New directions: integrating a biopsychosocial approach in the design and delivery of programs for high risk services users in Her Majesty’s Prison and Probation Service

Abstract

Recently, Mann and Carter (2012) have proposed a biopsychosocial model of change building on the Good Lives Model and principles of Risk-Need-Responsivity. The first stage of the model provides a biopsychosocial explanation of dynamic risk factors predictive of sexual recidivism. The second stage articulates a set of compatible organizing principles for program design. In this article we expand the model by providing a preliminary account of the biological, psychological and social basis of dynamic risk factors associated with different offence typologies. Subsequently, details are provided of two widely accessible high intensity HMPPS programs which implement the organizing principles of the model.

Full text

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NEW DIRECTIONS: INTEGRATING A BIOPSYCHOSOCIAL APPROACH
IN THE DESIGN AND DELIVERY OF PROGAMS FOR HIGH RISK
SERVICE USERS IN HER MAJESTY’S PRISON AND PROBATRION
SERVICE
DRFATED MANUSCRIPT
Dr. Jamie S. Walton
Intervention Services, Her Majesty’s Prison and Probation Service, United Kingdom
Laura Ramsay
Intervention Services, Her Majesty’s Prison and Probation Service, United Kingdom
Cara Cunningham
Intervention Services, Her Majesty’s Prison and Probation Service, United Kingdom
Sarah Henfrey
Intervention Services, Her Majesty’s Prison and Probation Service, United Kingdom

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Abstract:
Recently, Mann and Carter (2012) have proposed a biopsychosocial model of change building
on the Good Lives Model and principles of Risk-Need-Responsivity. The first stage of the
model provides a biopsychosocial explanation of dynamic risk factors predictive of sexual
recidivism. The second stage articulates a set of compatible organizing principles for program
design. In this article we expand the model by providing a preliminary account of the
biological, psychological and social basis of dynamic risk factors associated with different
offence typologies. Subsequently, details are provided of two widely accessible high intensity
programs which implement the organizing principles of the model.
Published version to be cited as:
Walton, J. S., Ramsay, L., Cunningham, C. & Henfrey, S. (2017). New directions: integrating a biopsychosocial approach
in the design and delivery of programs for high risk services users in Her Majesty’s Prison and Probation Service.
Advancing Corrections: Journal of the International Corrections and Prison Association, 3, 21-47

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Rehabilitative programs should demonstrate convincing effects so that desirable impacts on
recidivism are at some point established using accepted standards of scientific rigor. Where
this is absent, correctional investors risk commissioning interventions that are not effective.
The most robustly evidenced principles for effective programs are Risk, Need, Responsivity
(RNR) (see originally Andrews, Bonta, & Hoge, 1990), with the basic pattern of positive
outcomes replicated by a number of research teams, often including high quality randomized
studies in generating results (e.g. Andrews & Bonta, 2006; Wilson, Bouffard & Mackenzie,
2005). Following the RNR model, program dose should be provided proportionate to risk;
programs should limit targeting to criminogenic needs, and content should be delivered in ways
responsive to personal circumstances. The development of meta-analytic research
discriminating changeable ‘dynamic risk factors’ (a term here used interchangeably with
‘criminogenic needs’) predictive of different types of offending (e.g. Mann, Hanson &
Thornton, 2010; Stith, Smith, Penn, Ward & Tritt, 2004) has supported adherence to the need
principle of RNR in particular.
Despite the principles of RNR, it is clear programs, particularly those that are specialized for
distinct offence typologies, have not always adhered to evidence informed practice. For
example, the acceptance of victim empathy and offence responsibility as program targets for
those convicted of sexual offences (McGrath, Cumming, Burchard, Zeoli & Ellerby, 2010) has
opposed the need principle since these targets are intuitive by design, and lack in established
relationships with recidivism (Hanson et al. 2010). In other cases, programs have rejected RNR
in favor of single factor theories. Duluth programs for instance aimed at educating men about
patriarchy have been based on feminist ideology which explains intimate partner violence
(IPV) in terms of a cultural strategy supporting female subservience (Dobash & Dobash, 1979;
Yllö, 2005). In each case, non-criminogenic targets or a minimal empirical treatment paradigm
have been influential (see example reviews Ware & Mann, 2012, Dutton & Corvo, 2006).

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RNR has also been criticized for being excessively focused on risk management. In short, Ward
and his colleagues (e.g. Ward & Stewart, 2003) have highlighted concerns with RNR regarding
an overemphasis on the removal of risks, and lack of attention to human agency and capacity
building, advocating instead a Good Lives Model (GLM) of offender rehabilitation. However,
despite observed effects of short-term outcomes (e.g. Harkins, Beech & Woodhams, 2012), the
GLM currently lacks demonstrable superiority over RNR, particularly in reducing recidivism.
In addition, many assumptions of the GLM are incorporated into RNR (Wormith, Gendreau &
Bonta, 2012; Looman & Abracen 2013). For example, the current GLM (Good Live Desistance
Model; Ward & Laws, 2010), asserts that programs should capitalize on desistance processes
by strengthening an individuals’ capacity to engage with valued activities and goals. Likewise,
the RNR model focuses on strengthening an individual’s repertoire of skills, thereby helping
them to develop alternative conditions to those supporting offending.
A second criticism relates to the theoretical hollowness of dynamic risk factors (Ward & Beech,
2015). It is commonly agreed that there are four risk domains (e.g. Thornton, 2013): Sexual
(sexual deviancy), Cognitive (antisocial attitudes), Relationships (interpersonal skills and
intimacy deficits) and Self-Management (emotional dysregulation or poor self-control).
However, whilst labelling ‘risks’ provides a common language for describing a problem, this
lacks information relevant to the biological, developmental and social origins, from which the
problem has manifest. Indeed, this is an aspect of RNR that requires consideration and to which
we attempt to contribute by making use of the biopsychosocial model of change proposed by
Mann and Carter (2012).
Mann and Carter’s model of change attempts to support evidenced informed practice by
articulating the underlying causes of dynamic risk factors, thereby progressing RNR, and also
enhances the GLM by proposing more precisely, the therapeutic methods that are most likely
to work. Stage one of the model (outlined in figure 1) describes the biological, psychological

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and social influences on dynamic risk factors associated with sexual recidivism. Stage two
outlines a framework of program design principles that are consistent with a biopsychosocial
conceptualization.
Figure 1: Biopsychosocial Model:
In this discussion, we first develop stage one of the model by providing a biopsychosocial
account of dynamic risk factors associated with different types of offending, in the contexts of
those with and without learning disability (LD). We suggest this is reasonable for at least two
reasons. Firstly, observation of the criminological literature indicates consistency in the
dynamic risk factors associated with recidivism across perpetrator groups; namely violent and
sexual offending, and IPV. Secondly, although the LD literature is in its infancy, we suggest it
is reasonable to cautiously accept that many factors associated with recidivism apply to the LD
population. Subsequently, we describe two aligned high intensity programs developed within

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Her Majesty’s Prison and Probation Service (HMPPS) in the United Kingdom (UK) that adhere
to stage two. Prior to outlining our extension of stage one, we provide a brief synopsis of
offending in the context of LD.
Learning Disability and Offending
Intellectual functioning is often assessed through intelligence quotient (IQ) testing. Mild LD is
diagnosed when impairment in IQ (<70) is chronic, present before the age of 18 years, and
associated with problems in conceptual (language, thinking, knowledge), and social domains
as well as daily functioning (American Psychiatry Association; APA, 2013). Whilst borderline
intellectual functioning (BIF), usually characterized by an IQ of 70 – 85, is not classified as a
disability, individuals who fall into this range of functioning are likely to experience adaptive
problems. They are at an increased risk of poverty (Emerson, 2011), may struggle with daily
living and show increased rates of substance use and personality disorders (Hassiotis, Strydom,
Hall, Ali, Lawrense-smith, Meltzer, Head & Bebbington, 2008). Despite these vulnerabilities
they experience difficulties accessing specialist services. This is regularly because individuals
with BIF become adept at masking their disabilities. In general, facilities to identify and support
the needs of those living with LD in the UK Criminal Justice System (CJS) have been reported
to be lacking (e.g. Criminal Justice Joint Inspection, 2015).
The limit availability of services for offenders living with LD is reflected by the comparative
lack of research attention this group has received. The literature also suffers from heterogeneity
in how LD is assessed and defined, thereby restricting generalizability. Despite these
limitations, it is clear that offending pathways differ on some variables for individuals with and
without LD. For example, violent offenders with LD show higher levels of hostile attribution
and are more likely to choose aggressive responses to provocation than violent offenders

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without LD (Larkin, Johada & MacMahon, 2013). Whilst not distinguishing them from
individuals with LD who do not offend (Tabolt & Langdon, 2006), offenders with LD are also
more likely to have limited sexual knowledge which may influence inappropriate sexual
expression (Linsday, 2009). There are however a number of similarities of dynamic risk factors
between LD and non-LD offenders (e.g. Fitzgerald, Grey, Taylor & Snowden, 2011; Lindsey,
Elliot & Astell, 2004). There is also potential for individuals with LD to represent a substantial
minority subgroup in samples used to determine dynamic risk factors. Criminogenic
characteristics found among men with LD which are unlikely to differentiate them from other
groups include antisocial attitudes, familial criminality, personality disorder, psychopathy and
being young (Keeling Rose & Beech, 2007; Lindsay, Hogue, Taylor, Mooney, Steptoe,
Johnson, O’Brian & Smith, 2006; Turner, 2005).
Stage 1: Beyond Dynamic Risk Factors
In expanding the biopsychosocial model, we have retained the four risk domains mentioned
above to organize the dynamic risk factors which are applicable across the three perpetrator
groups. We assert a similar parameter to Mann and Carter in expanding their model; that is, the
biopsychosocial influences in the domains below are not intended to provide an etiological
theory. Instead, we suggest they illustrate the need to think beyond dynamic risk factor labels,
towards recognizing that biological, psychological and social influences are important in
understanding offending behavior and coordinating methods to support change.
Sexual Interests:
Factors in this domain include sexual offence paraphilia and sexual preoccupation (Mann et
al., 2010). LD samples have been reported to show more deviant pedophilic interests (indexed

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by offence history and/or phallometrically) than non-LD comparators (Blanchard, Watson,
Choy, Dickey, Klasson, Kuban & Ferren, 1999; Rice, Harris, Lang & Chaplin, 2008).
Biological Influences:
Converging evidence supports an early neurodevelopmental predisposition towards pedophilia,
associated with greater prevalence of prenatally influenced characteristics in pedophilic
samples compared to controls (Cantor, Blanchard, Christensen, Dickey, Klassen, Beckstead,
& Kuban, 2004; Fazio, Lykins, & Cantor, 2014; McPhail & Canter, 2015; Levenson &
Ackerman, 2016; Dyshniku, Murray, Fazio, Lykins & Cantor, 2015). For a recent review of
the relevant neurobiological evidence we recommend Tenbergen, Wittfoth, Frieling, Ponseti,
Walter, Walter, Beier, Schiffer and Krueger (2015).
Psychological Influences:
Masturbatory conditioning has been considered causal of offence paraphilia (Laws & Marshall,
1990). Underpinning this behavioral model is the assumption that paraphilia are acquired,
especially where insecure attachment in children raises both the likelihood of sexual abuse and
the use of deviant sex as a coping strategy (Marshall & Marshall, 2000). Although appealing,
not least because such a theory implies value in conditioning therapies, evidence that
conditioning plays a role in the etiology of deviant sexual preference (e.g. pedophilia), is weak
(Seto, 2008; Camillari & Quinsey, 2008). Nevertheless, it remains plausible that conditioning
reinforces sexual arousal patterns.

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Social Influences:
A recent American Psychiatric Association Task Force report cited examples of the
sexualization of female children in western culture, including sexualized toys, child beauty
pageants and provocative clothing marketed to children (APA Task Force on the Sexualization
of Girls, 2007). Conversely, society is noted to regard individuals with LD as non-sexual (Di
Giulio, 2003; Richards, Miodrag & Watson, 2006), typically disregarding their sexual behavior
and causing some to suppress sexual expression (Hingsburger, 1992). Griffiths, Fedoroff and
Richards (2009), suggest the effects may possibly alter an individual’s response to instigations
of normative sex, and in some cases prompt a shift to response patterns that appear abnormal.
Offence Supportive Attitudes:
Attitudes supportive of sexual offending, including child sexual abuse attitudes, pro-rape and
sexual entitlement beliefs, are empirically supported risk factors (Helmus, Hanson, Babchishin
& Mann, 2013; Mann et al., 2010). Hostile beliefs towards women as deceitful are a promising
risk factor (Mann et al. 2010). Evidence of association between patriarchy (traditional sex role
ideology) and IPV is weak (Sugarman & Frankel, 1996; Stith et al., 2004). Larger effects sizes
have been found for attitudes that condone violence against women (e.g. Stith et al., 2004).
Violent attitudes are clinically evaluated due to their association with violence generally (e.g.
Douglas, Hart, Webster & Belfrage, 2013).
Antisocial attitudes have been found to predict recidivism in men with LD (Lindsay et al.
2004). Whilst child abuse and rape supportive belief have been shown to discriminate between
offending and non-offending LD groups (e.g. Lindsay, Michie, Whitefield, Martin, Grieve &
Carson, 2006), these have not been found to be associated with convicted status or reoffending
(Green Gray, & Willner, 2002; Heaton & Murphy, 2013). Evidence that problems with

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attitudes are associated with violence in individuals with LD is less substantial than for those
without LD, although has been demonstrated in a UK residential setting (e.g. Lindsay, Murphy,
Smith, Murphy, Edwards Chittock, Grieve & Young, 2004).
Biological influences:
There have been few attempts to establish the biological correlates of pro-offending attitudes.
Ward and Beech (2006) propose that problems in a particular neuropsychological system;
namely the ‘perception and memory system’ associated with hippocampal formation (which
plays a role in emotional memory and learning), and the posterior cortex at the back of the
brain, may cause maladaptive core beliefs.
Psychological Influences:
Beliefs which endorse offending are most likely to develop as a consequence of an individual’s
learning history. The most tangible model of these beliefs is the information processing model,
inclusive of the concept of ‘schema’ (Young, 1990). A schema may be defined as a knowledge
structure, comprising attitudes and beliefs which bias information processing in such a way as
to be self-confirmatory (e.g. Beck, 1964). Since schema are used to organize information about
the world and how to respond to it, those that are maladaptive often arise from childhood
adversity. ‘Hostile masculinity’ has been a focus of understanding male hostility towards
women for over two decades (Malamuth, Heavy & Linz, 1993; Malamuth, Linz, Heavey,
Barnes & Acher, 1995) and may be conceptualized as a distinctive schema (Mann & Shingler,
2006). A ‘hostile world’ schema, specifically a belief system characterizing the world as unsafe
in which vigilance and hostility is considered necessary for survival, is also characteristic in
violence.

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There are numerous observations indicating that many adolescent offenders with LD come
from dysfunctional homes (see Browne & McManus, 2009). Children with low verbal IQ and
from homes characterized by poor parenting, conflict and low income have been shown to be
more likely, several decades after being assessed, to be involved in IPV (Lussier, Farrington &
Moffitt, 2009). According to Lussier et al., (2009), a potential mediator among antisocial
tendency, verbal IQ deficits and subsequent IPV is a social information processing bias.
Social Influences
Socio-cultural norms influence an individual’s attitudes to the extent that they are internalized.
There is substantial cross-cultural evidence of the prevalence of norms condoning sexualized
violence in countries where such behavior is more common (World Health Organization
[WHO], 2009). Patriarchal societies where the position of women is submissive and where
there is support for the systemic dominance of women also show higher rates of female abuse
(WHO, 2005). The social acceptance of violence as a conflict resolution strategy can also
influence youth violence (Champion & Durant, 2001).
Relationships
This risk domain pertains to an individual’s social and emotional functioning. Grievance/anger
and hostility or hostile rumination are synonymous characteristics associated with sexual, IPV
and violent recidivism (Mann et al. 2010; Hanson, Harris, Scott & Helmus, 2007, Norlander &
Eckhardt, 2005; Huesmann, 1998). Antisocial peer association is correlated with general and
sexual recidivism (Andrews & Bonta, 2006; Mann et al., 2010). Antisocial peers have also
been found to predict recidivism in sexual offenders with LD (Lindsay et al. 2004). Anger has
been shown to predict violence in individuals with LD and offending histories (Novaco &

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Taylor, 2004), however there are no predictive studies to confirm (or disconfirm) that
grievance/hostility is a specific risk factor for offenders with LD.
A lack of adult intimacy characterized by the lack of a close, trusting relationship is predictive
of sexual recidivism (Mann et al., 2010), and is similarly described in the IPV literature as
marital discord (Stith et al., 2004; Stith, Green, Smith & Ward, 2008). Low self-esteem is not
strongly correlated with sexual recidivism but may have some criminogenic value (Mann et al.
2010). An emotional congruency with children (referring to an inflated emotional connection)
is associated with recidivism in extrafamilial sexual offenders (McPhail, Hermann & Nunes,
2013). Jealousy, linked to anger and threatening behavior is associated with IPV (Schumacher,
Feldbau-Kohn, Slep & Heym, 2001; Stith et al., 2004). There is no evidence to indicate that
jealousy is any more or less relevant to IPV in perpetrators with LD, nor is there any to indicate
that an emotional congruency with children is any more or less relevant to sexual offenders
with LD. Some authors have found that a lack of intimacy, marital status and self-esteem do
not predict recidivism in samples of LD sexual offenders (Lindsey et al. 2004; Green et al.
2002).
Biological Influences:
Adolescents with certain genetic predispositions may be more likely to select antisocial peers
and be more vulnerable to negative influence (Beaver, Wright & DeLisi, 2008; Boisvert,
Boutwell, Vaske & Newsome, 2013; Harden, Hill, Turkheime & Emery, 2008). Biological
sources for hostility and grievance may be explained in part by the threat response system.
Thornton (2008) for instance, suggests that an aggrieved angry interpersonal style occurs when
adverse childhood environments cause the amygdala to become over-reactive, leading to a
sense of persistent threat. Similarly, Ward and Beech (2006) propose that deficits in the

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‘motivation and emotion system’, associated with the limbic system, particularly the amygdala,
caused by genetic factors and/or childhood adversities, could underlie hostility as well as other
factors in this domain. In antisocial populations, reduced levels of serotonin in the brain may
lower the threshold for perceiving threat and initiating aggression (Siegel & Douard, 2011).
Hypersensitive processing to mildly threatening provocative facial expressions in IPV
perpetrators may also represent a neurobiological predisposition to relationship aggression in
some men (Lee, Chan & Raine, 2008).
Additionally, jealousy is considered to have an evolutionary purpose (Wilson & Daly, 1992)
Because reproduction involves females carrying offspring, males face the problem of investing
resources in children that may be allegedly sired by rival males—an adaptive problem not faced
by females (Buss, 2013). Consequently, male jealousy is thought to be adaptively predisposed
to focus on female infidelity (Buss, 2013).
Psychological Influences
Marshall and Marshall (2010) and Ward, Hudson and Marshall (1996) have provided formative
accounts of how intimacy deficits in sexual offenders result from distorted internal models of
relationships associated with early attachment problems. Similarly, Dutton (1998) proposed
that adult IPV reflects insecure maternal attachment developed during childhood, associated
with abandonment anxiety and anger. We speculate that children with intellectual impairment
may be at increased risk to attachment adversity and the associated effects for two reasons.
Firstly, for these children, a protective factor against associated conduct problems is secure
parental attachment (Carlson & Sroufe, 1995), although unfortunately, parents of children with
intellectual impairments have been shown to display lower positive engagement and more
negative controlling strategies compared to the parents of normally developing children

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(Fenning, Baker, Baker & Crnic, 2007; 2014). Secondly, intellectual competency can be a
protective factor for children facing chronic adversity (Garmezy & Masten, 1994). However,
this is inherently lacking in children with impaired cognitive functioning.
Parental monitoring and parent-adolescent closeness are critical for protecting adolescents
from antisocial peer influence (Dishion, Nelson & Bullock, 2004; Kiesner, Poulin, & Dishion,
2010). However, antisocially prone adolescents can often be the children of antisocial parents,
who expose them to substantial adversity including a chaotic home environment and
substandard childrearing (Jaffee, Belsky, Harrington, Caspi, & Moffitt, 2006; Jaffee, Caspi,
Moffitt, & Taylor, 2004). Finally, grievance and hostility may also be influenced by attachment
problems caused in early threatening environments. Individuals with overactive threat response
systems, and a cognitive style to support the persistent experiences of threat, may develop a
hostile world schema (Thornton, 2008). Hostile world thinking, where others are seen as
malicious and the world as unjust, underpins the grievant interpersonal style.
Social Influences
For adolescents living in deprived neighborhoods, such as those characterized by residential
instability, high crime rates and substandard institutional resources, the accessibility and
elevated status of antisocial peers often includes an increased likelihood of associated
affiliation (see Ingoldsby & Shaw, 2002; Ingoldsby, Shaw, Winslow, Schonberg, Gilliom, &
Criss, 2006). Grievance and hostile rumination may also be socially influenced, for example
where a child observes positively framed revenge displayed by significant others. Additionally,
individuals with hostile rumination are likely to view their social environment as undeservingly
antagonistic. One social outcome is the dismissal of sympathetic individuals and the attraction
of likeminded grievance thinkers, whilst another is a reduced capacity for intimacy. In terms

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of jealousy, a capitalist society which places premiums on possessions is thought to support
partner jealousy through how it extends to encourage possession of others (Bhugra, 1993).
Self-Management:
This domain includes risk factors relevant to lifestyle and self-regulation. Lifestyle impulsivity
is a determinant of general criminality including violent and sexual recidivism (Hanson &
Morton-Bourgon, 2004). Similarly, impulsivity/problems in self-control is associated with IPV
(see Stewart et al. 2013 for a discussion). Impulsivity has not been found to be associated with
reconviction in sexual offenders with LD (Lindsay et al., 2004; Green et al., 2002). Despite
this, some features of lifestyle impulsivity such as a lack purposeful daily routine have been
noted in a significant minority of individuals referred to learning disability services in the UK
(see O'Brien, Carson, Holland, Lindsay, Middleton, Taylor & Wheeler, 2010). Alcohol abuse
is associated with IPV (Stith et al., 2004; Capaldi, Knoble, Shortt, & Kim, 2012), and is an
established correlate of violence (Collins & Schlenger, 1988; Felson & Staff, 2010). This factor
has been found to be predictive of violence in a sample of LD offenders (Fitzgerald et al. 2011).
Emotion management/anger (Norlander & Eckhardt, 2005), similarly termed ‘dysfunctional
coping’ by Mann et al. (2010), is a common predictor of IPV and promising risk factor for
sexual recidivism. Anger has been shown to be associated with violence in men with LD
(Novaco & Taylor, 2004). Finally, poor problem solving skills are predictive of general
recidivism (Hanson et al. 2007) and sexual recidivism (Hanson et al. 2010), with a similar
factor ‘career/life stress’ found to be predictive of IPV (Stith et al., 2004). Components of poor
problem solving have not been found to be predictive of sexual recidivism in LD samples
(Lindsay et al., 2004). Notwithstanding this, aggressive LD individuals have been found to be
poorer problem solvers than non-aggressive LD controls (Basquill, Nezu & Klein, 2004).

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Biological Influences:
Poor self-regulation may be related to executive control functioning (ECF) deficits. ECF refers
to ‘higher order’ processes such as planning, decision making and impulse control. ECF takes
place primarily in the prefrontal cortex at the forefront of the brain. Areas associated with
aggression, particularly impulsive acts, are located in the prefrontal context (Bassarth, 2001).
Reviews of neuroimaging research have revealed significantly reduced structure and function
in prefrontal regions of the brain in antisocial individuals (e.g. Yang & Raine, 2009).
Greater prefrontal deficiency are to be expected in individuals living with LD. Firstly, many
studies demonstrate children with BIF have ECF problems (e.g. Van der Molen, Henry & Van
Luit, 2014; Alloway, 2010; Schuchardt, Gebhardt & Maehler, 2010). Secondly, adults with LD
have been shown to exhibit ECF comparable to that of normally developing children matched
on fluid intelligence (the ability to reason independent of past knowledge) (Nummienen, Lehto
& Ruppila, 2001; Nummienen, Service & Ruppila, 2002). These observations suggest aspects
of poor ECF (e.g. impulsivity) are unlikely to distinguish offenders with LD from non-
offending LD controls, given that these aspects may be normatively characteristic of ECF
deficits associated with LD.
In terms of affective regulation, Davidson, Putnam and Larson (2000) identify a region of the
prefrontal cortex—the orbitofrontal context, as being important in the management of emotion.
The orbitofrontal cortex regulates the amygdala and in turn suppresses emotion‐driven
behavior. Davison and his colleagues propose that damage to these areas inhibits use of non-
violent conflict resolution strategies initiated by higher order brain regions. Indeed, those with
conduct disorder and antisocial personality disorder (conditions characterized by poor affective

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control) as compared to those without, show reductions in the volume of the orbitofrontal
cortex (Raine, Yang, Narr, & Toga, 2011).
Psychological Influences:
Psychological influences on self-regulation may originate from early attachment episodes. The
brain is at its most malleable during infancy, where the primary caregiver performs as a co-
regulator for the infant’s undeveloped nervous system (Schore, 2009). Because the prefrontal
areas of the brain are in a critical period of development during infancy, and since these
structures are involved in coping throughout life, early interpersonal stress-inducing and stress-
regulating events have lasting consequences. A secure, synchronized infant-parent relationship
influences development of a central nervous system that provides the bases for future adaptive
states (Siegel 1999). Deprived, abusive and inconsistent parent-child relationships direct the
attachment system along a different trajectory. Such toxic interactions expose the development
of the child either by triggering and/or not repairing dysregulated states. The most substantial
consequence is the child’s failure to develop a capacity for self-regulation. The extent to which
dysregulated states endure, determines the significance of associated biochemical imprinting
on the malleable brain architecture and the degree to which they evolve into stable personality
traits.
Social Influences:
Association with antisocial peers seems to weaken self-regulatory control, as does emotional
isolation from peers (Calkins & Keane, 2009). This is likely to be due the fact that although
individuals vary in levels of trait self-control, self-control is also state dependent (Galliot &
Baumesiter, 2007). The impact of alcohol consumption is also likely to be culturally

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influenced. For instance, violent homicide rates are influenced by alcohol sales and more so in
European countries where drinking culture is characterized by heavy drinking (Rossow, 2001).
Biopsychosocial Informed Programs for High Risk Service Users
Below we report on implementing stage two of Mann and Carter’s biopsychosocial model of
change with two clinically aligned programs for high risk service users with convictions for
violence, IPV or sexual offending; namely Kaizen, designed for services users without LD, and
Becoming New Me+ (BNM+), developed for individuals with BIF and mild LD. The first two
principles mirror the risk and responsivity principles from the RNR framework. The following
three principles separate the need principle into three components, reflecting how a
biopsychosocial explanation of the abovementioned dynamic risk factors reflects a necessity
to strengthen participants’ biological, psychological and social resources for change. Finally,
the sixth principle concerns the need to strengthen processes involved in crime desistance.
Organizing Principle 1: The program approach should be designed and delivered in a
way that is proportionate to the risk of each participant.
Adequate intervention dose for high risk individuals with acute criminogenic needs prevalent
across multiple risk domains is considered to be 200 to 300 hours of combined intensive
programming and supervision (Hanson, Bourgon, McGrath, Kroner, D’Amora, Thomas,
Tavarez, 2017). A broadly applicable cognitive-behavioral core syllabus, in combination with
optional clinical content in both programs allows for versatile targeting of the range of dynamic
risk factors outlined above. Split over main group and individual or small group delivery,

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Kaizen, on average offers approximately 160 hours, and BNM+ offers approximately 176
hours. Both programs have the flexibility to amend this dose in response to variations in
individual need profiles.
Organizing Principle 2: Treatment will be delivered in a way that makes it accessible and
appealing to participants whatever their biological, psychological, and social
circumstances.
Biological, psychological and social vulnerabilities to offending influence an individual’s
responsiveness to programs. Given that neurodevelopmental adversity can increase an
individual’s vulnerability to offending in the first place, it is unsurprising that the prevalence
of complex trauma and traumatic brain injury (TBI) as well as specific neurodisability in the
UK CJS is high (e.g. Hughes, Williams, Chitsabesan, Davies & Mounce, 2012). Kaizen and
BNM+ have been developed with attention towards maximizing opportunities for success,
whilst moderating neuro-processing obstacles (Creedon, 2004) such as language deficits, poor
ECF and hypersensitivity to threat.
Multimodal Learning
In order to ameliorate language deficits, Kaizen and BNM+ include dynamic methods which
can be delivered in a variety of multi-modal ways, widely recognized as visual, auditory and
kinesthetic (VAK). In short, visual methods include drawing information such as thoughts,
behavior and situations, showing what is meant or using images to express concepts. Auditory
learning includes use of sound and voice such as asking questions, giving tangible examples
and varying one’s tone. Changes to pace and tempo, story-telling, humor and music are also
relevant. Kinesthetic methods include active learning methods using social modelling,

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gestures, making collages, playing games and using physical movement. ‘In-action’ techniques
and skills practice are the most essential aspects of kinesthetic learning. Combining VAK
modes for learning is key to the brain-friendly approach (Carter, Williams & Mann, 2012), not
only in appealing to different learning preferences, but in helping individuals feel more
connected to tasks and understood by others.
Supportive Authority
Hypersensitivity to threat is characteristic of many chronically antisocial individuals. When
presented with rehabilitative opportunities, this may manifest as a resistance to perceived
authority. Pressuring these individuals to undertake programs usually leads to confrontation in
an effort to undermine the perceived threat to one’s autonomy (Harris, Attrill & Bush, 2004).
Successful engagement is more likely to involve harnessing one’s desire for autonomy by
promoting choice and provoking curiosity about change. To this end, Kaizen and BNM+ are
grounded in the concept of supportive authority (Bush, Harris & Parker, 2016). The basic
principle of supportive authority is that rules are the conditions under which groups are able to
work towards achieving mutual goals. This is applied using the ‘conditions for success’ which
establish parameters for engagement. Participants have the right to make a choice as to whether
to accept the conditions and be coached in achieving them, or not to accept them and not
participate in the program. Whilst free to choose not to abide by the conditions, they cannot at
the same time choose to continue participating. Therefore, the participant’s motivation to direct
their own life pervades supportive authority, with the role of staff being to non-judgmentally
implement the consequences attached to their choice. This underpins a key ethos of Kaizen and
BNM+ in that the programs do not aim to change participants; rather, they provide a choice to

21
learn skills for change. In essence, Kaizen and BNM+ challenge participants to recognize their
engagement as an opportunity to enhance capacity for choice and autonomy.
If misconstrued, routine behaviors common in those living with LD, such as expressions of
frustration and impulsive verbal violations, may be regarded as an active choice to disregard
the agreed conditions. Therefore, specific responsivity issues in relation to the conditions for
success form an important part of staff training.
Organizing principle 3: In addressing criminogenic need, treatment will strengthen
biological resources such as neurocognitive functioning
The plasticity of the brain allows for the formation of new connections and neural rebuilding.
This is particularly important in response to traumatic brain injury. An increasing emphasis on
trauma prevalence rates in the UK CJS, has stimulated direction towards neurobiologically
informed programs (Williams & Carter, in press). Broadly, a neurobiologically informed
program recognizes that whilst neurodevelopmental adversity can increase vulnerabilities to
offending, methods designed to strengthen and create neural connections within the brain can
reduce vulnerabilities through supporting acquisition of new learning. Responsivity to brain
trauma and efforts to strengthen neurocognitive functions has therefore been at the forefront in
the design of Kaizen and BNM+. Mann and Carter (2012) have offered an account of
techniques that attend to this principle. Three key neurobiological responsive techniques are
outlined below:

22
Executive Control Functioning and the Great Eight Tactics.
Prefrontal lobe deficiencies often lead to difficulties with ECF such as planning, decision
making, inhibition of impulse and emotional regulation. Kaizen and BNM+ introduce
participants to a toolbox of tactics called the “Great Eight” which help individuals improve
ECF and thereby strengthen potential for success. The tactics are learnt vicariously and directly,
then rehearsed through coached skills practice and self-monitoring of real life situations. The
figure below depicts the Great Eight tactics which represent skills for strengthening a ‘New
Me’ identity such as consequential thinking (what happens to me), perspective taking (their
shoes) and perseverance (sticking at it).
Figure 2: The Great Eight tactics
Mindfulness Here and Now
Mindfulness involves the process of bringing ones attention to an experience in the present
moment with intention, purpose and without judgment. Emphasis is placed on accepting things

23
as they are with curiosity rather than trying to change them. Several studies have shown that
mindfulness can alter levels of activity in the prefrontal cortex and limbic structures of the brain
involved in emotion such as the amygdala (e.g. Chiesa & Serretti, 2010; Hölzel Carmody,
Vangel, Congleton, Yerramsetti, Gard & Lazar, 2011). Singh and colleagues in particular have
documented a body of preliminary outcomes indicating the potential merits of mindful
observation for individuals with LD in reducing aggression (Singh, Lancioni, Winton, Adkins,
Wahler, Sabaawi, & Singh, 2007; Singh, Lancioni, Winton, Adkins, Singh & Singh, 2007;
Singh, Lancioni, Winton, Singh, Adkins, & Singh, 2008), and in increasing control over
unhealthy sexual thoughts (Singh, Lancioni, Winton, Singh, Adkins, & Singh, 2010). At
present, although feasible and effective in correctional settings (see Shonin, Van Gordon, Slade
& Griffiths, 2013), the therapy remains largely experimental in this use.
The Great Eight tactics incorporate a mindfulness informed technique called ‘Here and Now’.
This technique teaches participants about being in touch with the present moment, being non-
judgmental and being open to experiences. Here and Now is taught through mindful breathing
or more simple observation before moving to acceptance of aggressive, distressing or other
risky thoughts and feelings.
Observation and Repetition through Self-monitoring
At a neurobiological level, persistent antisocial behavior will reflect robust neural pathways.
These continually strengthen as the patterns of associated functioning are maintained, therefore
perpetuating what we conceptualize as ‘Old Me’ behavior. If new skills are to serve as practical
alternatives, then the neural connections which underpin them must be strengthened through
rehearsal so they too become robust, and the skills are in effect familiar through experience.

24
Kaizen and BNM+ support the repetition and rehearsal of skills with use of self-monitoring,
vicarious learning and skills practice techniques.
Problem Solving Training
Self-control is likely to be difficult for those with ECF deficits owing to the nature of the
symptoms impeding inhibition of impulse behavior. Ross and Hoaken (2010), provide
guidance for optimizing the impact of structured step-based problem solving strategies for
those with prefrontal deficiencies. Problem solving training for participants with LD, with
emphasis on practical rather than verbal exercises, has also been shown to improve pre- and
post-test positive problem solving and reduce self-report impulsivity (Lindsay, Hamilton,
Moulton, Scott, Doyle & McMurran, 2011). Kaizen and BNM+ teach a short structured
problem solving strategy.
Organizing principle 4: In addressing criminogenic need, treatment will strengthen
psychological resources, such as cognitive and emotional flexibility and empathic relating.
Mann and Carter propose that programs can strengthen psychological resources thorough
specific program content and through therapeutic process. Content should be directed towards
strengthening healthy forms of psychological functioning, such as adaptive beliefs and social
and emotional functions enabling healthier relationships. Therapeutic process should offer a
safe, compassionate environment for cognitive and emotional connection with these processes,
including self-discovery and self-reflection. Outlined below are methods aimed at
strengthening psychological resources.

25
Personal Rules
Constrictive, hostile schema cause unhelpful interpretations of the world and inherently reduce
scope for psychological health. We have used the term ‘personal rule’ (‘my rules’ in BNM+)
as a more accessible term to support understanding about schema. Consistent with a cognitive
therapy approach to schema modification (Padesky, 1994), personal rules are conceptualized
as hypotheses to be tested, rather than absolute truths. Use of a life map provides the basis for
self-discovery of unhelpful beliefs and related behavior, those being the qualities of ‘Old Me’,
as well as more flexible and adaptive ‘New Me’ thinking. The option of kinesthetic
engagement, means that participants are able to ‘zoom in’ on life events specific to the
development and reinforcement of personal rules using in-action techniques. The value of the
life map spans beyond recognition of personal rules. It allows participants to look at other life
patterns such as those involving coping, sexual interests, substance use and relationships.
In Kaizen personal rules are subject to evaluation through a number of cognitive re-appraisal
techniques such as assessment of consequences or consideration of opposing evidence. BNM+
enables participants with LD to examine unhelpful “my rules” through more straightforward
practical tasks. Crucially, in both Kaizen and BNM+, reappraisal results in the scope for the
strengthening of alternative, less ridged and more benign beliefs. These represent ‘New Me
personal rules’ which are put to the test within the programs and beyond to establish their
credibility in meeting personally valued goals – status, family, relationships etc. We view this
activity as consistent with the appeal to work with schema rather than surface-level cognitive
distortions (e.g. Maruna & Mann, 2006).

26
Emotional Management
Emotional dysregulation is evidenced in current behavior and life map patterns and is targeted
through emotional awareness work enabling participants to identify bodily sensations, thoughts
and labels for feelings as well as the impact of emotional arousal on behavior. Techniques for
strengthening emotional wellbeing include a broad range of coachable self-help skills including
Here and Now, urge management and self-talk. Consistent with the cognitive therapy method,
neither emotional states nor skills to manage them are explored in the absence of reflecting on
the situation, thinking and related personal rule(s). Participants who access Kaizen are
encouraged to identify interacting thoughts, arousal, feelings and behavior with use of their
self-monitoring learning log, considering which aspects reflect Old Me and New Me. BMN+
encourages simpler reflections with use of pictures and symbols.
Therapeutic Climate
Mann and Carter propose that psychological functioning can be strengthened by generating
parallel emotional and cognitive activation, enabling learning at the schema level. For many
hypervigilant and hostile men however, expressions of one’s feelings, especially those
signifying vulnerability, encroaches on the over-compensatory strategies of managing external
threat and portraying a tough exterior. Experience tells us that therapeutic alliance with these
individuals, must occur gradually if it is to enable the foundations on which to strengthen
psychological resources such as perspective taking, empathizing and managing distress. For
many participants, Kaizen and BNM+ may represent the first time others have shown them
genuine compassion and acceptance. Therefore, because these are largely unfamiliar actions of
others, any change in behavior or routine, such as the absence of another person, or late start
to a session, may activate suspicion orientated personal rules and threat response behaviors. It

27
is in working with these live situations that some of the most influential events in reappraising
personal rules can occur. In all cases, consistent displays of compassion, curiosity, validation
and flexibility on part of program staff are likely to be of benefit.
Organizing principle 5: Treatment will strengthen social resources such as social capital.
According to Mann and Carter, two concepts are central to strengthening social resources:
‘citizenship’ (enabling individuals with the knowledge and skills to engage fully with society)
and ‘social capital’ (the amount of social resources that a person has to draw on for emotional,
psychological and social support). Kaizen and BNM+ aim to strengthen social resources in a
number of ways.
Interpersonal Skills
Many individuals accessing interventions are likely to present with limited interpersonal skills.
Such is their historic and perpetuating adversity, that they may rely on hostile strategies to
resolve conflict. There is a need not only to recognize that these strategies have served valued
goals (e.g. status, security), but that there are other ways of achieving those goals. To this end,
Kaizen and BNM+ provide participants with alternate options through skills based learning of
assertiveness, conflict resolution skills, asking for help, negotiation and active listening. The
programs offer continuous opportunity for practice and refinement, and are inclusive of broad
scope to reinforce, rehearse and determine the credibility of new learning.

28
Social Support Networks
Imprisonment results in the restriction of external relationships, both criminal and pro-social.
Implicit in this consequence is the issue of social capital that is capable of reinforcing antisocial
characteristics and/or strengthening protective capacities. Participants are of course free to
shape their own social lives, however Kaizen and BNM+ attempt to cast a wide net in terms of
connecting or reconnecting participants with sufficient social support to ensure change is a
realistic option. In all cases, safeguarding measures for family and partners who are victims are
balanced with attempts to involve significant others in a post-program review that celebrates
success. BNM+ involves three one-to-one sessions in which a personal support champion is
invited to participate as a way to strengthen available support for the participant. Kaizen
promotes peer mentoring throughout its delivery by maximizing opportunities for more
experienced participants to support and coach those newer to the group. Both programs guide
participant’s attention to their current and future support networks in terms of the necessary
social capital that will empower New Me life plans.
Organizing principle 6: Treatment will strengthen the intention to desist from offending.
Mann and Carter (2012) base this principle on the theory of reasoned action (TRA) (Fishbein
& Ajzen, 2010) as a framework for guiding motivation to desist from crime. In short, the theory
suggests that behavioral intention is predictable based on one’s attitude towards a particular
behavior (behavioral beliefs), the extent to which the behavior is considered to be within one’s
control (self-efficacy) and what is considered to be the view of others toward the behavior
(normative beliefs). Kaizen and BNM+ have been designed to equip skills for change, thereby
supporting self-belief in change and motivation for change. This is underpinned by
motivational interviewing techniques (Miller & Rollnick, 2002), which enable participants to

29
develop self-efficacy through their evaluation of personal goals and behaviors. Three further
methods are relevant to this principle.
Pro-social Identity
The process of desistance involves separation from a criminally orientated lifestyle, with efforts
to live a purposeful, offence free life; essentially creating a pro-social identity (Maruna, 2001).
Previously, denial was thought to impede potential for a reformed self, since this was lacking
in the personal responsibility considered necessary for individuals to benefit from intervention
(Salter, 1988). However, confessional approaches, namely that of pursuing ‘passive
responsibility’ for one’s past offending (e.g. “I did it”), have more recently been considered
restrictive, especially of efforts toward self-led transformation (Maruna & Mann, 2006; Ware
& Mann, 2012). ‘Active responsibility’ on the other hand is future-focused, reflecting an
individual’s attempts to make good. This process is not necessarily obstructed by denial or
minimization, in fact can be assisted by them (Maruna, 2001; Farmer, McAlinden & Maruna,
2015), and is compatible with pursuits towards a reformed identity. To this end, Kaizen and
BNM+ are accessible to men in denial. Focus is placed on developing ‘active responsibility’
by enhancing autonomy through equipping skills for change rather than perusing confessions
for previous crime.
Both Kaizen and BNM+ support participants in creating pro-social identities through setting
goals, and recognizing the value in building upon existing key strengths and successes. The
strengths-based concept of ‘Old Me/New Me’ (Haaven, 2006) is used to support this process.
In both programs, Old Me and New Me are conceptualized as competing in a ‘tug of war’,
reflecting continuous co-existing capacities for desistance and offending. In particular, the
strengthening of New Me can be equated with a strengthening of a new self-identity which

30
empowers the individual with increased autonomy and choice in how to define and achieve
their goals, and promotes recognition of what is important to them; ‘New Me values’. Examples
include, “I am a kind person”, “I stick at things when the going gets tough” and “I work hard
to provide for my family”.
We have also implemented a tool called the ‘Success Wheel’ to enhance promotion of existing
skills and possibilities for change in this process. Where the four risk domains outlined above
are the focus in Kaizen and BNM+, the success wheel helps to reconfigure these in ways that
correspond to topics of existing key strengths and opportunity for growth towards goals for
better living. For example, the cognition domain, ‘Offence Supportive Attitudes’ becomes
‘Healthy Thinking’ (see fig. 3). ‘Old Me’ characteristics (e.g. hostile personal rules) are
conceptualized as destabilizing the success wheel, whereas New Me is able to bring about
balance in life, for example using more flexible personal rules likely to enable interpersonal
success. Participants are encouraged to set approach-focused goals, and to strengthen New Me
values in relation to all relevant segments of the success wheel. Through self-discovery of their
existing New Me strengths and areas for development (e.g. jealousy, anger control, intimacy
problems), participants are able to gain an awareness of pre-existing foundations on which
skills towards those goals and values can be developed through the programs and beyond.

31
Figure 3. The Success Wheel
Purpose Goals
Participants are supported to set goals in relation to three established influences on desistance,
comprised in the ‘sense of purpose’ domain of the success wheel. As discussed above, Kaizen
and BNM+ aim to promote desistance identity by introducing choice, improving self-efficacy
and enriching conditions for agency through strengthening New Me. This is aligned with core
conditions for change predicted by TRA; namely, promoting positive attitude and improving
self-efficacy.
The second factor, citizenship refers to the desire for legitimate community partnership,
including pro-social constructive relationships. Skills for strengthening pro-social networks are
connected to principle five. Success in this area promotes social inclusion and normative beliefs
inconsistent with crime. Supportive authority naturally promotes agency and self-responsibility
Positive
relationships
The Success Wheel
Healthy
sexual
interests
Managing
life's
problems
Sense Of
Purpose
Healthy
thinking
Positive
relationships
The Success Wheel
Healthy
sexual
interests
Managing
life's
problems
Sense Of
Purpose
Healthy
thinking

32
linked to choice and consequence, enhancing relationships with perceived authority including
societal rules. The third factor is Employment, or more precisely a stable purposeful routine
(Uggen & Staff, 2001). Once participants have set their New Me goals, they are supported
during the programs in working towards them though skills practice, real life try outs and
associated self-monitoring. Beyond this, they have further opportunity to access support
through ‘New Me MOT’ and Living as New Me (LNM), see below.
Engaging Support: Building Capability Beyond the Group
Successful long-term desistance may be gradual. It is likely to depend on society’s investment
in an individual’s social reintegration and reconciliation with communities, family and friends
(McAlinden, 2016). Access to post-program support that helps individuals refine their goals as
they strengthen a sense of agency and self-efficacy through implementing skills for change is
central to this task. Both Kaizen and BNM+ have embraced the value of after-program support,
and HMPPS offender management services attended to this in a number of ways. The ‘New
Me MOT’ facilitates Kaizen and BNM+ graduates’ ongoing commitment to their New Me life
plans, particularly during transitional periods which may be challenging for New Me (e.g.
custodial transfers). New Me MOT is participant led and embedded within HMPPS offender
management model, delivered by custodial or probation staff. It elongates program dose where
needed and supports participants in continuing to monitor and refine their values, goals and
skills towards a better life and New Me identity
LNM has been designed as a more structured group based service which supports graduates
from BNM+ in continuing to practice their New Me skills. The program can be delivered at
any point following completion of BNM+, and participants have the option of accessing the
program on a flexible basis as their lives and needs direct.

33
Close:
Kaizen and BNM+ are grounded in a biopsychosocial model of change and are inherently New
Me orientated, as well as strengths-focused and skills-based. Both programs have been awarded
full accredited status by the Correctional Service Accreditation and Advice Panel (CSAAP)
and will soon undergo phased implementation in HMPPS. The programs are state-of-the-art
interventions, yet are presently untested. As such HMPPS’ next steps include process
monitoring prior to an outcome evaluation that adheres to high standards of scientific rigor.
Those convicted of severe crime as well as the communities accommodating their reintegration
are wholly deserving of high quality services, and we believe Kaizen and BNM+ may have the
potential to contribute to effective rehabilitation. Unfortunate though it may be, it is a fact that
many individuals accessing these programs have endured harsh conditions and
neurodevelopmental adversities which render a life without crime very difficult. Despite their
misfortune, they like all of us, have many strengths, talents and ambitions. Kaizen and BNM+
not only celebrate the existing key assets individuals possess within, but offer opportunities for
successful self-discovery of such assets, as well as personal growth in representing a New Me
identity. We recognize that success in operationalizing this offer relies upon the skills and
attitudes of the program staff. Therefore, staff selection and training is at the heart of successful
delivery of these programs.
Finally, it should be acknowledged that there are a number of routes through which individuals
can progress towards desistance. It is our belief that rehabilitative programs should be
recognized as a route for provoking curiosity and equipping people with skills for change,
rather than being responsible for causing change. Individuals are empowered to choose to
access Kaizen or BNM+, and if electing to do so, can expect to discover their intrinsic strengths
and develop new skills towards enhancing self-efficacy and autonomy. In doing so, they confer

34
themselves a greater sense of choice to create and capitalize on desistance opportunities. This
goes hand-in-hand with society offering such opportunities as a basic standard of helping some
of our most vulnerable members find their way back.

35
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