Acceptance and Commitment Therapy for Incarcerated Males:

A Retrospective Study

Leticia Armstrong

A Dissertation Submitted to the Faculty of

The Chicago School of Professional Psychology
In Partial Fulfillment of the Requirements
For the Degree of Doctor of Psychology

July 13, 2012

 UMI Number: 3557813

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ii
 Acceptance and Commitment Therapy for Incarcerated Males:
A Retrospective Study

A Dissertation Submitted to the Faculty of

The Chicago School of Professional Psychology
In Partial Fulfillment of the Requirements
For the Degree of Doctor of Psychology

Leticia Armstrong

2013

Approved By:

Sandra Georgescu, PsyD, Chairperson

Associate Professor, The Chicago School of Professional Psychology

Ken Fogel, PsyD, Member

Associate Professor, The Chicago School of Professional Psychology

Kenneth Heinrichs, PsyD, Member

Psychologist–Licensed, Wisconsin Department of Corrections

iii
 Acknowledgements

Sincere thanks to Dr. Sandra Georgescu, for her unwavering encouragement,

support, and patience throughout this work. And to Dr. Ken Fogel, whom I have known

since the very first day of this journey: Thank you for seeing me through the final hoop of

fire.

I want to thank Dr. Kenneth Heinrichs for lending his time and support

throughout this project. I appreciate you encouraging me to “run” with my ideas and for

reminding me to “smile, breathe, and go slowly.” Also, thank you to the Wisconsin

Department of Corrections for opening your doors to this research project.

Thank you to my parents for your faith in me from such a young age. I am forever

grateful to my sisters, Sarah and Angela, for your unconditional love and friendship, and

for being present at every important and unimportant moment; “I carry your heart in my

heart.” Thank you to The Grandma for making this academic journey a little easier on a

mother; no one could have cared for my angel more sweetly during this time. Thank you

to my partner and love, Dustin, for understanding me, supporting me, and for your

flexibility. And to Jamie Fickert, my dear friend, thank you for walking beside me and for

riding the wave of emotions with me when we were literally and metaphorically lost. You

are a forever friend whom I truly cherish.

Most importantly, to my greatest accomplishment, my “Lil Red,” thank you for

being so very patient while mommy completed this journey, for teaching me the beauty

of being in the present moment, and for showing me what is truly meaningful in life.

Your face will always be my sweet spot.

iv
 Abstract

Acceptance and Commitment Therapy for Incarcerated Males:

A Retrospective Study

Leticia Armstrong

Since the 1960s, the number of inmates has steadily increased in the United

States. Limited resources have resulted in relatively few programs available for inmates

to address rehabilitative or treatment needs. Currently, Cognitive Behavioral Therapy

(CBT) appears to be the most utilized form of treatment in corrections, particularly for

areas such as substance abuse and problematic anger. CBT attempts to facilitate a change

or reduction in faulty thinking, thus affecting criminal behavior patterns. Newer research

on the paradoxical effects of thought suppression encourages the use of interventions that

do not focus on the control of cognitions. This study examined the effectiveness of

Acceptance and Commitment Therapy (ACT), a new and promising contextual CBT

approach to treatment that integrates acceptance and mindfulness strategies. The archived

pre- and post- measures from a pilot ACT program offered to inmates were analyzed and

included an assessment of acceptance and psychological flexibility (AAQ-2), anger-

related behavior (ACQ), and thought suppression (WBSI). While the small sample size

likely contributed to the lack of significant results (p = .255, .666, & .818), the study

highlights the potential of ACT in regards to the treatment of problematic anger-related

behavior and with inmate populations.

v
 Table of Contents

Copyright ............................................................................................................................ ii

Signature Page ................................................................................................................... iii

Acknowledgements ............................................................................................................ iv

Abstract ............................................................................................................................... v

List of Tables…………………………………………………………………………..…ix

List of Figures…………………………………………………………………………….x

Chapter 1: Introduction ....................................................................................................... 1

Chapter 2: Literature Review .............................................................................................. 7

Rising Numbers of Prisoners: The Need for Treatment in Corrections ................. 7

Historical factors ......................................................................................... 7

Mentally ill inmates .................................................................................. 10

Treatment of Offender Populations in Context..................................................... 12

Correctional psychologists ........................................................................ 12

Correctional programs and outcomes ....................................................... 13

CBT in corrections .................................................................................... 19

CBT Limitations ................................................................................................... 31

Thought control ......................................................................................... 32

Experiential avoidance .............................................................................. 33

Acceptance and Commitment Therapy Targets Experiential Avoidance ............. 37

vi
 ACT philosophy ........................................................................................ 37

ACT theory ............................................................................................... 38

Six core processes of ACT ........................................................................ 41

Effectiveness of ACT ................................................................................ 49

Present Study ........................................................................................................ 50

Research Questions and Hypothesis ..................................................................... 52

Hypothesis 1.............................................................................................. 52

Hypothesis 2.............................................................................................. 52

Hypothesis 3.............................................................................................. 53

Chapter 3: Research Design and Methodology ................................................................ 54

Research Design ................................................................................................... 54

Main study variables ................................................................................. 54

Participants ................................................................................................ 54

Measures ................................................................................................... 55

Procedure .............................................................................................................. 57

Intervention ............................................................................................... 58

Statistical Procedures ............................................................................................ 58

Chapter 4: Findings ........................................................................................................... 59

Descriptive Statistics............................................................................................. 60

Analysis ................................................................................................................ 61

Test of hypothesis 1 .................................................................................. 61

Test of hypothesis 2 .................................................................................. 62

vii
 Test of hypothesis 3 .................................................................................. 63

Chapter 5: Discussion and Recommendations.................................................................. 65

References ......................................................................................................................... 80

Appendix A: Letter of Support from WI DOC ............................................................... 107

Appendix B: Act Intervention: Session Outline and Sessions ........................................ 108

viii
 List of Tables

Table 4.1: Participant Characteristics……………………………………………….….60

Table 4.2: Level of Psychological Flexibility/Acceptance………………………….……61

Table 4.3: T-test for ACT Group Effects Over Level of Psychological
Flexibility/Acceptance Level……………………………………………………..62

Table 4.4: Level of Thought Suppression……………………………………...…………62

Table 4.5: T-test for ACT Group Effects Over Level of Thought Suppression…………..63

Table 4.6: Frequency of Maladaptive Anger-Related Behavior…………………………63

Table 4.7: T-test for ACT Group Effects Over Frequency of Maladaptive
Anger-Related Behavior………………………………………………………….64

ix
 List of Figures

Figure 1: Six Core Processes of ACT That Represent Psychological Inflexibility………47

Figure 2: Six Core Processes of ACT That Represent Psychological Flexibility………..48

Figure 3: Procedures of the Study………………………………………………………..59

x
 Chapter 1: Introduction

Over the last two decades, the United States (U.S.) has witnessed a drastic

increase in prison population rates, including a rise in the number of mentally ill inmates

(Beck, 2000; Bureau of Justice Statistics, 2009; James & Glaze, 2006; West, Sabol, &

Greenman, 2010). The Bureau of Justice Statistics (BJS) reported that the United States

currently has the highest jail and prison populations in the history of the nation (The

Sentencing Project, 2010). The number of inmates with mental illness and substance

abuse problems has increased over the years presenting a challenge to correctional staff

who remain generally untrained in the treatment and management of symptoms of

mentally ill individuals.

Compared with the general public, correctional populations (e.g., jails and

prisons) continue to report higher rates of mental health disorders, substance abuse

disorders, and comorbid substance abuse and mental health disorders among inmates

(Diamond, Wang, Holzer, Thomas, & des Cruser, 2001; Fazel, Bains, & Doll, 2006;

Veysey & Bichler-Robertson, 2002). As high as 50% of this population have mental

health symptoms (James & Glaze, 2006); nearly 50% have a substance abuse disorder

(Baillargeon et al., 2009; Mumola & Karberg, 2006; Peters, Greenbaum, Edens, Carter,

& Ortiz, 1998); and an estimated 3–11% of inmates have both a mental health disorder

and substance abuse disorder (Baillargeon et al., 2009; Peters & Hills, 1993). Jails and

prisons in the U.S. appear to have replaced the psychiatric hospitals and larger

institutions that once housed and treated a large number of the mentally ill individuals.

Given this shift, treatment for mental illness, substance abuse disorders, and other

1
problematic behaviors has been integrated into the corrections setting and has become an

essential part in the effort to decrease the correctional populations and recidivism rates.

Across all offender programs and services in general, treatment effectiveness

studies show variable results depending on the program goals or outcome criteria (e.g.,

recidivism rates or improved psychological symptoms, reduced behavioral infractions, or

reduced self-report of substance use or anger; Bourgon & Armstrong, 2005; French &

Gendreau, 2006; Inciardi, Martin, & Surratt, 2001; Knight, Simpson, & Hiller, 1999;

Lipsey, Chapman, & Landenberger, 2001; McGuire, 2002; Pearson, Lipton, Cleland, &

Yee, 2002; Ronan, Gerhart, Dollard, & Maurelli, 2010). There remains a lack of uniform

effectiveness among programs with regard to responding to individual offenders’ needs,

and in reducing recidivism and substance abuse relapse rates as offenders undergo

reintegration into society (Hollenhorst, 1998; Lipsey et al., 2001; Pearson et al., 2002).

Further confounding this issue are the various measures of success which makes

comparison across programs difficult. Overall, recidivism has been viewed as the most

compelling outcome measure of offender programs (Almquist & Dodd, 2009; Lipsey,

1992; Milkman & Wanberg, 2007; Pearson et al., 2002); however, reduced recidivism

may be a costly and lofty goal of mental health interventions and is not necessarily the

immediate or long-term outcome goal such interventions are designed to target.

Currently, most programming and research on programming is provided for the general

offender, with goals of reducing criminal thinking patterns and criminal behavior (i.e.,

recidivism). Although some recent research and meta-analyses have demonstrated some

positive effects with prison-based treatment for mentally ill offenders on criminal

2
involvement, recidivism, and psychological symptom reduction (Martin, Dorken,

Wamboldt, & Wootten, 2012; Morgan, Flora, Kroner, Mills, Varghese, & Steffan, 2012;

Rothbard, Wald, Zubritsky, Jauette, & Chhatre, 2009), there remains a lack of published

research regarding whether or not improved mental health outcomes lead to improved

recidivism outcomes (Douglas & Skeem, 2005). In other words, decreases in mental

health symptoms do not necessarily predict re-arrest rates or future criminal behavior

(Case, Steadman, Dupuis, & Morris, 2009). Still, recidivism continues to be the highest

valued measure of success for offender programs.

With the growing amount of empirical support for treatment and program services

in corrections, increased funding has been provided for evidenced-based treatment

approaches in corrections particularly for those treatment modalities found most

effective, namely Cognitive Behavioral Therapy (CBT; Hollenhorst, 1998; Lipsey et al.,

2001; Pearson et al., 2002). Currently, Cognitive Behavioral Therapy (CBT) appears to

be the most widely utilized and effective treatment for general offender populations, and

it has produced strong positive outcomes with respect to reduced recidivism and

substance abuse relapse (Andrews & Bonta, 2006; Bewley & Morgan, 2011; Gendreau &

Andrews, 1990; Hollin, 2004). Overall, CBT outcomes for general offender populations

seem to be positive, although mixed regarding the level of effectiveness.

CBT is empirically supported as an effective treatment for an assortment of

mental health and behavioral problems such as substance abuse, anger, and depression

(Nathan & Gorman, 2002). In light of the typical offender’s presenting problems (e.g.,

lack of impulse control, failure to plan ahead and thoughts that lead to criminal

3
behaviors), CBT helps offenders improve their impulse control, increase tolerance and

manage/correct negative thought and/or “criminal thinking” patterns. CBT approaches

promote change by helping individuals restructure cognitions and increase interpersonal

and social skills (Clark, 2011; Lipsey et al., 2001; Milkman & Wanberg, 2007).

While the positive benefits of CBT are well known and accepted in the field of

psychology, more recent research on the mechanisms of change failed to demonstrate that

the cognitive work, which is at the core of CBT conceptualization, had an additive effect

on treatment outcomes for depressed patients (Dimidjian et al., 2006). Further, research

has questioned the role of cognitions as the mediating variable in treatment (Zettle &

Hayes, 1987; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Reproduction and

adaptation of evidence-based treatments for various problems and populations (e.g.,

applying effective treatments to inmate populations) requires knowledge of the pertinent

components that are necessary for therapeutic change to occur (Kazdin, 2011). In

addition to the lack of evidence supporting cognitive work as a mechanism of change in

CBT, a closer look at the evidence on thought suppression, control and distraction

(commonplace among interventions in traditional CBT packages) seems to indicate that

while these cognitive strategies may be beneficial in the short-term, they can become

counterproductive and have a rebound effect in the longer term (Clark, Ball, & Pape,

1991; Gold & Wegner, 1995; Wegner, 1989, 1992, 1994; Wegner, Schneider, Carter, &

White, 1987; Wegner, Schneider, Knutson, & McMahon, 1991). These are important

aspects to consider when generalizing CBT treatment to inmate populations.

4
 In light of the above research, it may be advantageous to utilize additional

empirically supported Contextual Cognitive Behavioral Therapies (CCBT) which have

shown positive outcomes for a variety of psychological problems (Hayes et al., 2006;

Hayes, Levin, Plumb, Boulanger, & Pistorello, in press) and for a range of ethnic groups,

social classes, and problem severity. Acceptance and Commitment Therapy (ACT),

offers a radically different approach to psychological suffering and related problematic

behaviors, such as anger and substance abuse (Hayes et al., 2006; Hayes, Wilson,

Gifford, Follette, & Strosahl, 1996; Hayes, Strosahl, & Wilson, 2012; Wilson & Byrd,

2004). There has also been some indication of a trend in which effects of treatment seem

to grow beyond post-intervention assessments (Hayes et al., 2006).

ACT targets rigid and inflexible psychological (cognitive and emotional) and

behavioral repertoires often elicited in response to one’s aversive private experience

(Hayes et al., 2012). More broadly, ACT targets experiential avoidance, or the tendency

to change or avoid one’s unpleasant internal experience, including thoughts, feelings,

physiological sensations, or memories as a functional class (i.e., a group of

behaviors/responses that share the same function; Hayes et al., 1996). ACT balances

acceptance, mindfulness, and behavior change strategies to assist individuals in

identifying and moving toward individually derived and chosen valued directions (Hayes

et al., 2012). Reviews of ACT thus far have demonstrated its effectiveness with a variety

of presenting problems including work stress, pain, smoking, anxiety, depression,

diabetes management, substance abuse, stigma toward substance users in recovery,

adjustment to cancer, epilepsy, coping with psychosis, borderline personality disorder,

5
and trichotillomania (see Hayes et al., 2006, for a review). More recently, ACT has been

established as an empirically supported treatment with moderate support for depression,

strong support in pain (APA, Division 12) and has been listed by the Substance Abuse

and Mental Health Services Administration (SAMHSA) as an empirically supported

treatment for substance abuse.

Given the variable range in effectiveness found for traditional CBT applied in

correctional settings as well as the paradoxical effects of though suppression, this study

investigated archived pre- and post-measures to assess the effectiveness of a six-session

ACT group protocol for incarcerated men. The individual, more immediate targets of

treatment examined were psychological flexibility, thought suppression and anger-related

behavior. Although the outcome of the study is limited in generalization to adult,

incarcerated males, this has been an under-researched population in the effectiveness

studies of treatment for offenders. Continuing to implement and review effective

interventions with inmate populations can contribute to the management of institutional

behavior, crisis management in corrections, reduction of recidivism rates, and public

safety concerns.

6
 Chapter 2: Literature Review

Rising Numbers of Prisoners: The Need for Treatment in Corrections

The number of incarcerated individuals has continued to increase over the years

leading to overcrowding of correctional facilities, and copious amounts of budgetary

spending. By the end of 2009, more than 1,613,740 inmates were being held in state and

federal prisons, according to the Bureau of Justice Statistics (BJS), which is the highest

jail and prison population in the history of the nation (West et al., 2010). Over the last 25

years, the United States’ prison population has quadrupled. Between 1990 and 1999

alone, the number of male inmates rose 60% (Beck, 2000). Many researchers have

attributed the growing numbers to deinstitutionalization during the 1960s, and legislative

changes over the years. For example, the “three strikes” laws led to the enforcement of

longer mandatory sentences for repeat offenders, and the War on Drugs and Crime

campaign introduced in the 1980s expanded criminal sanctions for drug crimes (Byrne &

Brewster, 1993; Higgins, 1996; Shichor & Sechrest, 1996). These legislative changes

along with historical events that occurred beginning in the 1960s resulted in a shift from

the once stable incarceration rates to a significant and ongoing increase beginning in the

1970s and continuing beyond the 1990s. The movement also impacted approaches to

corrections, sentencing, rehabilitation, and treatment for this population.

Historical factors. Historically, the field of corrections has undergone numerous

pendulum swings in philosophies and roles of service. Where there was once a strong

emphasis on rehabilitation, the 20th century brought about new correctional philosophies

7
stressing retribution and crime control (Byrne & Brewster, 1993; Pacheco, 1994).

Originally, the correctional system emphasized “corrective treatment,” focused on the

skill acquisition necessary for offenders’ reentry into society, and treatment for obstacles

such as psychological disorders, aggression, and substance abuse problems (Benson,

2003; Rees, 2000). The end of the 1960s were marked by a drastic increase in crime

rates and a “nothing works” zeitgeist in corrections (Martinson, 1974), which led to the

abandonment of rehabilitation as a guiding philosophy (Cullen & Gendreau, 2000). The

“nothing works” idea arose from Martinson’s (1974) study in which he examined 231

evaluations of various rehabilitative treatment programs conducted between 1945 and

1967. Martinson (1974) concluded that rehabilitation efforts had been unsuccessful in

decreasing recidivism rates, triggering the abandonment of rehabilitation in corrections

(Lipton, Martinson, & Wilks, 1975). Despite significant limitations (e.g., the inclusion of

poorly implemented programs; Palmer, 1975), the conclusion that “nothing works”

elicited a correctional philosophical shift back toward retributive punishment and crime

control until approximately 2000. Whether prisons are meant to function as a place of

rehabilitation or a place to hold individuals who threaten community safety remains a

source of public debate (MacKenzie, 2001; Mauer, 2002; Rees, 2000).

The legislative changes presented above occurred concurrently with other

historical events that led more specifically to an increasing number of mentally ill

inmates. For example, during the 1960s psychiatric hospitals closed in favor of

community based programs in response to the overcrowded psychiatric hospitals and

increased availability of medication (Butterfield, 1998; O’Keefe & Schnell, 2007;

8
Thomas, 1998; U.S. Department of Health and Human Services, 1994). While these

changes were meant to better serve the needs of the mentally ill within a community

setting, limited funds were available during the 1970s and following the Vietnam War for

the proposed community mental health centers. In addition, tighter limits set on coverage

by health insurers and the limited availability of space in hospitals meant police officers

had few options for action when confronted with the behavioral challenges of the

mentally ill within the community (Teplin, 1983). The chronically mentally ill in turn

were arrested for misdemeanors such as trespassing and larceny, as well as more severe

charges such as murder. In the 1980s, the war on drugs triggered an additional increase

in the number of inmates with co-occurring mental illness and substance use disorders

(Byrne & Brewster, 1993). Overall, the U.S. prison system houses three-times the

number of severely mentally ill than psychiatric hospitals (Abramsky & Fellner, 2003).

The actions contributing to the rise in number of general and mentally ill inmates

combined with the fact that mentally ill offenders are more likely to recidivate, leads to a

seemingly endless cycle.

In sum, there is agreement in the field of corrections pertaining to the desire to

create change in offenders; however, the way to induce necessary change continues to be

an area of debate. Although offender programs and psychological services remain

available for offenders, they are often provided outside the prison walls and are not

always available while offenders are incarcerated. The focus of such services provided

within corrections has been grounded in behavioral theories of retribution and

punishment, as well as institutional safety and management, even amidst research which

9
has found interventions based on punishment and deterrence are less effective than those

based on counseling or the enhancement of skills (Lipsey et al., 2001). One of the most

difficult challenges to institutional safety and management can be observed among

substance abusing inmates, and inmates with problematic behaviors (i.e., anger and

aggression) alongside acute mental health problems.

Mentally ill inmates. There is a dearth of solid data regarding the availability

and success of corrections-based interventions for mentally ill offenders, including their

ability to reduce psychological symptoms and whether or not this leads to reduced

recidivism rates (Douglas & Skeem, 2005). Compared to the general offender population

and the mentally ill population in the community, little is known regarding the mental

health needs and the prevalence of mental health disorders in prison populations,

particularly with respect to the prevalence of coexisting diagnoses (Edens, Peters, &

Hills, 1997; Peters & Hills, 1997). Some research suggests that compared to the general

population, prison populations have higher overall rates of mental health problems,

substance use disorders and comorbid substance use and mental health disorders

(Diamond, Wang, Holzer, Thomas, & Cruser, 2001; Fazel, Bains, & Doll, 2006; Veysey

& Bichler-Robertson, 2002). Estimates of the prevalence of inmates with severe mental

health disorders have ranged from 15–24% (James & Glaze, 2006; Diamond, Wang,

Holzer, Thomas, & des Anges, 2001; Teplin, 1990). More recently, the Bureau of Justice

Statistics reported that 56.2% of inmates within state prisons and 44.8% of inmates in

federal prisons had a mental health problem (James & Glaze, 2006). Regarding

10
institutional safety and management, rule violations, and injuries from fights are more

common among inmates with mental health problems (James & Glaze, 2006).

Nearly 50% of state and federal inmates have a substance use disorder

(Baillargeon et al., 2009; Mumola & Karberg, 2006; Peters, Greenbaum, Edens, Carter,

& Ortiz, 1998). While little information is available regarding prevalence rates of co-

occurring mental health disorders and substance use disorders among prisoners,

researchers have estimated between three and 11% of prisoners have a concurrent mental

health and substance abuse disorder (Baillargeon et al., 2009; Peters & Hills, 1993).

James and Glaze (2006) estimated that among prisoners who had mental health problems,

64%–76% also had substance dependence or abuse problems. Considering there is an

estimated 2.6% of individuals within the general population of the United States who

have a mental health problem, (Beck & Marushak, 2001) inmates are grossly

overrepresented when it comes to mental illness (Teplin, 2000). Blumstein and Beck

(1999) reported that the major contributors to the overall growth observed in

incarceration rates were drug offenders. Making psychological treatment and program

services more readily available to inmates, particularly mentally ill and substance abusing

inmates may help to address individual needs and to reduce the occurrence of re-offense

through rehabilitation. However, it is unclear if reduced psychological symptoms lead to

reduced recidivism (Case et al., 2009).

11
Treatment of Offender Populations in Context

Correctional psychologists. Similar to the changes that occurred in the

correctional philosophy over the years, the role of psychologists has changed as well.

Whereas the focus of psychology was initially on ‘treatment’ during the mid-twentieth

century, by the 1970s and 1980s, the primary focus of correctional psychologists became

institutional safety and community safety leaving mentally ill inmates neglected.

Accordingly, court rulings (Wellman V. Faulker, 1983) soon found that this neglect of

psychiatric services for the mentally ill was a violation of human rights, which in turn

added the treatment focus once again to the role of the correctional psychologist in

addition to the other roles they had assumed. Today, correctional psychologists have two

primary functions: to assist in the rehabilitation and reintegration of offenders and to

assist with institutional safety through evaluating the prison population, managing

disruptive inmates, and providing evaluations and recommendations for offenders prior to

release (Bennett, 1998; Hawk, 1997). The department of psychological services therefore

carries a large burden of corrections by assisting in the rehabilitation and reintegration of

offenders, institutional and community safety, and in the treatment of mentally ill

offenders. These numerous roles of mental health professionals are likely one reason that

ongoing, intensive, and individual psychological treatment is not feasible for most

inmates and occurs much less frequently than group therapy (Wilson, Bouffard, &

Mackenzie, 2005). To address these primary areas of focus along with the increasing

numbers of mentally ill inmates and limited resources, programming available to inmates

in group format has become the standard in corrections and is not always developed and

12
facilitated by mental health staff. The majority of the programming provided in

correctional facilities is focused on the general and substance abusing offender, while

specific treatment of mental illness for mentally ill offenders is often treated separately

and the goal of treatment is focused on symptom reduction.

Correctional programs and outcomes. Recidivism rates are an important

outcome measure for assessing individual offender risk level as well as examining the

effectiveness of programming and interventions for offenders (Almquist & Dodd, 2009;

Lipsey, 1992; Milkman & Wanberg, 2007; Pearson et al., 2002). Overall, approximately

two-thirds of all prisoners will be rearrested within three years following their release

(The Sentencing Project, 2010). Recidivism has been found to be more common for the

mentally ill offender, particularly for those with co-occurring substance abuse disorders

(Baillargeon, et al., 2009; Hartwell, 2004; Messina, Burdon, Hagopian, & Prendergast,

2004; O’Keefe & Schnell, 2007). Thus, there has been recognition of the importance in

treating dually diagnosed and mentally ill offenders as well as those exhibiting behavioral

problems (e.g., criminality), despite limited research in this area (Morgan et al., 2012).

Whether to focus treatment on mental health goals (i.e., symptom management) or

correctional goals (i.e., reduced recidivism) is difficult to determine given this

relationship between the two is not a direct relationship.

The relationship between mental illness and criminal behavior is complex with

some suggesting that mental illness increases an individual’s likelihood of engaging in

criminal behavior (Hodgins & Janson, 2002) and others proposing that risk factors for

13
criminality (e.g., homelessness, substance abuse) are often found among the mentally ill

thereby increasing the chance of criminal behavior (Hiday, 2006). Therefore, it remains

unclear whether mentally ill individuals commit more criminal behaviors, or if it is the

associated risk factors that leave the mentally ill susceptible to engaging in criminal

behavior. This complex relationship often complicates the treatment approach to

mentally ill offenders.

From a psychological perspective, the goal of treatment of mentally ill offenders

often extends beyond correctional goals of reduced recidivism rates or criminal behavior

and may entail improved psychological functioning. Initially, diversion programs were

created to keep mentally ill offenders in the community receiving treatment rather than

incarcerated (Redlich, Steadman, Monahan, Robbins, & Petrila, 2006). Offenders who

participated in these diversion programs have demonstrated significant reductions in

mental health symptoms and re-arrest rates (Case et al., 2009), thereby supporting the

hypothesis that mental-health issues and recidivism are indeed related. Unfortunately,

the nature and directionality of this relationship (improved mental health leads to reduced

recidivism or vice versa; Douglas & Skeem, 2005) has little research behind it. More

recent prison-based treatment for mentally ill offenders has been examined and meta-

analyses have demonstrated some positive effects on criminal involvement and symptom

reduction (Martin et al., 2012; Morgan et al., 2012). Although positive effects are being

shown in the ability of such programs to potentially reduce both recidivism and

psychological symptoms, research on these treatment programs is still limited (Rothbard,

Wald, Zubritsky, Jaquette, & Chhatre, 2009). Even fewer prison-based treatment

14
programs exist for offenders with co-occurring disorders (i.e., substance abuse and a

mental health disorder; see Edens, Peters, & Hills, 1997; Wexler, 2003, for a review).

Further, Case and colleagues (2009) pointed out that decreases in mental health

symptoms do not necessarily predict re-arrest rates or future criminal behavior suggesting

that the direction of the mental health and recidivism relationship needs to be further

addressed. Still, recidivism rates remain an important goal for corrections and some

general offender treatment programs have been shown to correlate with reduced

substance abuse relapse rates, criminal behavior, and recidivism (Cullen & Gendreau,

2000; Inciardi et al., 2001; Lipsey et al., 2001; Pearson et al., 2002).

Correctional treatment research has typically focused on non-mentally ill

offenders where the interventions developed and adapted generally target their criminal

behavior (Andrews & Bonta, 2006; Gendreau 1996). These goals include managing

inmate behavior, institutional safety, reducing recidivism rates, and increasing public

safety following the release and parole of inmates. With the number one goal of

correctional programs being to increase public safety (i.e., reduce crime), the most

utilized measure of success for programs in corrections has been re-offense or recidivism

rates (Almquist & Dodd, 2009; Lipsey, 1992; Milkman & Wanberg, 2007; Pearson et al.,

2002). Funding agencies, policy makers, and program developers consistently target

decreased recidivism as the most compelling marker of a successful treatment program

for the general and even the mentally ill offender. Demonstrating a reduction in criminal

recidivism suggests an improvement in the individual offender’s stability and public

safety, and also lends support to the desired and promised reduction in daily jail housing

15
costs necessary for maintaining funding sources. Overall, there has only been a modest

effect of incarceration on crime reduction (Blumstein, Cohen, Roth, & Visher, 1986;

Reiss & Roth, 1993), which does not seem to support the current philosophy of

punishment and crime control.

While the mental health issue among prisoners is an accepted reality in

psychology, corrections, and society at large, closer examination of “who does what and

to what end” highlights a conflict between correctional goals and mental health outcome

treatment goals. In general, mental health interventions focus on improved psychological

functioning (usually measured through symptom reduction) while interventions for

general offenders focus on increased public safety (measured through decreased

recidivism and relapse rates). Interventions focused on decreasing psychological

symptoms do not necessarily address criminal behavior, and those focused on reducing

criminal behavior do not typically address psychological symptoms. Furthermore,

standard CBT treatment usually targets short-term first order change (e.g., decrease in

symptomology at post-treatment) while recidivism rate reductions imply longer-term

outcome (e.g., post incarceration) in a new context (e.g., out in the community vs. the

prison setting) that may or may not be achievable through first-order change

interventions. General relapse rates in psychology, particularly in the area of substance

abuse for example (Dimeff & Marlatt, 1998) and more recently in the area of anxiety

(Mavissakalian & Prien, 1996; Yonkers, Burce, Dyck, & Keller, 2003) may explain some

of the mixed results found with treatment overall and more specifically in corrections.

More research is clearly needed to examine the overall clinical outcomes of prison-based

16
treatment and their relationship to recidivism. The rest of this section focuses on

outcomes specific to criminal behavior and recidivism given this has been thoroughly

covered in research.

The focus of offender treatment and rehabilitation programs is to induce change in

the individual in order to help them lead a life absent of criminal behavior. Recent

literature reviews suggest rehabilitation can effectively change some offenders and

decrease their criminal behavior (Cullen & Gendreau, 2000). Although debates over the

effectiveness of prison-based treatment programs were sparked by Martinson’s (1974)

“nothing works” report, numerous studies for general and specific (e.g., sex-offending,

substance abusing individuals) offender populations have since demonstrated consistent

positive effects on recidivism and drug relapse rates as well as on the incidence of prison

misconducts (e.g., Bourgon & Armstrong, 2005; French & Gendreau, 2006; Inciardi et

al., 2001; Knight et al., 1999; Lipsey et al., 2001; Pearson et al., 2002; Ronan et al.,

2010). Numerous meta-analyses have been published since the 1980s and 1990s

suggesting offender programs do have a positive effect on the re-arrest rates (Andrews &

Bonta, 2006; Lipsey et al., 2001; Pearson et al., 2002; Wilson et al., 2005). Even though

it is difficult to calculate overall effects due to the variability in the approach of each

review, the overall impact of all programs and services for offenders has been estimated

to yield an average effect size of .10 (McGuire, 2002). This is consistent with other

estimates suggesting an 8% reduction in re-offense rates for offenders who participate in

programming (Aos, Miller, & Drake, 2006). However, an effect size of .10 is considered

to be low by most and may be the reason why some have strongly opined that

17
correctional treatment programs are mostly altogether ineffective (Whitehead & Lab,

1989). Across all forms of offender treatment and programming, it has also been found

that the effect sizes vary greatly with some programs demonstrating increased recidivism,

others demonstrating moderate decreases, and still others demonstrating significant

reductions of 20%-30% in recidivism rates (Andrews et al., 1990; Andrews & Bonta,

2006; Lipsey, 1992; Lipsey & Wilson, 1998).

The heterogeneity among effects of offender programming does not take away

from the evidence that prison-based programs have been shown to be somewhat positive

and cost effective with respect to outcome measures (Welsh, 2004). When narrowing

examination to those programs producing the greatest reduction in recidivism rates, two

factors stand out. First, the programs that follow particular interventions for specific

offenders have been shown to be more effective. For example, treatment programs

following the Risk-Need-Responsivity (R-N-R) approach to treatment (Andrews et al.,

1990) appear to have the greatest impact on reducing recidivism rates (Dowden &

Andrews, 2000; Morgan et al., 2012; Ward, Mesler, & Yates, 2007). This approach

includes an assessment and identification of individual risk factors related to recidivism

followed by implementation of Cognitive Behavioral treatment programs to higher risk

offenders, matching the individual needs of offenders. Second, the highly effective

treatment programs have typically been CBT oriented and have consistently produced the

greatest effects on recidivism rates (Lipsey et al., 2001; Pearson et al., 2002; Wilson et

al., 2005).

18
 Although CBT oriented programs have produced the greatest effect on the

correctional goal of increased public safety (i.e., reduced recidivism rates), there appears

to be a gap in research regarding the consistent effectiveness of various programs with

goals or measures of outcome other than recidivism and relapse rates. For example, it

may be that some programs are effective with outcomes such as decreased prison

misconduct, mental health symptoms, or improved overall wellbeing (Gendreau &

Andrews, 1990). Literature reviews and meta-analyses focusing on recidivism as the

only outcome measure may be underestimating the overall effectiveness of some prison-

based treatment programs. In addition, the assumption that prison-based programs can

affect change once the offender has reentered the community ignores contextual variables

that the offender is in contact with once released that were absent while incarcerated.

The limitations of generalizations are well documented in CBT literature (Barlow, Levitt,

& Bufka, 1999; Gruber, 2006) and should be considered when investigating this

relationship. Collaboration among correctional clinicians (whose advantages include

access and insight to inmate populations) and researchers (who have the time without the

correctional demands to conduct treatment-outcome studies) would help with filling in

the gaps in the research in this area, including gathering a variety of immediate and long-

term outcome measures (Morgan et al., 2012; Wormith et al., 2007). Given CBT’s

popularity, a review of CBT oriented programs in corrections follows.

CBT in corrections. An approach to programming for offenders aside from the

development of those that target general offender needs (e.g., thinking styles, antisocial

19
attitudes, problem-solving skills) has been to adapt and implement structured mental

health interventions that have been effective with a variety of clinical features often

associated with criminal behavior (e.g., social skills deficits, environmental

misperceptions and frustration tolerance, substance abuse) and the faulty thinking that is

thought to precipitate criminal behavior (Galietta, Finneran, Fava, & Rosenfeld, 2009;

Milkman & Wanberg, 2007; Osher & Steadman, 2007; Rotter & Carr, 2011).

Researchers have suggested that among habitual offenders, one of the most prominent

characteristics is distorted thinking (i.e., criminal thinking; Mandracchia, Morgan, Garos,

& Garland, 2007). They have found that many inmates experience cognitive deficits or

deficits in problem-solving ability and interpersonal skills (Ross & Fabiano, 1985; Ross,

Fabiano, & Ewles, 1988). The assumption is that “criminal thinking” leads to criminal

behavior; thus, changing or reducing such though patterns will reduce associated

problematic behaviors. Programs (e.g., Reasoning and Rehabilitation) have been

developed to address the dysfunctional and criminal thinking patterns of offenders

(Milkman & Wanberg, 2007). To specifically address general offender involvement with

the criminal justice system, these recidivism-focused interventions have been

implemented and target dynamic factors shown to be related to criminal behavior (e.g.,

family support, substance abuse, and homelessness; Osher & Steadman, 2007). Upon

examination of research regarding the treatment services and programs for offenders,

since the 1980s the preferred type of approach and the most effective appears to have

been Cognitive Behavioral Therapy (CBT; Hollin, 2004) with most cognitive-behavioral

20
programs for offenders focusing on cognitive deficits and distortions (i.e.,

thoughts/cognitions; Cullen & Gendreau, 2000).

Given that the average cost of housing and caring for an inmate has been

estimated to be $17,818 (and higher when inmates are confined in special housing) per

inmate each year (Stephan, 2004), CBT is a viable choice of treatment within corrections

offering a time-limited, empirically supported approach for many psychological and

behavioral problems. CBT also addresses maladaptive thinking patterns, a main factor

thought to be associated with criminal behavior. In the general population of mentally ill,

CBT is utilized to treat a variety of problematic behaviors and psychological symptoms

with methods such as exposure, problem solving skills training, relaxation training, and

social skills training being the most empirically supported (Butler, Chapman, Foreman, &

Beck, 2006; Nathan & Gorman, 2002; Roth & Fonagy 2005). Meta-analyses have shown

that Cognitive-Behavioral Treatment approaches are effective within inmate populations

as well utilizing recidivism as the measure of success (Clark, 2011; Lipsey et al., 2001;

Pearson et al., 2002; Shaffer & Pratt, 2009), despite continued overall high rates of

recidivism (The Sentencing Project, 2010).

CBT overview. The goal of cognitive behavioral interventions is symptom

reduction and improvement in individual functioning with a focus on cognitive and

emotional processes thought to mediate between various stimuli and behaviors; thus

CBTs target both the cognitive and behavioral areas for change (Bandura, 1977;

Meichenbaum, 1977). CBT integrates the behavioral theories of the 1950s and 1960s,

21
which began with the work of Watson (1913), Pavlov (1927), and Skinner (1938).

Combined, this work focused on observable, measurable, and external behaviors

involuntarily triggered by a particular stimulus and based on positive and negative

reinforcing and punishing consequences. Cognitive theory added internal mental

processes to the maintenance and modification of behavior (Bandura, 1969; Beck, 1976).

These blended components of behavioral and cognitive psychology formed the basis of

CBT (Ellis, 1962; Meichenbaum, 1977). Behaviorally, in CBT, the individual begins to

develop an awareness of triggers and consequences of behavior to influence actions. To

address the cognitive domain during CBT, the individual develops skills assisting them in

uncovering and challenging the maladaptive views of the self and the world.

Meichenbaum (1977) viewed cognitive processes as the mediating factor for

behavior change and taught individuals mental coping skills, which were practiced upon

exposure to a stressful event or situation. He theorized that a shift from negative to

positive internal thoughts or dialogue would change behavior from negative to positive.

Shifting toward positive internal talk about the self and the world was thought to

influence core beliefs and lend support for a shift from maladaptive to adaptive behavior.

Beck (1976) referred to a person’s core schemas as one’s beliefs about the self and the

external world. He posited that psychological distress increased distortions in thinking

and led to maladaptive behavior. Justly, therapy should focus on identifying and

correcting the dysfunctional thoughts in an effort to influence behavior. This focus on

cognitive distortions is considered to be the overall mechanism for change in cognitive

behavioral therapy interventions; the assumption being that as unwanted thoughts

22
diminish, the psychological symptoms caused by the thoughts and related behaviors will

dissipate (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979).

CBT programs within corrections maintain this assumption for behavior change

and psychological treatment; identifying maladaptive thoughts and restructuring them,

and integrating social, interpersonal, and problem solving skills training and practice

(National Institute of Corrections, 2007). CBT places the responsibility of cognitive

changes and thought control in the hands of the offender. CBT programs for offenders

are focused on correcting the maladaptive and “criminal thinking” patterns through

cognitive restructuring. CBT typically involves social and interpersonal skills

development in addition to the challenging and/or altering of cognitions. Corrections-

based CBT also involves an additional component, prosocial skills building (Milkman &

Wanberg, 2007). Thus, these CBTs may involve offenders learning to manage anger,

accepting personal responsibility for individual behavior, problem solving, setting goals,

developing life skills and developing a perspective, and skills necessary for moral and

empathic interpersonal behavior. Correctional CBT is not simply intrapersonal, focused

on symptom reduction and an individual sense of feeling and functioning better, but also

the ability to live in accord with the community and positively contribute to society. The

goal of CBT in prison-based treatment and rehabilitation is for the individual to anticipate

and understand consequences that follow inappropriate or maladaptive behaviors. In

turn, a reduction of such behaviors should occur, beginning while incarcerated and

continuing into the community upon release, in order to decrease the likelihood of future

criminal behavior (i.e., recidivism; Loza & Loza-Fanous, 1999). Subsequently, offenders

23
develop more adaptive ways of thinking, allowing them to evaluate and react differently

in situations that once elicited criminal behavior.

Outcomes. Overall, CBT based programs appear to effectively address criminal

thinking associated with concerning criminal behaviors within inmate populations,

showing lower rates of recidivism among offenders in treatment groups compared to

treatment-as-usual control groups (Lipsey et al., 2001; Pearson et al., 2002; Wilson et al.,

2005). While earlier meta-analyses of CBT for offenders found no significant reduction

in recidivism rates for treated offenders (Garrett, 1985; Gottschalk, Davidson, Mayer, &

Gensheimer, 1987) or significant differences compared to other treatment programs

(Whitehead & Lab, 1989), more recent analyses have found positive results. For

example, meta-analyses have demonstrated a 20–30% decrease in recidivism rates for

offenders who participated specifically in CBT oriented programs compared to untreated

controls (Pearson et al., 2002; Wilson et al., 2005).

Lipsey and colleagues (2001) conducted one of the most notable meta-analyses to

date. They restricted their analysis to 14 studies since 1985, tightened their definition of

CBT, included only general offender populations, excluded any study that failed to utilize

experimental or strong quasi-experimental designs, and limited their outcome measure to

recidivism rates. They found CBT programs overall produced a significant moderate

effect demonstrating substantial reductions in recidivism rates. Further, they found the

most effective programs reduced the recidivism rates of treated offenders by one-third

when compared to the treatment-as-usual control group. However, the researchers noted

24
that demonstration programs (those only lasting the required length for outcome

assessment) were the programs that produced the greatest effect. These programs were

also more likely to have occurred outside of correctional institutions (i.e.,

probation/parole programs) and typically involved juvenile populations which makes it

difficult to generalize the positive results to adult, incarcerated populations (National

Research Council, 2007; Lipsey et al., 2001). Adult inmates may present with a different

variation of maladaptive thinking and behaviors than juveniles and may require more

intensive treatment in higher doses given the length of time they have been practicing

those behaviors. In addition, adult inmates face different contextual variables than

juveniles in the community or even those in detention centers. The ability for offenders

to begin participating in ongoing treatment while incarcerated is imperative to their long-

term success and functioning (National Research Council, 2007).

Programs. Most CBTs in corrections tend to be highly structured, include

detailed manuals and are delivered in group settings (Dobson & Khatri, 2000). As

mentioned earlier, individualized, one-to-one CBT offered by psychologists and other

mental health professionals to inmates is not feasible in general. Some of these specific

and manualized CBT oriented programs for inmates include Aggression Replacement

Training (ART), Strategies for Self Improvement and Change (SSC), Moral Reconation

Therapy (MRT), Relapse Prevention Therapy (RPT), Thinking for a Change (T4C),

Lifestyle Changes, and Options (see Milkman & Wanberg, 2007, for a more in-depth

review of some of these programs), although these programs are not offered in every jail

25
or prison. In general, CBT in correctional settings is most often consistently employed to

address behavioral changes associated with substance abuse problems and anger in

(Hollenhorst, 1998); two problematic behaviors that often prompt inmates to access

mental health services (Morgan et al., 2012).

Substance abuse treatment programs for offenders are the most commonly

researched with recidivism and relapse rates as the outcome measure. While anger

therapy has been cited as the most commonly provided therapy group in corrections,

there has been little research done on outcomes of prison-based anger management

(Morgan, Wintercrowd, & Ferrell, 1999). Given the earlier mentioned statistics on the

number of drug offenders and the increased rates of recidivism for offenders with co-

occurring mental disorders and substance use disorders, focusing treatment to target these

two areas seems warranted. These specific prison-based, CBTs for anger and substance

abuse will be the focus of this review given their prevalence in the literature and

relevance to the nature of this study and the population from which the data was gathered.

Substance abuse treatment. It has been estimated that more than half of offenders

used drugs in the 30 days leading up to the time of arrest, and 83% of all those

incarcerated have reported a history of drug use (Griffith, Hiller, Knight, & Simpson,

1999). Drug treatment within correctional settings has been shown to effectively reduce

drug use and related maladaptive behavior as well as recidivism rates and inmate

misconduct (Butzin, Martin, & Inciardi, 2002; Gerstein et al., 1997; Hubbard, Craddock,

Flynn, Anderson, & Etheridge, 1997; Knight et al., 1999; Langan & Pelissier, 2001;

26
Lipsey et al., 2001; Staton-Tindall et al., 2009). Depending on the respective program,

the goals of drug treatment range from abstinence to harm reduction to avoidance of re-

offense.

CBT remains one of the most supported treatments for substance abuse (Carroll,

1998; Finney & Moos, 2002; McCrady & Ziedonis, 2001). In the U.S. prison system, the

modified Therapeutic Community treatment (TC) is the most commonly utilized method

of substance abuse treatment operated since the late 1960s. TCs are structured and

regimented in a way that is well suited for the correctional environment and inmates work

up through phases of the system gaining increasing responsibilities. The inmates

(residents) are involved in all of the day-to-day functions of the TC and responsible for

the treatment of all residents. TC’s approach treatment from a biopsychosocial model

and utilize a community-housing setting where inmates enrolled in the program reside

together until treatment is complete and the TC is staffed with a variety of recovering

addicts, treatment specialists, and mental health professionals (Raney, Magaleta, &

Hubbert, 2005). This treatment model includes key CBT concepts such as cognitive skill

building, and the examination and challenge of “criminal thinking.” The program also

focuses on relapse prevention, interpersonal skills building, wellness, and transition.

Daily groups and meetings utilize positive persuasion to facilitate attitude and behavior

changes. The groups also provide an opportunity for peers to confront one another when

rules or values are violated by a resident. Typically, TC treatment lasts six to 12 months

with dosage and continuity of treatment in the community critical for long-term treatment

success (Butzin et al., 2002; Inciardi et al., 2001).

27
 Unfortunately, only 13% of inmates receive treatment for their substance abuse

problem, according to the Office of National Drug Control Policy (Goodrum, Staton,

Leukefeld, Webster, & Purvis, 2003). One CBT treatment program, Acceptance and

Commitment Therapy (ACT; Hayes et al., 2012), has recently been listed by the United

States Substance Abuse and Mental Health Services Administration (SAMHSA) as an

empirically supported method and as part of its National Registry of Evidence-based

Programs and Practices (NREPP). ACT, while not currently researched in corrections,

approaches treatment by working on the underlying function that substance abuse serves

to an individual, and will the subject of this study.

Anger management. Novaco (1975) created the first known approach to the

treatment of anger, which overlaps with later approaches established by Beck (1976) and

Ellis (1977) and together form the foundation of CBT for anger. CBT approaches to the

treatment of anger have been shown to reduce intensity and the associated problematic

behaviors that are typical consequences of anger (Beck & Fernandez, 1998; Bowman-

Edmonson & Cohen-Conger, 1996; DiGiuseppe, 1999; DiGiuseppe & Tafrate, 2003;

Glancy & Saini, 2005). Anger management implemented within correctional settings

follows the same basis for change as this form of CBT for anger (Beck & Fernandez,

1998; Hollenhorst, 1998). The underlying cognitions of inmates are examined,

specifically looking for problematic patterns in thinking, or criminal thinking patterns,

that are thought to maintain the maladaptive behavior. Within groups, more appropriate

behavior is modeled and reinforced. Chances for role-play and dialogue are presented

28
throughout therapy, encouraging adaptive behaviors and beliefs among individuals.

Treatment focuses on the awareness of arousal associated with anger and anger cues,

identification and avoidance of anger triggers, cognitive restructuring, and cognitive

coping skills (Deffenbacher, 1996).

CBT treatments for anger in general have been validated for effectively

decreasing the intensity and the consequential associated problematic behaviors (Beck &

Fernandez, 1998; Del Vecchio & O’Leary, 2004; Edmondson & Conger, 1996; Glancy &

Saini, 2005), still improvements could be made. Beck and Fernandez (1998) conducted

perhaps the most well-known meta-analysis of the effectiveness of anger management

and found an overall mean effect size of 0.7. However, the majority of the studies used

child and adolescent populations (e.g., school children, college students, juvenile

delinquents, and young clinical populations) and less included adult populations (e.g.,

abusive parents), and only six studies used inmates. The evidence of CBT for anger

remains limited as it applies to individuals from diverse backgrounds, special populations

(e.g., adult clinical populations), and individuals struggling with co-occurring disorders

(e.g., substance abuse and mental health disorders; Glancy & Saini, 2005). Correctional

populations include many of these less researched adult populations. Although anger

management has been shown to be effective for some clinical and non-clinical

populations (e.g., schoolchildren, college students; Beck & Fernandez, 1998), the results

cannot necessarily be generalized to a violent or even general adult offender population

(Walker & Bright, 2009). Adults may display/respond to anger differently than

children/adolescents and violent behavior is not necessarily caused by feeling angry.

29
Further, among the published outcome research on cognitive behavioral interventions,

anger management is one of few where published studies demonstrate no treatment

benefit (Sharry & Owens, 2000; Watt & Howells, 1999).

The overall effectiveness of anger management programs specifically in

corrections remains mostly unknown even amidst its wide implementation (McKenzie,

2001; Hollenhorst, 1998). One study (Vannoy & Hoyt, 2004) computed an effect size

from the studies that used inmates that were included in the Beck and Fernandez (1998)

meta-analysis. With recidivism again used as the outcome measure, they found the effect

size to be 0.85 among five inmate studies that utilized treatment control groups. Only six

of the 50 studies, however, used an inmate population and four of those six studies were

unpublished dissertations. Mills and Kroner (2006) found no evidence for a relationship

between anger and recidivism, yet the few existing prison-based studies of anger therapy

continue to utilize recidivism as an outcome measure despite these mixed results. Few

studies have examined other outcomes, including aggression, feelings of guilt, self-

esteem and anxiety. These limited studies found that anger therapy for inmates failed to

yield a significant effect on self-reported aggression or increased guilt (Valliant & Raven,

1994), while demonstrating positive effects on self-esteem and anxiety (Valliant &

Antonowicz, 1991; Valliant & Raven, 1994).

Given that problematic anger can lead to an increase of substance abuse problems

(Marlatt & Gordon, 1980), and substance abuse problems are related to recidivism, more

studies on the effectiveness of treating problematic anger and related behavioral problems

within inmate populations may be beneficial. Anger and aggression may overlap;

30
however, anger (the feeling) does not necessarily cause aggression (the behavior). To

decrease aggressive behavior among inmates, a functional approach to analysis and

treatment may be more beneficial than assuming that all aggressive behavior is a result of

feeling angry and vice versa. Aggressive/violent behavior may serve a variety of

purposes (e.g., self defense, power, control, escape/avoidance, or attention) depending on

the context and anger-related behaviors can topographically take many forms (e.g., verbal

and physical aggression or isolation and withdrawal). Further investigation into the

function of aggressive behavior more broadly and in context may clarify the mixed

results found for anger management programs and their relationship to recidivism.

CBT Limitations

While research highlights the positive outcomes and empirical support of CBT

interventions (Nathan & Gorman, 2002; Roth & Fonagy, 2005), the studies and the

intervention itself are not without limitations. In general, the goal of CBT is symptom

reduction and overall improvement in individual emotional and social functioning. As

previously mentioned the overall assumption behind CBT interventions inside and

outside of corrections is that faulty thinking patterns and aversive, undesirable thoughts

can result in problematic behavior and psychological symptoms (Beck, 1976; Beck,

Rush, Shaw, & Emery, 1979; Ellis, 1962; Meichenbaum, 1977). For improvement to

occur in CBT, the problematic thoughts must no longer occur in order for associated

behaviors to change and maintain. Unfortunately, studies have failed to provide support

for the proposed cognitive mechanisms of change in CBT treatments (Beck & Perkins,

31
2001; Burns & Spangler, 2001; Gortner, Gollan, Dobson, & Jacobson, 1998; Hayes et al.,

2006; Olatunji & Lohr, 2004; Zettle & Hayes, 1987). In fact, change is often seen in

CBT treatment prior to the implementation of cognitive interventions (Ilardi &

Craighead, 1994). CBT research has been unable to provide evidence as to why behavior

change occurs. The inability to identify the underlying psychological processes of

treatment change linked to the theory limits the necessary scientific basis needed for the

progression of the field of psychology, specifically behavioral and cognitive therapies

(Hayes et al., 2006). For example, CBT has thus far been unable to explain why the

treatment of anger works (Olajunti & Lohr, 2006) when it does, and why it is effective

across offender groups in reducing criminal behavior and recidivism (Clark, 2011).

Thought control. Recent research on the paradoxical effects of thought

suppression may shed some light on a potential problem with cognitive interventions in

CBT. It has been found that direct attempts at control, reduction, or suppression of

thoughts (as is standard in correctional CBTs) and emotions, while beneficial in the short-

term, seem to eventually lead to the maintenance of, or an increase in, the undesirable

thoughts and emotions (Clark et al., 1991; Corrigan et al., 2001; Langer, Fiske, Taylor, &

Chanowitz, 1976; Gold & Wegner, 1995; Smart & Wegner, 1999; Wegner, 1989, 1992,

1994; Wegner et al., 1987; Wegner et al., 1991). Thought suppression may also lengthen

undesirable mood states and make them worse (Wenzlaff & Wegner, 2000). This may

have a profound effect on an inmate who is already experiencing depression or anxiety

related to becoming incarcerated. Further, there is evidence that suggests suppression of

32
emotion can result in an increase of the negative emotion, and a decrease in positive

affect, self-esteem, and overall wellbeing (Gross & John, 2003). For example, think of

an inmate who is instructed to control his anger, or try not to feel depressed and the

paradoxical effect this could have on his mood. Thought suppression can be beneficial in

the short-term or in certain contexts; however, it can be ineffective and counterproductive

when overgeneralized and across contexts, resulting in a prolonged state of undesirable

mood or mind frame that was hoped to be avoided (Hayes, Strosahl et al., 2004).

Suppression, avoidance and control of thoughts and other internal experiences, such as

memories, emotions, and physiological sensations, has been referred to in literature as

experiential avoidance (Hayes et al., 1996).

Experiential avoidance. Experiential avoidance is defined as an individual’s

tendency to try and avoid, control, change, or escape unpleasant or unwanted private

events which can include thoughts, feelings, bodily sensations, urges, and memories

(Hayes et al., 1996; Hayes, Strosahl et al., 2004). Other terms similar to experiential

avoidance include “cognitive avoidance” and “emotional avoidance,” all of which are

viewed by most systems of therapy as problematic in certain contexts (Hayes et al.,

1996). Experiential avoidance can be viewed as having an emotion regulation function

rather than strategy (Boulanger, Hayes, & Pistorello, 2010). As a functional class of

behaviors, experiential avoidance is negatively reinforcing in the short-term, through the

avoidance of, or removal of, some type of unwanted internal experience. In the long-

term, experiential avoidance can become problematic when it increases psychological

33
rigidity and limits necessary value behaviors. Experiential avoidance has been linked to a

wide range of psychopathology (Chawla & Ostafin, 2007; Hayes Strosahl et al., 2004).

Avoidance of negative thoughts, feelings or physical sensations may be beneficial

for some animals, including human beings, given the context. For example, a rat who

receives an electric shock in a chamber will be less likely to return to that particular

chamber (Blanchard & Blanchard, 1968). Similarly, an individual who grows up in a

violent neighborhood and experiences an assault one evening may become hesitant to

walk the streets alone at night. In each of these scenarios, there is a clear survival value

in the organism’s ability to avoid signs, memories, and thoughts of danger and bodily

harm. In these contexts the coping is effective and adaptive. While experiential

avoidance is not always problematic, the inability to remain in contact with unpleasant

internal events can become problematic when doing so prevents one from engaging in

valued actions, or behaviors that are consistent with or in service of what is most

meaningful to an individual (Hayes, Strosahl et al., 2004). For example, the individual

above may begin to lead a constricted life, never leaving her house in an effort to escape

the thoughts associated with the potential of a re-occurrence. Or, she may begin using

alcohol or drugs at times she ventures out in an effort to avoid the internal fears, thoughts,

or memories elicited when walking the streets at night. In these instances, she may feel

that by never leaving her home or engaging in substance abuse, “works,” experiencing

relief in the immediate moment yet failing to notice that over time the effect these

avoidance strategies have had on her life, more broadly.

34
 Avoidance becomes problematic when a verbal rule is formed regarding the need

to remove or avoid instances of aversive private experience, resulting in ineffective

behavior toward long-term goals (Hayes, Strosahl et al., 2004). In the external world,

language allows an individual to predict, evaluate and avoid aversive events. It is our

entanglement with language and cognition that leads to an overgeneralization of

avoidance that may be effective in the external world, to experiential avoidance that

seems to produce paradoxical effects when applied to our internal experiences (Hayes,

Barnes-Holmes, & Roche, 2001). We begin to sort emotions, thoughts, physiological

sensations and memories into positive and negative categories and consequently, seek out

and avoid “negatively” labeled experiences. In an attempt to eliminate a thought from

one’s mind, it is necessary for the individual to follow a verbal rule and the thought being

avoided is found within that verbal rule. (e.g., “Don’t think of X. Instead of thinking of

X, think of Y.”) The problem then becomes that over time as one attempts to continue

control or rid their mind of the problematic thought which is not in and of itself

dangerous one paradoxically produces that exact undesired thought (Gold & Wegner,

1995; Wegner et al., 1987). Evidence has also demonstrated this to be true with attempts

at suppressing and avoiding emotional content (Wegner et al., 1987). For example, in an

attempt to control anxiety, one has to think about anxiety, which then produces anxiety.

The ironic effects of suppression have been studied in relation to various other

experiential states such as pain (Hayes et al., 2012; Masedo & Esteeve, 2007) and

experimentally induced distress (Levitt, Brown, Orsillo, & Barlow, 2004; Campbell-Sills,

Barlow, Brown, & Hofmann, 2006a, 2006b). Overall, the data shows that attempts to

35
escape or avoid unwanted, undesirable internal experiences may paradoxically increase,

or at the very least maintain, the exact internal experiences one is trying to avoid (Hayes

et al., 2012).

An additional problematic component resulting from experiential avoidance is

further suffering and the development and maintenance of psychopathology (Boulanger

et al., 2010; Hayes et al., 2006; Hayes et al., 1996). There is growing evidence to support

the role of experiential avoidance in the development and maintenance of

psychopathology and various behavioral problems (Chawla & Ostafin, 2007; Hayes,

Strosahl et al., 2004; Kingston, Clarke, & Remington, 2010). Experiential avoidance has

been shown to correlate highly with depression, anxiety, stress, substance abuse,

posttraumatic stress disorder (PTSD), phobias, pain intolerance, trichotillomania, and

general psychological distress (Hayes et al., 2006). Additionally, experiential avoidance

has been negatively correlated with overall quality of life and general health (Hayes,

Strosahl et al., 2004). There is also evidence that many problem behaviors (e.g.,

substance abuse, self-harm) co-occur often in individuals where one identified problem

behavior already exists (Haw, Hawton, Casey, Bale, & Shephard, 2005; Regier et al.,

1990). While each problem behavior may appear topographically different (e.g., cutting,

hitting, burning, ruminating, deviant sexual behavior or substance abuse), they may all

share the common function of avoiding aversive private experience (e.g., feelings of

powerlessness, boredom, pain, sadness or fear; Cooper, Wood, Orcutt, & Albino, 2003;

Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). In other words, each of these

problem behaviors can be viewed as falling under a class of responses in which the

36
individual attempts to avoid, alter or escape an aversive internal experience as well as the

contexts within which they are elicited (Hayes, Wilson, & Strosahl, 1999; Hayes et al.,

1996).

Experiential avoidance has sown to be related to many of the problems that

inmates present with including depression, anxiety, substance abuse, and general

psychological distress (Chawla & Ostafin, 2007; Hayes, Strosahl et al., 2004; Hayes et

al., 2006). Further, incarcerated males are one group of individuals who can often exhibit

multiple problem behaviors (e.g., substance abuse, self-harm, problematic anger-related

behaviors, and rumination). Though each of these problematic behaviors can be

associated with various diagnostic categories, they may share a common avoidant

function. A treatment that has the potential to address the function of behaviors rather

than their topography would benefit this population and the systems that house them

(Barlow, 2004; Barlow, Allen, & Choate, 2004). Given that many inmate problems are

similar to those that have been found to correlate with experiential avoidance this study

focuses on ACT as a potential intervention for experiential avoidance in an inmate

population.

Acceptance and Commitment Therapy Targets Experiential Avoidance

ACT philosophy. Acceptance and Commitment Therapy (ACT) specifically

targets experiential avoidance as a functional class. Given the functional contextual

philosophy underlying ACT (Biglan & Hayes, 1996; Hayes, 1993; Pepper, 1942), this

treatment espouses a different approach to treatment than traditional CBT. ACT views

37
thoughts as behavior and experiential avoidance as one common underlying problem.

Thus, ACT teaches individuals to relate and respond in a different manner to aversive

private experiences.

The pragmatic philosophical groundings of ACT, functional contextualism, view

the unit of analysis as the dynamic, interactive whole event or the ongoing-act-in context

with the goal of prediction and influence of events (Biglan & Hayes, 1996; Hayes, 1993;

Pepper, 1942). The act-in-context is the total complex interaction of the behavior and the

current, historical, and biological context in which it occurs. From a functional

contextualist perspective, workability is the truth criterion by which action is evaluated

(Biglan & Hayes, 1996; Hayes, 1993). Given a predetermined goal, in this case

flexibility to move in the direction of one’s freely chosen values, progress towards that

end is measured by investigating whether an action effectively moves one away from or

closer to their goal. In this regard, experiential avoidance has been shown to be an

ineffective strategy (Hayes et al., 2012; Pepper, 1942).

ACT theory. Underlying ACT is the basic theory of language and cognition,

Relational Frame Theory (RFT; Hayes et al., 2001); a theory that explains how our verbal

abilities are developed. From an RFT perspective, there are four processes that arise

through operant learning and get reinforced as children become verbal: 1) mutual

entailment, 2) combinatorial entailment, 3) transfer of stimulus functions, 4) and

arbitrarily and derived relating. Unlike most other nonverbal animals, human beings

have the ability to derive relationships that are not explicitly taught. This process of

38
learning to relate events (stimuli) in a variety of ways without having been explicitly

taught or reinforced for those specific relations is referred to a derived relational

responding. For example, learning to fear a tiger even when one has never experienced a

tiger or been taught to fear a tiger. The relationship between one’s fear and the tiger is a

derived relationship. In derived relational responding, human beings discriminate

between relationships of stimuli (i.e., experiences, events), rather than to the formal

properties of each stimuli (can be seen, heard, touched, tasted or smelled) alone. Mutual

entailment and combinatorial entailment are the two types of derived relational

responding (Hayes et al., 2001).

Mutual entailment (bidirectionality) refers to the reversal of a specific relation

between A and B once one direction has been trained in a given context (Hayes et al.,

2001). Combinatorial entailment, the second type of derived relational responding, is

explained by the addition of a third stimulus or an additional mutual entailment. When

an additional relation takes on the properties of mutual entailment, the two mutual

relations combine. For example, if in the same context as A relates to B, the stimulus C

relates to B in some specific way, then in that same context a relation is entailed between

A and C, as well as between C and A. The derived reciprocal relationship between A and

C is referred to as combinatorial entailment because A and C were not ever directly

related to one other and came to be related only through their relationship with B.

Consequently, as relations are made over time among stimuli (events) in the world, some

of the functions of each stimulus may be transferred among them according to contextual

cues (e.g., “is/is not like” or “bigger than”); this is known as transfer of stimulus

39
functions (Hayes, Kohlenberg, & Hayes, 1991; Hayes et al., 2001). Once relating is

learned through multiple exemplar training, words acquire the functions of various events

and arbitrary relations (e.g., “X is smarter than Y,” or “Y is prettier than X”) can be

formed among an endless number of events (experiences; Hayes et al., 2001). This entire

process is an operant process that becomes shaped repeatedly over time, becoming

increasingly complex and under explicit contextual control.

From an applied perspective, take for example a man who has been arrested and is

now entering jail. In the past, he has likely been taught that “murderers” are

“dangerous,” “kill,” and are contained in “jails,” and likewise inversely relates “jails”

contain “murderers” (i.e., mutual entailment). Consider the relationship between the

man, “I/me,” “jail,” and “murderer.” There is no direct connection between “I/me” and

“murderer” but since both stimuli are related to “jail” he is able to derive a combinatorial

relation between them. In this case, “I know that murderers are contained in prison, and I

also know that I am currently contained in a prison.” When he combines these two

relations (combinatorial relating), he derives that “there is a murderer somewhere in the

prison that I am now in.” In this context, “I/me” would take on the stimulus functions of

“danger” as well (transfer of stimulus functions).

As relational skills increase in strength with ongoing reinforcement for relating,

vast relational networks are created, and individuals begin to live more and more in a

world where functions are verbally acquired and transferred to other verbal events. As

humans mature and become more and more language able, they begin to spend more time

in their heads (their verbal world) and less time in contact with direct contingencies in the

40
world leading to rigid and inflexible ways of living. Taking language literally can lead to

an increase in pain and tendency to generalize problem-solving thinking to solving pain.

Consequently, an individual may become focused on escaping and avoiding pain,

entangled in thinking, believing and defending conceptualized stories of themselves, thus

losing contact with the present moment and what they want (Hayes et al., in press). ACT

targets this literality of language and the accompanying experiential avoidance that leads

to psychological inflexibility. (See Figure 1 for the model of psychological inflexibility

and Figure 2 for the model of psychological flexibility.)

Six core processes of ACT. There are six core processes of ACT that together

are hypothesized to influence change throughout treatment by increasing psychological

flexibility.

Present moment. The same contexts that reinforce cognitive fusion and

experiential avoidance can also lead to a loss of flexible contact with the present moment,

leaving the individual fused (i.e., taking thoughts literally, further described below) with

thoughts about a past that cannot be changed or a future that has not yet happened. Said

another way, when individuals are fused with thoughts and other private experiences, and

focused on the past or future, contact with the present moment is lost. Alternatively,

contact with the present moment involves contacting internal experiences, even painful

internal experiences, in the moment without judging or avoiding them (Hayes et al.,

2012). Practicing present moment awareness increases an individual’s ability to

41
experience their internal and external world more openly, contributing to increasingly

more flexible and value directed behavior. The experience of non-judgmentally

observing the ongoing stream of internal experience (common among mindfulness

exercises) is also referred to as “self as process” in ACT and will be described later

(Hayes et al., 2012).

Acceptance. Acceptance is the alternative to experiential avoidance and is

conceptualized as the awareness of internal experiences without judgment or avoidance

(Hayes et al., 2012). Acceptance involves remaining in contact with one’s internal

experiences without attempting to alter their form or frequency while persisting in

purposeful behaviors that are consistent with one’s own values. For example, individuals

with depression are encouraged to let go of the struggle with depressive thoughts or

aversive internal experiences, and those with anxiety are encouraged to fully experience

the feeling of anxiety completely and without resistance. Acceptance offers alternative

and more flexible ways of responding and relating in the presence of aversive private

experience; willingness to do plays a major role in acceptance (Hayes et al., 2012).

Cognitive defusion. Cognitive fusion refers to the over-extended use of taking

thoughts literally, becoming attached to them and failing to observe the process of

thinking, even when this becomes problematic (Hayes et al., 2012). Individuals become

caught up in the content of their thoughts and view them as reality, rather than seeing

them for what they are: merely just thoughts. While cognitive fusion is not inherently

42
bad, it becomes problematic when it is no longer helpful moving action in valued

directions. For example, a depressed man who has the thought “I cannot get out of bed

until I no longer feel depressed” and believes this to be true, may choose to remain in bed

until the feeling subsides. However, this becomes problematic when believing that

thought interferes with his chosen values of showing up for his family or job. Cognitive

defusion is a way of distancing from thoughts and private experience, thereby creating an

opportunity to respond differently when attachment to them is not workable.

Mindfulness techniques, such as watching thoughts like leaves on a stream and labeling

them as such help to diminish their literality. Cognitive defusion results in weakening an

individual’s attachment to internal experiences by changing the context in which they

occur (Hayes et al., 2012).

Self-as-context. The “self” in ACT has three levels: 1) self-as-content; 2) self-as-

context; 3) and self-as-process (Hayes et al., 2012). The self-as-content is a view of

oneself from a literal perspective, or fusion with one’s self-concept. The thoughts,

feelings, sensations, and memories one has experienced become the story of the self. For

example, “I am…” followed by a variety of attributes one constructs over time, creates a

story that the individual fuses and identifies with. As a result, one can become rigid in

their behaviors, finding ways to distort or reinterpret and defend events so they remain

consistent with this conceptualization of the self, even when doing so results in harm

(Hayes et al., 2012); this is another form of cognitive fusion. Self-as-context involves the

experiencing of events from an “I/here/now” perspective, in which one experiences and

43
remains distinct from those events (“observer self”). This is a form of cognitive defusion

and involves the individual stepping back from their personal narratives and taking an

observer stance, observing that the story is separate from the person doing the noticing.

This includes self-as-process, an ongoing, defused and nonjudgmental awareness and

description of private events in the moment (Hayes et al., 2012). Once self-as-context

has been developed, an individual becomes increasingly aware of the continuous stream

of experiences as they arise, without becoming attached to them. Mindfulness exercises,

metaphors, and various experiential processes all help to foster this transcendent sense of

self, and the individual learns the story they are attached to is just one of many, can be

held lightly, and may or may not be working well for them (Hayes et al., 2012).

Values. At times, an individual may present with behaviors inconsistent with

what they view to be important in life. Rigid and inflexible ways of behaving, such as

fusion and experiential avoidance, can interfere with one’s quality of life in a variety of

domains including family, work, health and others (Hayes et al., 2012). Avoiding the

aversive private experience becomes the main focus and clients begin to lose touch with

what is most important. Clarifying values provides motivation and ability to engage in or

alter behavior in service of valued directions. Values work involves contacting what is

most important to the individual. Various exercises assist individuals in choosing life

directions that are not based on avoidance or social compliance. Contacting values

provides a course of direction for purposeful and intentional goal directed actions with

goals being specific, concrete, observable points in the direction of a chosen value which

44
is ongoing and does not end (Hayes et al., 2012). For example, one may value intimacy

which cannot be checked off a list or compassion, another ongoing value with no end for

which goals are created like checkpoints on a path.

Committed action. Inaction, impulsivity and avoidance are all examples of rigid

inflexible behavior that can stand in the way of living a value directed life (Hayes et al.,

2012). For example, an individual may be so consumed with avoiding painful internal

experiences that they become inactive with respect to values or they may act in ways that

are harmful to themselves or what they truly care about. Committed action, on the other

hand, involves setting goals according to selected values and acting intentionally and

flexibly, even in the presence of the unpleasant internal experience, in service of

individual valued ends (Hayes et al., 2012). This involves concrete, achievable goals that

are values consistent. The development of committed action requires a willingness to

remain in contact with aversive private experiences and the contexts in which they occur

as well as ongoing contact with values.

In sum, ACT is a mindfulness-based, contextual cognitive behavioral therapy that

teaches individuals how to change the way they relate to ongoing private experience

(willingly and non-defensively) with the goal of flexible, committed action in the service

of valued living. The interaction between these six psychological flexibility processes

contributes to the overall wellbeing of humans (Hayes et al., 2012; Hayes et al., 2006;

Hayes et al., in press). Published empirical trials support the claim that ACT treatment

works through the basic psychological processes identified by its theory (Hayes et al.,

45
2006). Recently, an increasing number of protocols have become available for use of

ACT with specific populations. The focus of each protocol is on the six core processes,

and the common goal is increasing psychological flexibility and decreasing experiential

avoidance. Therefore, implementing and tailoring protocols to fit a variety of populations

may exhibit the overall positive outcomes ACT has been found to produce. Growing

evidence supports ACT as an effective treatment for a variety of problems (Hayes et al.,

2006; Hayes et al., in press).

46
Figure 1: Six Core Processes of ACT That Represent Psychological Inflexibility
(Hayes et al., 2012)

Inflexible Attention

Disruption of
Values;
Dominance or
Experiential
Pliance, Fused
Avoidance
or Avoidant
“Values”

Psychological
Inflexibility

Inaction,
Cognitive Impulsivity,
Fusion or Avoidant
Persistence

Attachment to the
Conceptualized Self

47
Figure 2: Six Core Processes of ACT That Represent Psychological Flexibility
(Hayes et al., 2012)

Flexible Attention to the Present

Moment

Acceptance Values

Psychological
Flexibility

Committed
Defusion Action

Self-as-Context

48
 Effectiveness of ACT. To date, ACT has proven to be an effective therapeutic

approach applicable to a variety of psychological problems including depression (Zettle

& Hayes, 1986, 2002; Zettle & Rains, 1989; Zettle, 2004), anxiety (Levitt et al., 2004;

Orsillo, Roemer, Block, LeJeune, & Herbert, 2004; Twohig & Woods, 2004; Zettle,

2003), chronic pain (Dahl, Wilson, & Nilsson, 2004; Robinson, Wicksell, & Olsson,

2005), work stress (Bond & Bunce, 2000), medically related psychological distress

(Branstetter, Wilson, Hildebrandt, & Mutch, 2004; Robinson et al , 2005), psychosis

(Bach & Hayes, 2002; Gaudiano & Herbert, 2006), epilepsy (Dahl & Lundgren, 2005),

treating children and adolescents (Greco, Blackledge et al., 2005; Murrell & Scherbarth,

2006), smoking cessation (Gifford et al., 2004), trichotillomania (Woods, Wetterneck, &

Flessner, 2006; Twohig & Woods, 2004), and substance abuse (Gifford et al., 2004;

Hayes, Bissett et al., 2004; Wilson & Byrd, 2004).

The evidence for ACT has shown somewhat larger effect sizes with more severe

problems, and follow-up effect sizes equally as large or larger than post-intervention

(Hayes et al., 2006). Reviews of randomized controlled trials (RCTs) of ACT have

estimated an overall effect size for ACT in the moderate range (0.66 – 0.68; Hayes et al.,

2006; Öst, 2008).

In order to expand this model further, future research could focus on other

populations and presenting problems, such as inmates who predominantly present with

issues around anger and substance abuse as well as many of the mental health problems

ACT has shown efficacy with including depression, anxiety, and psychosis.

49
 In sum, prison-based treatment has been shown to have positive effects with

offender populations, particularly CBT oriented interventions, on recidivism and relapse

rates. However, reduced recidivism is not necessarily the outcome goal of all programs,

can underestimate immediate needs of inmates in their current environment, is costly and

difficult to track, and it may be an unrealistic expectation of a mental health treatment

program. In treating mentally ill offenders specifically, clinical needs may be met through

psychological treatment (i.e., symptom reduction & improved functioning through CBT

treatment); however, treatment may not be addressing recidivism or criminal thinking and

behavior. Focusing on recidivism as the dependent variable could be problematic when

the original goals of the adapted intervention, CBT, are symptom reduction and overall

improved, individual functioning. Contextual CBT interventions targeting a wider

functional class (e.g., experiential avoidance) may be beneficial for inmate populations

who present with a variety of problems that have been shown to be correlated with

experiential avoidance. During incarceration, offenders and institutions may benefit from

overall individual improved functioning and quality of life. Thus, this study examined the

effect of ACT on individual psychological flexibility, thought suppression, and anger-

related behavior.

Present Study

This study investigated the impact of ACT on experiential avoidance with male

inmates. Specifically, this study examined changes in self-reported measure scores

following a 6-week ACT intervention for a group of male inmates within a Midwestern

50
state prison. The facility from which the archival measures were gathered offers an

ongoing substance abuse treatment program for inmates. Given the prevalence of

substance abuse and reported anger in inmate populations discussed earlier, and the fact

that the institution where data was gathered runs a separate substance abuse program, the

department of psychological services chose to tailor the ACT group after the protocol for

ACT and anger, HEAT, or Honorably Experiencing Anger and Threat. HEAT was

created by Santanello and Kelly (unpublished) and is largely based on the book ACT on

Life, Not on Anger (Eifert, McKay, & Forsyth, 2006). HEAT is six sessions long and

incorporates the six core processes of ACT. While the protocol was based on

problematic anger, the goal of the group was a common outcome goal among all ACT

protocols, to increase psychological flexibility (i.e, decrease experiential avoidance) and

cognitive defusion. Participants of the group discussed problematic anger-related

behaviors; however, they were encouraged to replace problematic anger-related behavior

with other areas they may be struggling with (e.g., depression, anxiety, substance abuse)

as well.

This program focused on improved individual functioning for incarcerated

individuals, rather than treatment impact on recidivism rates, chronic addiction patterns,

and other long-range rehabilitation goals. In order to examine the outcome of the ACT

group provided, this study examined the following archived measures completed by the

inmates as part of their participation in the group and archived within the institution: the

Acceptance and Action Questionnaire-II (AAQ-II), Anger Consequences Questionnaire

(ACQ), and the White Bear Suppression Inventory (WBSI). Research has supported the

51
relationship between psychological flexibility and acceptance in predicting mental health,

physical health, and positive outcomes in psychotherapy (Hayes et al., 1996). Therefore,

it was hypothesized that psychological flexibility and acceptance would be predictive of

improvements in outcome variables at post-treatment.

Research Questions and Hypotheses

To date, there have been no published studies examining the effectiveness of ACT

for anger or for use with prison populations in the United States. The purpose of this

study was to evaluate the effectiveness of an ACT group intervention for an inmate

population that was aimed at improving individual function including increasing

acceptance and psychological flexibility and decreasing thought suppression. Given that

an anger behavior measure was archived and available, the effect of the ACT group on

anger-related behavior was also examined. This study examined the following

hypothesis at an alpha level of .05 for significance:

Hypothesis 1. Results from Acceptance and Action Questionnaire-II (AAQ-II)

scores were expected to show an increase in acceptance/psychological flexibility from

pre- to post-test.

Hypothesis 2. Results from the White Bear Suppression Inventory (WBSI)

scores were expected to show a decrease in thought suppression.

52
 Hypothesis 3. Results from the Anger Consequences Questionnaire (ACQ,

action items only) were expected to show a decrease in self-reported frequency in anger-

related behavior.

53
 Chapter 3: Research Design and Methodology

Research Design

This study was a retrospective review of pretest-posttest (A-B) measures

following a six-session ACT intervention provided to inmates incarcerated at a state

correctional facility.

Main study variables. This review assessed the effects of the independent

variable, ACT group treatment, on three dependent variables: psychological flexibility

and acceptance, thought suppression, and self-reported anger-related behavior.

Participants. Questionnaires were reviewed for the seven male inmates (N=7)

who volunteered for the ACT group while housed at the transitional institution (i.e.,

prison). All volunteers were welcomed regardless of diagnostic presentations. Inclusion

criteria for the study included inmates who received the full ACT treatment group and

completed the associated questionnaires. Unlike many studies that may exclude

particular participants who do not meet diagnostic criteria for a particular disorder, do not

meet a baseline level of a particular measured construct, or have a substance abuse

problem, the present study was designed to evaluate the actual treatment provided to the

entire volunteer sample. Exclusion criteria included inmates who did not attend all six

sessions of the treatment group or who failed to complete all pre- and post-measures.

54
 Measures. The purpose of this study was to investigate changes in common

underlying psychological processes, such as psychological flexibility and thought

suppression on anger-related behavior. Archived measures collected pre- and post-group

were analyzed.

Acceptance and Action Questionnaire-II (AAQ-II). The most widely used

measure of experiential avoidance (or psychological inflexibility) is the Acceptance and

Action Questionnaire (AAQ; AAQ-II; Bond et al., in press; Hayes, Strosahl et al., 2004).

The AAQ assesses an individual’s avoidance of private experience and effective action

when faced with their event. The AAQ is often referred to as a measure of experiential

avoidance and psychological flexibility, depending on how the items are scored. The

AAQ-II was used in this study to assess psychological flexibility (or acceptance/

experiential avoidance) where higher scores indicate greater psychological flexibility.

Psychological flexibility is one proposed underlying process of change in ACT. The

AAQ-II (Bond et al., in press; Hayes, Strosahl et al., 2004) is a seven-item paper-and-

pencil self-report questionnaire. Each item on the AAQ-II is rated on a seven-point

Likert scale ranging from “never true” to “always true.” The AAQ-II appears to measure

the same concept as the AAQ-I (r = .97). The AAQ-II demonstrated adequate reliability

(alpha=.84), and good test-retest reliability at three- and 12-month follow up (.81 & .79

respectively). The AAQ-II demonstrates good convergent and predictive validity (BDI, r

=.71; WBSI, .63) and was the measure used in this study.

55
 White Bear Suppression Inventory (WBSI). The WBSI is a 15-item

questionnaire which was designed to measure the suppression of thoughts over time

(Wegner & Zanakos, 1994). The WBSI was measures the degree to which an individual

relies on thought suppression (Wegner & Zanakos, 1994), making it an appropriate

measure for use with ACT interventions given the research supported assumption that

suppression of unpleasant thoughts can paradoxically increase the occurrence of those

same unpleasant thoughts over time (Hayes, Strosahl et al., 2004; Wegner, 1989). Each

item of the WBSI is scored on a five point Likert scale ranging from “strongly disagree”

to “strongly agree” with a rating of five indicating “strongly agree.” Responses are

totaled, summed and can yield an overall score ranging from 15-75 with higher scores

indicating a greater tendency to suppress thoughts. The WBSI has good internal

consistency (alphas .87-.89) and test-retest reliability (one-week correlation .92, three-

week to three-month, .69). The WBSI demonstrates good convergent validity with

several measures including the Beck Depression Inventory and State-Trait Anxiety

Inventory.

Anger Consequences Questionnaire (ACQ). The ACQ is a 33-item, paper-and-

pencil self-report questionnaire used to measure the consequences of problematic anger

(Deffenbacher, 1996; Deffenbacher, Oetting, Lynch, & Morris, 1996; Dahlen & Martin,

2006). Only the 27 questions measuring action and overt behavior typical in response to

anger were included for this study as ACT targets one’s relationship to anger feelings

rather than the form or frequency of thoughts and feelings. This is one assessment

56
measure of anger where the action items can easily be separated and scored. Each

question is rated on a scale from zero to four (none, to four or more behaviors) with

higher scores representing a higher number of problematic actions.

Although these measures have not been normed on adult male inmates, subjects’

scores were used to compare pretest and posttest ratings for the same subjects. The

rationale for choosing to include these particular archived measures was that these were

considered to be valid and the best available measures for each construct of interest.

Procedure

The primary measures utilized in this study had been previously collected by the

department of psychological services at the institution, at pretreatment, and posttreatment

as part of the treatment-as-usual procedures. Prior to the first session, group members

completed all standard institutional forms including Department of Corrections (DOC)

consent forms for psychological and group services, and the assessment measures as is

standard in CBT practice. The ACT treatment group was offered for 60 minutes, twice

per week and therefore extended over the course of three weeks. At the end of the six

sessions, the group was terminated and all of the questionnaires were stored at the

institution in compliance with the standard institutional procedures.

Upon reception of a letter of support from the site (see Appendix A), approval by

the Department of Corrections Research Review Committee and The Chicago School

IRB, data was compiled and coded by a research assistant. In an attempt to protect the

inmates’ confidentiality the names and other specific, potentially identifying

57
demographic information, were omitted from the materials and not shared with this

researcher. The data set therefore included de-identified scores from the aforementioned

questionnaires at pre- and post-treatment group (AAQ-II, ACQ & WBSI).

Intervention. The ACT intervention was adapted from Santanello and Kelly’s

HEAT protocol (unpublished manuscript) and the ACT on Life, Not on Anger book

(Eifert et al., 2006). See Appendix B for an outline of each session that was provided by

the institution.

Statistical Procedures

Given that this study involved basic pretest-posttest procedures, the t-test

comparison of means statistical procedure was appropriately utilized (Gravetter &

Wallnau, 2008). Paired samples t-test (two-tailed), p< .05 were run to determine the

changes in overall pre-treatment and post-treatment AAQ-II scores for the participants

(Hypothesis 1), pre- and post-treatment WBSI scores for the participants (Hypothesis 2),

and the pre- and post-treatment ACQ scores for the participants (Hypothesis 3). The

overall pre- and post-test AAQ-II, ACQ and WBSI scores for each participant were

examined using the t-test comparison of means, p < .05. The statistical analyses for this

study were performed using PASW Statistics (v. 18). See figure 3 for a summarized

diagram of the procedures explained above.

58
Figure 3: Procedures of the Study

Three weeks later: Completed Measures

Spring 2011: Pre-Intervention
Measures and ACT Treatment

August 12, 2011: Department of

Corrections Research Review Committee
approval obtained

August, 26, 2011: IRB approval obtained

October 23, 2011: Data Obtained

November, 2011: Data Analysis

59
 Chapter 4: Findings

The following sections present descriptive statistics collected and pre- and post-

treatment scores on each of the measures by each individual. Results are presented and

examined as a repeated-measure, paired-samples t-test to determine the impact of the

ACT treatment group by comparing the pre to post-treatment scores. Finally, the

hypotheses were analyzed to determine whether or not the data suggests the rejection or

adoption of the null hypotheses.

Descriptive Statistics

Archival data was collected from seven inmates (N=7) who completed the

questionnaires as part of their voluntary participation in a six-session ACT treatment

group. Of these seven men, five of the participants were identified as Caucasian and two

of the participants were identified as African-American. The average age of the

participants was 38, and ages ranged from 20- to 62-years-old (see Table 4.1 for a

summary of participant characteristics).

Table 4.1: Participant Characteristics

Variable N Mean Range
Male 7
Caucasian 5
African-American 2
Age 7 38 20-62

60
Analysis

Test of hypothesis 1. Results from Acceptance and Action Questionnaire-II

(AAQ-II) scores were expected to show an increase in acceptance/psychological

flexibility from pre- to post-test. The mean AAQ pretreatment score was 28.86 (SD=

8.94). The mean post treatment AAQ score was 26 (SD= 8.406). Table 4.2 compares

means and standard deviations for participant’s pre and post AAQ scores. A repeated-

measures t-test of the differences between pre and posttest scores of the AAQ (level of

psychology flexibility/acceptance) failed to demonstrate a significant increase in the

overall level of psychological flexibility occurred, t(6) = 1.257, p= .255, two-tailed, for

inmates who completed the six-session ACT treatment group. Table 4.3 shows the

results of the ACT group on level of psychological flexibility/acceptance with a

significance level of .05. Therefore, hypothesis 1 was not supported by the results and

the null hypothesis could not be rejected.

Table 4.2: Level of Psychological Flexibility/Acceptance

(as measured by the AAQ-II)
Measure Mean SD
AAQ Pretest 28.86 8.494

AAQ Posttest 26.00 8.406

Change -2.86
Note: Negative change (post- minus pre-test score) reflects a decrease in the level of psychological
flexibility/acceptance level.

61
Table 4.3: T-test for ACT Group Effects Over Level of Psychological
Flexibility/Acceptance Level
Variable t Df Sig. (two-
tailed)
Level of psychological 1.257 6 .255
flexibility/acceptance level

Test of hypothesis 2. Results from the White Bear Suppression Inventory

(WBSI) scores were expected to show a decrease in thought suppression. The mean

pretreatment WBSI score was 54 (SD= 9.764). The mean posttreatment WBSI score was

54.29 (SD= 11.339). Table 4.4 compares means and standard deviations for participant’s

pre and post WBSI scores. A repeated-measures t-test of the differences between pre-

and posttest scores of the WBSI (level of thought suppression) was utilized to assess the

effect of ACT on level of thought suppression. Upon completion of the data analysis,

results showed no significant decrease in self-reported thought suppression occurred t(6)

= .671, p = .099. See table 4.5 below for a summary of the t-test results. Hypothesis 2

was therefore not supported and the null hypothesis could not be rejected.

Table 4.4: Level of Thought Suppression

(as measured by the WBSI)
Measure Mean SD
WBSI Pretest 54.00 9.764

WBSI Posttest 54.29 11.3398

Change 0.29
Note: Positive change (post- minus pre-test score) reflects an increase in the level of thought suppression.

62
Table 4.5: T-test for ACT Group Effects Over Level of Thought Suppression
Variable t Df Sig. (two-
tailed)
Level of thought -.240 6 .818
suppression

Test of hypothesis 3. Results from the Anger Consequences Questionnaire

(ACQ, action items only) were expected to show a decrease in self-reported frequency in

anger-related behavior (ACQ, action items only, frequency of maladaptive anger-related

behavior). The mean ACQ pretreatment score was 21 (SD= 8.307). The mean post-

treatment ACQ score was 26.43 (SD= 33.196). Table 4.6 compares means and standard

deviations for participant’s pre- and post-ACQ scores. A repeated-measures t-test of the

differences between pre- and post-test scores of the ACQ (frequency of maladaptive

anger-related behavior) was utilized to assess the effect of ACT treatment on problematic

anger. Results showed no significant decrease in overt, self-reported anger-related

behavior occurred post intervention, t(6) = .454, p = .666, two-tailed. See table 4.7 for a

summary of the t-test results. Therefore, hypothesis 3 was also not supported and the null

hypothesis could not be rejected.

Table 4.6: Frequency of Maladaptive Anger-Related Behavior

(as measured by the ACQ)
Measure Mean SD
ACQ Pretest 21.00 8.307

ACQ Posttest 26.43 33.196

Change 5.43
Note: Positive change (post- minus pre-test score) reflects an increase in the level of maladaptive anger-
related behavior.

63
Table 4.7: T-test for ACT Group Effects Over Frequency of Maladaptive Anger-Related
Behavior
Variable t Df Sig. (two-
tailed)
Frequency of maladaptive -.454 6 .666
anger-related behavior

64
 Chapter 5: Discussion and Recommendations

The number of mentally ill, substance abusing, and non-mentally ill inmates has

steadily increased over the years (Diamond et al., 2001; Fazel et al., 2006; Veysey &

Bichler-Robertson, 2002). The United States prison system houses three times the

number of severely mentally ill individuals than all the psychiatric hospitals combined

(Abramsky & Fellner, 2003). While these increasing numbers over the last decade may

seem shocking, some suggest these estimates are still an underrepresentation of the true

number of inmates suffering from a mental health disorder (Rice & Harris, 1997).

Although many programs are available to offenders on parole or probation in the

community, prison-based treatment services are equally important, particularly for

mentally ill inmates, to the rehabilitation and reintegration process (National Research

Council, 2007; Morgan et al., 2012).

Correctional philosophies focused on crime control and retribution during the

twentieth century (Byrne & Brewster, 1993; Pacheco, 1994) appeared to be ineffective

when considering the number of released offenders who recidivate. In response to the

continued growing number of inmates and the outcomes of a number of meta-analyses

that indicated programs for offenders can indeed be effective (Aos et al., 2006; Cullen &

Gendreau, 2000; Lipsey et al., 2001; Pearson et al., 2002; Ronan et al., 2010), a return to

treatment and rehabilitation in the philosophy of corrections has taken place more

recently. This shift makes outcome research vital in the search for “what works” in the

treatment of general, substance abusing, and mentally ill inmates. This search requires an

increased emphasis on the relationship between mental health and recidivism, necessary

65
in closing the gap between psychology and correctional goals and uncovering the most

effective forms of intervention. This requires continued examination of short-term

outcomes of prison-based treatment as well as follow-up, longer-term outcomes.

While recidivism continues to be the most desired outcome of treatment in

corrections, it may not be the outcome goal for all interventions, it is costly and difficult

to track, and it may seem lofty and unrealistic to mental health professionals. Continuing

to utilize recidivism as an outcome measure may underestimate the ability for some

prison-based interventions to have an effect on more immediate intended outcomes (i.e.,

symptom reduction, reduced problematic behavior, overall individual functioning).

Currently, recidivism is the most widely studied outcome of offender treatment and has

been shown to be reduced by some offender programs more than others (Lipsey, 1992;

Pearson et al., 2002). When examining the most effective programs in corrections, CBT

oriented programs appear to be producing the greatest effects and are the most utilized

approach to treatment in corrections (Hollin, 2004), demonstrating positive outcomes

related to the reduction of future criminal behavior (Lipsey et al., 2001; Shaffer & Pratt,

2009). Still, research in this area is limited in its ability to be generalized to incarcerated

adults as well as in its short-term effects on psychological wellbeing and how this relates

to recidivism rates. Further, it remains unclear how these CBT interventions work when

they are shown to be effective.

Although CBT is thought to assist offenders in eliminating or changing their

faulty, “criminal” thinking patterns, more recent research does not support this proposed

mechanism of change in CBT (Hayes et al., 2006). Instead, research suggests efforts to

66
suppress or alter specific thoughts can paradoxically increase the frequency of those same

undesirable thoughts (Clark et al., 1991; Wegner, 1989, 1992, 1994; Wegner et al., 1987).

An approach to treatment that can address the noted gaps in offender treatment research

along with these limitations of CBT while remaining as effective would be valuable.

Acceptance and Commitment Therapy (ACT), a contextual cognitive and

behavioral therapy, integrates acceptance and mindfulness techniques with behavioral

activation, addresses the paradoxical effects of thought control, and targets experiential

avoidance as a broad functional class (Hayes et al., 2012). This approach may be one

alternative that both addresses the longer-term effects of psychological treatment on

behavior and bypasses the issues of associated generalization. ACT has progressively

gained empirical support as an effective treatment approach for many problems

(including those often found in inmate populations), is applicable to a variety of

populations, and has demonstrated putative hypothesized processes of change to be in

line with the underlying theory (Hayes et al., 2006; Hayes et al., in press).

While the corrections field is shifting toward a “what works” approach to the

treatment of offenders, the field of correctional psychology would benefit from continued

funding, implementation, and examination of well-documented programs in order to

identify programs that are most effective relative to a pre-determined goal (Cullen &

Gendreau, 2001; MacKenzie, 2000; Snyder, 2007). Part of the role of psychology in the

field of corrections might be to work with researchers in ongoing investigation of

effective treatment programs.

67
 The purpose of this pilot study was to examine the effectiveness of an ACT

treatment group in a correctional setting. The research examined changes in the

frequency of self-reported levels of psychological flexibility, acceptance, thought

suppression, and maladaptive anger-related behavior from pre- to post-treatment

following six sessions of the ACT group.

Results yielded statistically insignificant findings for this ACT group and the

treatment group appeared to have the opposite effect on outcomes than was hypothesized.

Despite these findings, the three measured variables still appeared related. More

specifically, the level of psychological flexibility decreased slightly for participants from

pre- to post-treatment compared to their reported baseline level. In other words, they

appear to have engaged in higher levels of experiential avoidance over the course of the

three weeks. The relationship between psychological flexibility and thought suppression

was predicted to be an inverse relationship, such that as psychological flexibility

increased, thought suppression would decrease. Although thought suppression actually

increased, the demonstrated relation between thought suppression and psychological

flexibility appeared as hypothesized, in that higher levels of thought suppression were

observed with lower levels of psychological flexibility (i.e., increased experiential

avoidance). The direction of the relationship between these two variables seems

consistent with previous finding indicating that thought suppression has been considered

to be a form of experiential avoidance (Hayes et al., 1996). Further, anger-related

behavior was reported to have increased by volunteers as well which would seem logical

in light of the other two outcomes; the more avoidant individuals are, the more likely they

68
are to engage in ineffective behavior. While these findings are important as a first

attempt to study this approach with incarcerated males, they should be noted as being

inconsistent with most of the ACT outcome research thus far, and interpreted with

extreme caution in the context of the many limitations involved.

The first notable limitation was the extremely small sample size, N=7. A

drawback to a small sample size is the effect on power, or the ability to identify a change

if a change did in fact occur. Therefore, finding a significant effect becomes more

difficult.

The shortened time between pre- and post-measures and bi-weekly administration

of the treatment (treatment dosage) may have also acted as a significant limitation to this

study. Given the pretrial nature of this setting and bi-weekly administration of the

treatment, only three weeks elapsed between pre- and post-measures. While some studies

argue that treatment dosage positively affects outcomes (Bourgon & Armstrong, 2005),

others have concluded treatment dosage is insignificant in predicting outcome (Shaw &

Morgan, 2011). For this study, the shorter time frame increased the intensity of content

and delivery and reduced the amount of time inmates had to process, practice, and apply

skills learned in group. This is important when considering ACT effectiveness studies,

which have been shown to produce greater changes over time (Hayes et al., in press). In

fact, in some ACT studies significant differences were not observed at post-treatment and

yet, significant differences were later found at follow-up (Páez, Luciano, & Gutierrez,

2007). Further, ACT has been shown to have better outcomes at follow up compared to

the post-treatment and follow-up of other empirically supported treatments that were

69
comparable at post-treatment (Gifford et al., 2004; Hayes, et al., in press; Arch et al.,

2012; Hayes, Strosahl et al., 2004). While ACT demonstrates significant improvements

at longer-term follow-up, there still have been a number of studies that have

demonstrated positive effects of very brief ACT interventions as compared to longer-term

therapy (Fernandez, Luciano, & Valdivia-Salas, 2012; Montesinos & Luciano, 2005;

Powers, Vording, & Emmelkamp 2009; Zettle & Hayes, 2002). Given the transitory

nature of the population at this institution, follow-up over longer time periods were not

feasible. Therefore, time and dosage limitations may have contributed to the trends and

insignificant findings for this particular study.

Data representing an alternative treatment or TAU was not available from the

institution to use as a control and would have provided further information regarding the

study. Thus, the research design, namely the lack of a control group, also acted as a

limitation. First, without a comparison group it is difficult to obtain information

regarding whether ACT, or any intervention could be effective given the context.

Second, lack of a control group limits the ability to eliminate possible causes for the

unexpected observed results, other than the ACT treatment group. More generally, other

variables may have interfered with the results outside of the treatment group. For

example, the length of time participants have been incarcerated, their current charge, or

the maximum length of time they may be facing could all be confounding variables

affecting the outcome of this study.

The nature in which participants for the group were gathered and the approach to

the group may have impacted the results of this study. Namely, the group was not

70
advertised as a group for anger, volunteers were provided with a very brief introduction

of what to expect in the ACT group, and throughout they were encouraged to apply what

they learned in group to other problems outside of anger. Further, inmates were admitted

to the group strictly based on interest and volunteered, they were not required to meet a

baseline level of experiential avoidance, thought suppression, or to have problems with

anger-related behavior in order to participate in the group. Therefore, they may have

signed up for the group without a clear understanding of what the group would address

and could have struggled with applying concepts to individual problems that were

unrelated to anger. Hayes (2012) has recommended that clients be well prepared prior to

participating in ACT therapy given the experiential and powerful experience individuals

may have during treatment. Some have suggested that the exercises and metaphors

presented during treatment cannot simply be general and should target the specific

problem clients are struggling with (Masuda, Hayes, Sackett, & Twohig, 2004). In fact,

one study targeting pain actually observed an increase in problem-behaviors that were not

directly targeted by the ACT intervention (Hayes et al., 2012). Still, some studies have

shown changes in behavior that were not direct targets of the ACT treatment (Lillis,

unpublished dissertation). In addition, ACT has shown greater improvements in

individuals who reported higher levels of experiential avoidance at pre-treatment

(Masuda et al., 2007; Ruiz & Luciano, 2009) and no improvement in low-level problems

(e.g., anxiety; Zettle, 2003). It may be that participants in this group had problems at too

low of a level for ACT to be effective.

71
 Another limitation included the naturalistic research nature of this study. As

previously mentioned, there is evidence to suggest offender treatment and rehabilitative

programs are more effective when implemented in the community than in institutions

(Andrews et al., 1990); perhaps the context of prison-based settings works against the

effectiveness of treatment in general. Experiential avoidance or anger-related behavior,

for example, may have an adaptive function within a prison setting where inmates may

occasionally use violence to maintain safety. Also, the feeling of anger may not

necessarily be related to overtly aggressive actions or violence. Even though there is a

need to examine the effectiveness and potential positive benefits of promising new

approaches to treatment in corrections, implementing research around already existing

practices in corrections can be challenging given the contingencies of the setting.

Specific to this case, the treatment setting was not particularly conducive for

group therapy. For example, anecdotal reports indicated that the room in which the group

was run was located in the inmate housing unit, with a large window facing the ongoing

action of the unit. This provided for many therapy interfering behaviors including:

distraction (i.e., noise and outside inmate action), behaviors related to social perceptions,

abrupt exits during group, and frequent interruptions. Given the context, many daily

challenges could arise presenting difficulty in utilizing a space to hold therapy as well as

a regular time for meeting. Given this limitation (specifically that inmates were watched

by other inmates and staff outside of the room) participants may have been more reactive

to stigmatizing perceptions and reticent to fully engage in the therapeutic process. This is

particularly problematic for ACT groups since much of the work is experiential.

72
 Given the absence of research with the original HEAT protocol and subsequent

adaptations made from the original veteran population to inmates for this particular

setting, program integrity and adherence was another area of potential bias. Although

records helped illuminate the specifics of each session, this adapted version may have

impacted outcomes. Further, while HEAT is a group protocol, there is data that suggests

ACT may be less effective in group settings compared to individual due to its functional

contextual foundation (Hayes, 1987; Zettle & Raines, 1989). Within a group, each

individual may be avoiding different private experiences and situations for a variety of

reasons and individuals may also demonstrate a variety of experientially avoidant

behaviors.

Another limitation concerns the chosen self-report measures. Specifically, the

ACQ, while a popular assessment measure in the treatment of anger, it is not necessarily

the most applicable to research with inmates or with ACT research. Certain items on the

questionnaire, depending upon the time the participant had been incarcerated or the

instructions provided (e.g., “over the last two weeks” vs “since incarcerated”), may not

have been applicable responses for the potential ways in which a participant responded to

anger. For example, an item that asked if anger had led one to driving recklessly or

drinking alcohol was likely not applicable to the men in this setting. This then limits the

items of the questionnaire even more as the non-action items had already been removed

to make it most applicable for use with ACT. Further, for some group members, the two-

week time frame the questionnaire asked one to reflect upon may have meant a change in

context occurred during the time they responded from pre- to post-treatment. This meant

73
that for some individuals, responses on pre-ACQ may have been more applicable to how

they respond to anger in the community and their typical environment, whereas post-

ACQ responses were more likely their response to anger in a prison environment. Given

that anger behavior likely serves a different function in the context of prison, this may be

one reason why an increase was observed to occur over time on the ACQ. In a group

setting, members may have also been more hesitant to admit any reading difficulties they

had while completing the questionnaires or to ask about terms they did not understand.

With the distraction of others and potential fear that other members may be able to view

their responses, some members may have haphazardly completed questionnaires in an

effort to quickly complete them without their personal privacy being compromised.

Finally, ACT targets mainly one’s relationship and response to thoughts and

feelings (e.g., angry feelings, angry thoughts) rather than the increase or decrease of the

actual internal experience. Most standard CBT assessment measures for anger examine

the amount of angry thoughts and other internal experiences, and seek to decrease their

frequency and intensity over time. When utilizing these measures then as outcome

measures for ACT, there may be a problem with construct validity (this was the reason

for including only the action items of the ACQ). While it is difficult to control for all

possible limitations of a study, particularly when performed outside of the laboratory,

future research would benefit the field by addressing some of the limitations of this study.

While the findings of this research failed to support the initially proposed

hypotheses, future recommendations for ongoing research in an area currently neglected,

ACT within a correctional population, can be made in light of the noted limitations.

74
Most notably, follow-up measures and a larger sample size would be recommended.

Given the trend in follow-up data of ACT studies, gathering follow-up data for ACT with

inmates would provide information regarding whether any treatment gains were made

over time after the group ended and shed some light on delayed effects and their potency.

This type of follow-up data would be particularly useful with a prison population to

determine if the treatment impacted the inmates’ behavior upon their return to society,

which could provide additional information on the relationship between clinical outcomes

and recidivism. In the absence of longitudinal data, ACT is not recommended for this

population. Obviously, increasing the sample size would help to increase power in future

studies of ACT with inmate populations.

For future studies, the addition of a control group could help to determine if any

differences observed are due to the treatment itself or if a lack of differences observed

may be due to extraneous factors. Even if future studies demonstrated similar results,

having a comparison group made up of similar inmates could help further explain any

unexpected results. It may also be valuable to add a component of individual therapy or

to utilize an additional comparison group of inmates participating in individual ACT

therapy to determine if ACT is more effective with inmates in individual treatment verses

group.

A higher dosage of treatment is also recommended for future studies of ACT

within corrections. Inmates can be a resistant population with ingrained maladaptive

behaviors that have been reinforced for many years and may require increased

preparation prior to participating in treatment. Specifically for ACT, it may be beneficial

75
to spend more time developing “Creative Hopelessness” which has been shown to be

similar to Motivational Interviewing (MI; Bricker & Tollison, 2011) as they both seek to

activate and increase commitment to changing behavior, draw upon values as way to

evoke commitment, and utilize language processes to help facilitate change (MI through

“change talk” and ACT by undermining verbal self-rules). Also, the ACT treatment and

group should be developed, implemented and introduced as targeting specific

behavior(s). If baseline data suggests inmates of the group are not struggling with

entanglement and avoidance, focusing on other model-consistent areas such as values and

compassion may help to fix potential problems encountered when applying ACT to minor

problems or those who are not struggling with some sort of internal, personal pain.

Regarding the implementation of ACT groups, it is suggested that researchers and

clinicians work with the correctional staff in creating an environment as conducive as

possible to group therapy. Adjusting the setting could be helpful in increasing group

participation and decreasing interfering environmental factors and therapy interfering

behaviors. Arranging the setting in a way that creates more privacy for participants may

impact their experience and subsequent behaviors. While a correctional environment can

be a challenging place to implement therapy and research, it remains a setting in which

both are necessary. Before therapy can be truly effective, it may be necessary to rethink

and reform the prison environment. Research has indicated that dysfunctional patterns of

behavior can develop and are often maintained in environments that are invalidating

(Linehan, 1993). Prison can often be an environment that rewards negative behaviors

and experiential avoidance while punishing prosocial behaviors as well as contact with

76
and acceptance of certain private experiences. While the safety of the institution relies on

strict rules and control of inmates at all hours of the day, inmates may feel they lack the

ability to effect change or engage in values-driven behaviors. This strict, controlling

environment may leave inmates feeling invalidated leading to unpleasant emotional

experiences that trigger negative and maladaptive behaviors. Including staff in the

creation of correctional environments that are more conducive to positive therapeutic

outcomes could also be beneficial.

Examining the effectiveness of the use of ACT with correctional staff, could

highlight the benefits of an all-around ACT approach toward inmates as research already

suggests positive effects of ACT in producing decreased prejudice and negative

stigmatization of clients, and toward those with mental illness as well as decreased job-

related burnout (Hayes, Bissett et al., 2004; Lillis & Hayes, 2007; Masuda et al., 2007).

Providing services, such as ACT, in a context where contingencies for behavior are

already in place can make effectiveness difficult. Including staff in helping to create an

overall effective environment to produce positive change would be helpful.

Finally, tracking the use of protocols and implementing other outcome measures

is recommended for future research in this area of ACT in corrections. Regarding the use

of the HEAT protocol, adhering to the interventions outlined and noting any

modifications made would help in the comparison of future studies. This would also

provide stronger support that outcomes are based on treatment and not failure to maintain

program integrity. The addition of other measures (e.g., conduct reports, staff

observation) would help to validate self-report measures and provide further information

77
on the constructs being measured. With ACT studies, this would be particularly helpful

to gain insight into the overt behaviors of inmates through staff observation and report.

The number and range of ACT consistent measures is still limited and continues to grow

with research including measures outside of self-report that are consistent with the ACT

theory and model. Finally, the administration of a treatment satisfaction survey would be

beneficial in future studies as treatment satisfaction has been positively correlated with

outcome (Shaw & Morgan, 2011).

Providing services to mentally ill offenders during incarceration is imperative in

order to help mentally ill offenders transition into incarceration and then later transition

to society (National Research Council, 2007; Morgan et al., 2012). An absence of

services or disruption in the continuity of care for the mentally ill offender will continue

to have a significant impact on institutional management, criminal reoffending and

community safety. The value of examining the effectiveness of various therapeutic

groups and approaches within prison settings is that it may allow for psychological staff

to make better informed decisions regarding what types of programming to offer based

on the potential benefits of the program, and the costs to provide such services. The need

to close this gap between research and practice has been pointed out as a larger task in the

broader field of psychology (Kazdin, 2011). Examining the effectiveness of

interventions for mentally ill offenders must not be limited to a focus on mental illness or

criminal behavior alone; a program with the ability to address similar underlying

functions of psychological symptoms and problematic, “criminal” behavior, such as

ACT, would be advantageous to the field of correctional treatment. The effectiveness of

78
ACT with inmates and other more challenging populations (e.g., individuals with brain

injury and IQs below 70) is only in the early stages of research. Continuing to push the

model by exploring it within such populations will help to shed light on potential

weaknesses or deficiencies that can trigger changes necessary for further developing the

ACT model.

79
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Appendix A: Letter of Support from WI DOC

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 Appendix B: Act Intervention: Session Outline and Sessions

Session 1: Survival mode and the five parts of anger. This session covered

informed consent, group rules, limits of confidentiality, roles of the therapist, and

introductions. Introductions included each member stating one thing meaningful to them

in life. Also, an introduction to ACT was provided, followed by a discussion of survival

mode and the five parts of anger. The group was oriented to the ACT focus on

acceptance of difficult experience, and presented with information about survival mode,

the connection between threat perception and anger, and the five parts of anger. The

facilitators discussed cognitive, physiological and behavioral aspects of anger.

Experiential exercises asked group members to recall a time they experienced an anger-

provoking incident and to identify the five parts of anger. A brief introduction to goals

and values was provided to establish motivation for difficult work. Group members were

asked to share one meaningful thing in their lives. Finally, homework included a

Survival Mode Diary where participants were asked to practice the skill of noticing the

five parts of anger by completing a Survival Mode Diary entry each day. An additional

homework activity included asking the members to complete index cards with questions

related to values to be kept privately throughout the course of the group. The session

ended with facilitators asking for commitment from each member.

Session 2: Control and anger. This session began with an introduction to

mindful breathing followed by review of the homework. Exploring “Are you doing what

matters to you?” using the homework helped introduce workability, creative hopelessness

(cost of behaviors) and introduce a possible alternative to control. Members were

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oriented to the paradox of control, and struggle as the problem. The discussion focused

on struggling with anger as the problem, not the solution. During this session, members

were also presented with information about problems with control and the importance of

recognizing what they can and cannot control (e.g., people and emotions cannot be

controlled and individual behavior can be chosen and controlled). The use of metaphors

helped to clarify the discussion points. The discussion included the idea of ending the tug

of war with anger. Homework following this session focused on the questions, “what has

the struggle with anger cost you” (i.e., noticing anger-related behaviors and their

workability over the course of lifetime) as well as a “what I can and cannot control”

checklist. Members were also asked to practice daily mindful breathing.

Session 3: How the mind creates anger. This session began with a mindfulness

exercise and brief review of homework. The discussion focused on the connection

between thinking and anger, and the four models of thinking/anger relationships. This

session also included an introduction to the automaticity of anger-related thoughts, the

arbitrary nature in which thoughts get programmed into the human mind, and the

techniques that allow an individual to avoid “buying into” thoughts. During session, the

group practiced cognitive defusion and acceptance. The members also explored

interpersonal values and group leaders facilitated member contact with what was

important to each individual. Homework for members was to assess individual anger

trigger thoughts and practice applying defusion skills.

Session 4: Patience and acceptance. This session began with a mindfulness

exercise and a review of homework. Facilitators presented information regarding the

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usefulness of patience in working with thoughts and feelings related to anger. Metaphors

were utilized to help illustrate this concept. The discussion included a link of patience to

acceptance, with facilitators debunking the myths about acceptance. The group practiced

in-session with an exercise. Homework asked members to practice patience with

emotions.

Session 5: Resentment and forgiveness. This session began with a mindfulness

exercise and discussion of homework. Facilitators discussed the concept of resentment.

The group participated in an experiential exercise regarding the costs of resentment and

the possibilities offered through forgiveness. A discussion of forgiveness, and learning to

forgive, followed. Homework included asking members to use forgiveness to work on

resentment.

Session 6: Values and commitment. This final session began with a

mindfulness exercise and a discussion of the homework. The focus of this session was on

values and commitment. Group members were introduced to the idea that choosing anger

is only one option among many, and choosing valued behavior is an alternative. Various

exercises were utilized for values identification. Each member was asked to state an

individual commitment in front of the rest of the group. Homework for the final session

was for members to follow through on their stated commitments.

Following the closing of the last session, members were asked to complete

assessment measures again.

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