MST und MSFCT •  Unterstützt die Bevölkerung Therapieprogramme für StraPäter? •  Repräsenta?ve Untersuchungen weisen darauf hin, dass die Bevölkerung rehabilita?ven Massnahmen aufgeschlossen gegenübersteht.