A Multisite Randomized Trial of a Cognitive Skills Program for Male Mentally Disordered Offenders: Violence and Antisocial Behavior Outcomes

Journal of Consulting and Clinical Psychology, 2012, DOI:10.1037/a0030291 This article may not exactly replicate the final version published in the APA journal. It is not the copy of record. Journal of Consulting and Clinical Psychology 2012 American Psychological Association 2012, Vol. 80, No. 6, 000 0022-006X/12/$12.00 DOI: 10.1037/a0030291 BRIEF REPORT A Multisite Randomized Trial of a Cognitive Skills Program for Male Mentally Disordered Offenders: Violence and Antisocial Behavior Outcomes Alexis E. Cullen King s College London Amory Y. Clarke South London and Maudsley NHS Trust, London, United Kingdom Elizabeth Kuipers, Sheilagh Hodgins, Kimberlie Dean, and Tom Fahy King s College London Objective: Despite a large evidence base indicating that cognitive skills programs can reduce reoffending in individuals without mental illness, there have been no randomized controlled trials (RCTs) to determine their effectiveness in mentally disordered offenders (MDOs). In the first RCT of a cognitive skills program for MDOs, we aimed to investigate whether participation in the Reasoning and Rehabilitation (R&R) program reduced violence and antisocial behavior in this population. Method: Eighty-four male inpatients with a psychotic disorder and a history of violence were recruited from medium secure forensic hospitals. Participants were randomized to receive the R&R program, consisting of 36 two-hour sessions, or treatment as usual (). Incidents of violence and antisocial behavior (verbal aggression, substance use, and leave violations) were assessed during treatment and at 12-months posttreatment. Results: Relative to the group, incident rates of verbal aggression and leave violations during the treatment period were significantly lower in the R&R group; the effect on verbal aggression was maintained at 12-months posttreatment. Half of those randomized to receive R&R did not complete treatment; post hoc analyses were therefore conducted to compare treatment responses in program completers and noncompleters. After controlling for psychopathic traits, incidents of violence, verbal aggression, and leave violations during treatment were significantly lower in program completers, and there were significant effects of program completion on verbal aggression and substance use at 12-months posttreatment. Conclusions: R&R leads to a reduction in incidents of antisocial behavior in MDO populations, with potentially greater impact on those who complete treatment. Keywords: offending behavior, psychosis, treatment dropout, cognitive behavioral approaches, social problem solving Although the vast majority of people with mental disorders do not commit violent or criminal acts, there is a small subgroup of individuals with severe mental illness (SMI) who engage in these behaviors. In the United Kingdom, many of these individuals are transferred to medium secure forensic hospitals for care. Yet there are few studies to guide the provision of effective psychological treatments aimed at reducing antisocial behavior in this population. In contrast, a wealth of research indicates that cognitive behavioral programs are effective in reducing recidivism in offenders without SMI (Lipsey, Landenberger, & Wilson, 2007). A number of small, nonrandomized studies have investigated whether offenders with SMI, known as mentally disordered offenders (MDOs), might also benefit from cognitive behavioral interventions such as cognitive skills programs. These programs Alexis E. Cullen, Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King s College London, United Kingdom; Amory Y. Clarke, South London and Maudsley NHS Trust, London, United Kingdom; Elizabeth Kuipers, Department of Psychology, Institute of Psychiatry, King s College London; Sheilagh Hodgins, Kimberlie Dean, and Tom Fahy, Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King s College London. Sheilagh Hodgins is now at the Département de Psychiatrie, Université de Montréal, Montréal, Quebec, Canada. Kimberlie Dean is now at the School of Psychiatry, University of New South Wales, Australia. We are grateful for the financial support provided by the NHS National Research and Development Programme on Forensic Mental Health Science, United Kingdom. We thank Katy Lye and Hannah Rogers for their assistance with recruitment, data collection, and project management. Kimberlie Dean and Tom Fahy are joint final authors. Correspondence concerning this article should be addressed to Alexis E. Cullen or Tom Fahy, Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, King s College London, London, UK. E-mail: alexis.cullen@kcl.ac.uk or thomas.fahy@kcl.ac.uk 1

2 CULLEN ET AL. target deficits in social-cognitive skills and thinking styles that may underlie antisocial behavior. The results are encouraging and suggest that MDOs who complete treatment show improvements on measures of social problem solving, coping skills, and criminal attitudes (Clarke, Cullen, Walwyn, & Fahy, 2010), and reductions in disruptive and criminal behavior (Ashford, Wong, & Sternbach, 2008; Young, Chick, & Gudjonsson, 2010). Our study, the first randomized controlled trial (RCT) of a cognitive skills program with MDOs, evaluates the Reasoning and Rehabilitation program (R&R; Ross & Fabiano, 1985), a well-established cognitive skills intervention that has been shown to significantly reduce recidivism in offender populations (Tong & Farrington, 2006). We previously reported that MDOs randomized to receive R&R show improvements in social-cognitive skills and thinking styles (Cullen et al., 2012). Some of these improvements were maintained for up to 1 year posttreatment, and participants who completed the full program showed greater benefits. In the present study, we examined the effect of R&R participation on violence (primary outcome), defined as any physically aggressive behavior directed toward others, and antisocial behavior (secondary outcomes: verbal aggression, substance use, and leave violations) in a sample of male MDOs. We hypothesized that MDOs randomized to receive R&R, compared with treatment as usual (), would show a reduction in the number of incidents of violence and antisocial behavior occurring during treatment and during the 12 months following treatment. Only half of those randomized to receive R&R completed the program (Cullen, Soria, Clarke, Dean, & Fahy, 2011). Thus, we also investigated whether there were greater benefits for MDOs who completed the R&R program compared with those who did not, after taking account of potential confounders. Participants and Procedure Method Ethical approval was obtained from the Joint South London and Maudsley and Institute of Psychiatry NHS Research Ethics Committee, and the trial was registered with the International Standard Randomised Controlled Trial Number Register (ISRCTN 46561083). The trial was conducted in six medium secure forensic hospitals in the United Kingdom. Hospital staff referred potential participants to the research team, and the following inclusion criteria were used: (a) a primary clinical diagnosis of psychotic disorder (schizophrenia, schizoaffective disorder, bipolar disorder, or other psychotic disorder); (b) a history of violence; (c) not having participated in R&R or a similar program previously; (d) not actively psychotic (score 4 on each of the Positive and Negative Symptom Scale P items; PANSS [Kay, Opler, & Fiszbein, 2000]); (e) absence of significant cognitive impairments (i.e., IQ 70 or impairments likely to lead to an inability to cope with the demands of the group); and (f) proficiency in English language sufficient to allow participation in the program as judged by the treating team. Patients with comorbid personality or substance use disorders were not excluded. Participants gave written informed consent to partake in the study and for researchers to access clinical files. Owing to the fact that previous evaluations of cognitive skills programs focused on reoffending outcomes (arrest or reconviction), data reported in these studies could not be used to inform sample size calculations. On the basis of previous studies of inpatients in secure forensic hospitals (Ball, Young, Dotson, Brothers, & Robbins, 1994; Gudjonsson, Rabe-hesketh, & Wilson, 1999; Schanda, Gruber, & Habeler, 2000), we estimated the prevalence of violence in the 6 months preceding treatment to be 50%, which was subsequently supported by a study conducted in a U.K. medium secure forensic hospital (Dolan & Davies, 2006). Given the lack of previous studies examining treatments for violence and antisocial behavior in this population, we proposed a clinically significant reduction in these behaviors from 50% to 20%. Calculations performed at 80% power with an alpha level of.05 suggested that 38 participants per group were needed to detect this effect. In total, 121 patients were referred by clinical teams to the trial, 84 of whom (69%) participated in the present study. Reasons for nonparticipation are provided in Figure 1. Forty-four participants were subsequently randomized to receive R&R and 40 to. Baseline assessments, including clinical and research interviews and a review of the clinical file, were conducted prior to randomization. Clinicians completed the P and N scales of the PANSS (Kay et al., 2000); the antisocial personality disorder (ASPD) section of the Structured Clinical Interview for DSM IV Personality Disorders (First, Gibbon, Spitzer, Williams, & Benjamin, 1997); the Psychopathy Checklist: Screening Version (PCL:SV; Hart, Cox, & Hare, 1995); and the Historical, Clinical, Risk- Management 20 (HCR-20; Webster, Douglas, & Eaves, 1997). Block randomization stratified by site was conducted using equal block sizes with concealed allocation. Researchers who conducted assessments were not blinded to allocation status, as this information was often revealed in the clinical notes or by the patients themselves. Interventions R&R. R&R is a highly structured, manualized program targeting social problem-solving skills and thinking styles. The program is delivered over a minimum of 36 two-hour sessions and includes eight core modules: problem solving, assertiveness skills, social skills, negotiation skills, creative thinking, emotion management, values reasoning, and critical reasoning. The program was delivered by experienced staff who had received training during intensive 5-day workshops provided by the program authors. Sessions were held either twice or three times weekly (five to eight patients per group). Unit staff were given the flexibility to deliver either the original R&R program (Ross & Fabiano, 1985) or the revised program (Porporino & Fabiano, 2000), as they were very similar in content, length, delivery style, and materials. Program developers emphasize the need to ensure treatment integrity; when possible (i.e., when all participants in the group signed a release of confidential information form), sessions were recorded using audiovisual equipment, and randomly selected sessions were assessed by one of the authors (AYC) using an objective rating scale developed by the Cognitive Centre Foundation (www.cognitivecentre.com). Formal feedback based on these ratings was provided in supervision sessions, and strategies to improve delivery were also discussed. Reviews completed throughout the trial indicated that this procedure ensured that a high standard of program delivery was maintained.

COGNITIVE SKILLS PROGRAM FOR ANTISOCIAL BEHAVIOR 3 Assessed for eligibility (n = 121) Excluded (n = 37) - Not meeting inclusion criteria (n = 4) - Declined to participate (n = 28) - Transferred to other unit or discharged (n = 5) Randomized (n = 84) Allocated to R&R (n = 44) Allocated to treatment-as-usual (n = 40) Allocation Completed treatment (n = 21) Failed to complete treatment (n = 23) - Relocated prior to treatment start (n = 2) - Patient initiated dropout (n = 14) -Illness relapse (n = 3) - Absconsion prior program (n = 1) - Cognitive impairments (n = 1) - Excluded for disruptive behavior (n = 1) - Excluded for poor attendance (n = 1) Treatment period Data collected at the end of treatment - Data obtained from clinical files (n = 42) - Missing data (n = 2) End of treatment Data collected at the end of treatment - Data obtained from clinical files (n = 40) -Missing data (n = 0) Data collected at the 6-month follow-up - Data obtained from clinical files (n = 41) - Missing data (n = 3) 6-months posttreatment Data collected at the 6-month follow-up - Data obtained from clinical files (n = 39) -Missing data (n = 1) Data collected at the 12-month follow-up - Data obtained from clinical files (n = 42) - Missing data (n = 2) 12-months posttreatment Data collected at the 12-month follow-up - Data obtained from clinical files (n = 38) -Missing data (n = 2) End of treatment (primary outcome) - Analysed (n = 42) - Missing end of treatment data (n = 2) Posttreatment (primary outcome) - Analysed (n = 42) - Missing 6- and 12-month data (n = 2) Analysis End of treatment (primary outcome) -Analysed (n = 40) - Missing end of treatment data (n = 0) Posttreatment (primary outcome) -Analysed (n = 40) - Missing 6- and 12-month data (n = 0) Figure 1. Flow of participants through the trial. R&R Reasoning and Rehabilitation. Treatment completion. On the basis of the bimodal distribution of the number of R&R sessions attended (Cullen et al., 2011), participants who attended 30 or more sessions were defined as completers, and those who attended 30 or fewer as noncompleters.. Participants in both trial arms continued to receive other interventions for the duration of the trial. However, participants in the group were not permitted to attend the R&R sessions. None of the sites provided any other interventions that were aimed at reducing violent or antisocial behavior throughout the trial. Outcome Measures Violence and antisocial behavior were assessed at baseline for the 6 months preceding treatment, at the end of treatment, and at 6-months and 12-months posttreatment. Violence. In forensic inpatient settings, detailed observational notes are taken on each patient several times a day. These notes were reviewed to identify acts of violence as defined by the MacArthur Community Violence Instrument (Monahan & Stead-

4 CULLEN ET AL. man, 1994). We defined violence as any physically violent behavior ranging from pushing to weapons use. Verbal aggression. Incidents of verbal aggression, defined as any verbal threat or verbally aggressive/intimidating behavior directed toward others, were determined from the observational notes within the clinical files. Substance use. Random urine drug screens were conducted in all units as part of routine care. Drug use was defined as receiving a positive drug screen or refusal to provide a urine sample. Clinical files were also reviewed to identify incidents of alcohol use that were reported by the patient themselves or detected by a breathalyzer test. Leave violations. Clinical files were used to identify violations of leave conditions, defined as failure to return on time, visiting prohibited areas, and episodes of absconding. Analyses Data obtained at the 6-month and 12-month follow-ups were summed to create a variable reflecting the number of incidents of violence over the total follow-up period. This procedure was repeated for incidents of verbal aggression, substance use, and leave violations. All outcome measures yielded count data that were overdispersed. Consequently, four negative binomial regression models were used to examine the effect of R&R on incidents of violence, verbal aggression, substance use, and leave violations during the treatment period and during the 12-month follow-up period. Time was included as a covariate as the program length varied across sites; this additionally minimized the effect of missing data (i.e., participants with follow-up data at 6 months but not 12 months were included in the model with data adjusted to reflect the shorter length of time at risk). Each analysis was also adjusted for the number of incidents occurring in the 6 months prior to treatment (i.e., the effect of R&R on the number of incidents of violence during treatment was adjusted for the number of incidents of violence in the 6 months prior to treatment). Primary analyses were conducted on an intention-to-treat basis. Post hoc analyses were conducted to compare program completers and program noncompleters (both groups compared with ) and were adjusted for PCL:SV scores on the basis that psychopathy was found to be the strongest predictor of treatment noncompletion in this sample (Cullen et al., 2011). Covariates were entered altogether in one step. Analyses were conducted using SPSS Version 15. Results Table 1 presents the sample characteristics by randomization group; statistical analyses confirmed that the R&R and groups did not differ by chance on any variables that may have potentially impacted on outcome measures. Participant flow through the study and missing data are shown in Figure 1. Two participants randomized to R&R were transferred prior to treatment starting; of the remaining 42, only 21 completed the program, and reasons for program dropout are provided in Figure 1. Violence and Antisocial Behavior Outcomes: Intention-to-Treat Table 2 presents incident rate ratios (IRRs) comparing the number of incidents of violence, verbal aggression, substance use, Table 1 Demographic, Clinical, and Forensic Characteristics of the Sample Sample characteristic R&R (n 44) Test statistic p Age 35.4 years (SD 11.4) 35.4 years (SD 8.4) t 0.01.99 No. criminal convictions: median (range) 5 (0 31) 6 (0 30) U 788.00.64 No. previous psychiatric admissions: median (range) 2 (0 15) 1 (0 12) U 798.00.46 PANSS positive scale total score 12.1 (SD 4.4) 10.6 (SD 4.1) t 1.58.12 PANSS negative scale total score 14.2 (SD 5.2) 14.5 (SD 5.4) t 0.21.83 HCR-20 total score 23.0 (SD 6.4) 21.7 (SD 6.7) t 0.86.37 Diagnosis Fisher s exact 0.51.84 Schizophrenia 35 (79.6%) 34 (85.0%) Schizoaffective disorder 6 (13.6%) 4 (10.0%) Other psychotic disorder 3 (6.8%) 2 (5.0%) Education 2 0.03.99 No school leaving qualifications 20 (46.5%) 18 (45.0%) Obtained school leaving qualifications 17 (39.5%) 16 (40.0%) Obtained further/higher education qualification 6 (14.0%) 6 (15.0%) Ethnicity 2 0.21.90 White 15 (34.1%) 12 (30.0%) Black (African or African-Caribbean) 21 (47.7%) 21 (52.5%) Other 8 (18.2%) 7 (17.5%) Antisocial personality disorder diagnosis 20 (45.5%) 17 (42.5%) 2 0.00.96 Psychopathy (PCL:SV 16) 10 (23.8%) 6 (15.0%) 2 0.53.47 One or more violent incidents during the baseline period 15 (34.1%) 11 (27.5%) 2 0.17.68 Drug use problem (DUDIT score 6) 10 (22.7%) 12 (30.0%) 2 0.26.61 Note. R&R Reasoning and Rehabilitation; treatment as usual; PANSS Positive and Negative Symptom Scale; HCR-20 Historical, Clinical, Risk-Management 20; PCL:SV Psychopathy Checklist: Screening Version (European cutoff 16); DUDIT Drug Use Disorders Identification Test (Berman, Bergman, Palmstierna, & Schlyter, 2005). Drug use problem includes cannabis only (n 19); cannabis and cocaine (n 2); cannabis, cocaine, and amphetamine (n 1). Missing data: No. criminal convictions (n 2); PANSS positive scale (n 8); PANSS negative scale (n 9); HCR-20 total (n 2); Education (n 1); Psychopathy (n 2).

COGNITIVE SKILLS PROGRAM FOR ANTISOCIAL BEHAVIOR 5 Table 2 Incidents of Violence and Antisocial Behavior During Treatment and the Posttreatment Period by Randomization Group Outcome variable f Violence and antisocial behavior during treatment Descriptive statistics: Descriptive statistics: M (SD) Statistical analyses a M (SD) R&R (n 44) IRR [95% CI] p Violence and antisocial behavior during the 12-month follow-up R&R (n 44) Statistical analyses a IRR [95% CI] p Violence 0.55 (1.38) 0.68 (1.33) 0.52 [0.23, 1.15].11 b 0.90 (1.96) 0.88 (2.00) 0.86 [0.44, 1.66].65 b Verbal aggression 3.95 (8.42) 3.53 (6.44) 0.49 [0.28, 0.85].01 c 7.33 (10.83) 8.23 (15.71) 0.56 [0.34, 0.91].02 c Substance use 0.91 (2.64) 0.70 (1.77) 1.20 [0.59, 2.45].62 d 2.55 (6.19) 3.25 (6.85) 1.24 [0.71, 2.15].45 d Leave violation 0.33 (0.82) 0.83 (2.25) 0.37 [0.16, 0.84].02 e 0.52 (0.99) 0.60 (1.19) 0.88 [0.42, 1.84].74 e Note. R&R Reasoning and Rehabilitation; treatment as usual; IRR incident rate ratio; CI confidence interval. Missing end of treatment data: Violence (n 2); Verbal aggression (n 2); Substance use (n 1); Leave violation (n 2). Missing 12-month follow-up data: Violence (n 2); Verbal aggression (n 2); Substance use (n 2); Leave violation (n 2). Boldface values represent p.05. a Negative binomial regression with time included as a covariate in all models. b Adjusted for number of incidents of violence during baseline period. c Adjusted for number of incidents of verbal aggression during baseline period. d Adjusted for number of incidents of substance use during baseline period. e Adjusted for number of incidents of leave violation during baseline period. f All outcome variables are continuous (number of incidents). and leave violations in the R&R and groups. During the treatment period, participants in the R&R group engaged in incidents of violence 48% less often than the group (IRR 0.52), although this was not statistically significant (p.11). Relative to the group, rates of verbal aggression and leave violations in the R&R group were decreased by a factor of 0.49 and 0.37, respectively; both effects reached statistical significance (p.05). There was no significant effect of R&R on substance use (IRR 1.20, p.62). During the 12-month follow-up period, the R&R group engaged in incidents of verbal aggression significantly less often than the group (IRR 0.56, p.02). Incident rates for violence and leave violations during the 12- month follow-up period were lower in the R&R group relative to the group, but not statistically significant (p.05). Program Completer Analyses Despite having lost the advantage of randomization, we also conducted analyses to compare outcomes between the program completers, noncompleters, and the group (see Table 3). During the treatment period, R&R program completers engaged in incidents of violence 84% less often, incidents of verbal aggression 58% less often, and leave violations 81% less often, relative to the group; all three effects remained statistically significant after adjustment for PCL:SV scores (p.05). There was no significant effect of program completion on substance use. Program noncompletion was not a significant predictor of any of the outcomes during treatment. During the 12-month follow-up, there was a significant reduction in rates of verbal aggression (IRR 0.34) and substance use (IRR 0.26) in the program completers relative to the group; both effects remained statistically significant after adjusting for PCL:SV scores (p.01). Conversely, rates of substance use were significantly higher in program noncompleters (IRR 2.06, p.02); however, this effect failed to reach statistical significance after controlling for PCL:SV scores. Discussion In the first RCT of a cognitive skills program for MDOs, R&R participation was associated with a reduction in incidents of verbal aggression and leave violations during treatment and a reduction in verbal aggression during the 12-month follow-up. There were no differences between the participants randomized to R&R or in the number of incidents of violence or substance use; thus, our hypotheses were only partially supported. Given the high treatment dropout rate, post hoc analyses were conducted to examine program completers and noncompleters separately; but having lost the advantage of randomization, these findings need to be treated with caution. After adjusting for PCL:SV scores, program completers showed a significant reduction in incidents of violence, verbal aggression, and leave violations during treatment, and in verbal aggression and substance use during the 12-month follow-up. We did not observe a significant reduction in violence or antisocial behavior in program noncompleters. We failed to find a significant effect of R&R on violence using intention-to-treat analyses. However, a reduction in arrests for violent crimes was found among MDOs who attended a community-based cognitive skills program (Ashford et al., 2008). One explanation for the difference in findings may relate to the study settings and outcome measures used. Our primary outcome measure, inpatient violence, is very different from offending behavior in the community; inpatients in forensic hospitals have less opportunity to engage in violence than community patients due to the intensive level of monitoring in secure settings. Similarly, the low baseline rates of violence in this sample may have limited our ability to detect a treatment effect. Future evaluations of inpatient treatment programs might benefit from targeting MDOs with higher rates of inpatient violence. In contrast, the R&R group showed a significant reduction in incidents of verbal aggression and leave violations during treatment; the effects on verbal aggression were maintained at 12- months posttreatment. This finding is consistent with a recent inpatient evaluation of a modified R&R program for MDOs (Young et al., 2010): The authors reported a reduction in disruptive behavior, which included verbal aggression. These findings are encouraging and suggest that cognitive skills programs delivered in forensic secure hospitals can reduce forms of antisocial behavior that are more commonly seen in inpatient settings.

6 CULLEN ET AL. Table 3 Incidents of Violence and Antisocial Behavior During Treatment and the Posttreatment Period by Program Completion Group Violence and antisocial behavior during treatment Violence and antisocial behavior during the 12-month follow-up Descriptive statistics: M (SD) Statistical analyses a : IRR [95% CI] p Descriptive statistics: M (SD) Statistical analyses a : IRR [95% CI] p Noncompleters Completers Noncomp Comp Noncompleters Completers Noncomp Comp Outcome variable f Violence 0.10 (0.30) 1.00 (1.84) 0.68 (1.33) 0.16 [0.03, 0.76].02 b 0.88 [0.36, 2.17].78 b 0.43 (1.75) 1.38 (2.09) 0.88 (2.00) 0.56 [0.22, 1.39].21 b 1.18 [0.53, 2.62].68 b 0.17 [0.04, 0.82].03 b 0.88 [0.35, 2.22].79 b 0.52 [0.20, 1.33].17 b 1.08 [0.47, 2.47].86 b Verbal aggression 1.05 (1.91) 6.86 (11.14) 3.53 (6.44) 0.42 [0.20, 0.88].02 c 0.55 [0.27, 1.12].10 c 3.81 (6.98) 10.86 (12.87) 8.23 (15.71) 0.34 [0.18, 0.64].01 c 0.78 [0.43, 1.40].40 c 0.46 [0.21, 0.98].05 c 0.56 [0.27, 1.17].13 c 0.35 [0.19, 0.68].01 c 0.78 [0.42, 1.45].44 c Substance use 0.95 (3.49) 0.86 (1.52) 0.70 (1.77) 0.88 [0.35, 2.22].79 d 1.53 [0.66, 3.57].33 d 0.57 (1.33) 4.52 (8.28) 3.25 (6.85) 0.26 [0.11, 0.63].01 d 2.06 [1.11, 3.85].02 d 0.85 [0.30, 2.43].76 d 1.19 [0.47, 3.00].71 d 0.24 [0.09, 0.66].01 d 1.59 [0.78, 3.26].20 d Leave violation 0.14 (0.48) 0.52 (1.03) 0.83 (2.25) 0.19 [0.05, 0.68].01 e 0.60 [0.22, 1.64].32 e 0.38 (0.97) 0.67 (1.02) 0.60 (1.19) 0.61 [0.23, 1.62].32 e 1.21 [0.49, 2.95].68 e 0.20 [0.05, 0.73].02 e 0.43 [0.14, 1.31].14 e 0.62 [0.23, 1.67].35 e 1.49 [0.58, 3.84].41 e Note. IRR incident rate ratio; CI confidence interval; treatment as usual; Comp Reasoning and Rehabilitation program completers; Noncomp Reasoning and Rehabilitation program noncompleters. Missing end of treatment data: Violence (n 2); Verbal aggression (n 2); Substance use (n 1); Leave violation (n 2). Missing 12-month follow-up data: Violence (n 2); Verbal aggression (n 2); Substance use (n 2); Leave violation (n 2). Boldface values represent p.05. a Negative binomial regression with time included as a covariate in all models. b Adjusted for number of incidents of violence during baseline period. c Adjusted for number of incidents of verbal d aggression during baseline period. Adjusted for number of incidents of substance use during baseline period. e Adjusted for number of incidents of leave violation during baseline period. f All outcome variables are continuous (number of incidents). Analyses additionally adjusted for Psychopathy Checklist: Screening Version scores. Post hoc analyses, conducted on the basis that over half of those allocated to R&R failed to complete treatment, demonstrated a significant effect of program completion on incidents of violence, verbal aggression, and leave violations during treatment and on verbal aggression and substance use during the 12-month follow-up period. In contrast, significant reductions were not observed among program noncompleters. This pattern of results is consistent with our previous findings from this RCT (Cullen et al., 2012) and evaluations of cognitive skills programs in offender populations (Hollin & Palmer, 2009). Our finding that program noncompleters were more likely to use substances also concurs with a recent meta-analysis showing that offenders who terminate treatment are more likely to reoffend (Olver, Stockdale, & Wormith, 2011). However, pretreatment characteristics may be responsible for these findings. Our program completers were less likely than noncompleters to have a comorbid diagnosis of ASPD or psychopathy, and to have been violent at baseline (Cullen et al., 2011), and so may have been at lower risk of engaging in violent and antisocial behavior regardless of the amount of treatment received. We attempted to address this issue by controlling for PCL:SV scores, and we subsequently observed that the increased risk of substance use in the noncompleters failed to reach statistical significance. However, the benefits for program completers remained, which may suggest a genuine completion effect. Several limitations should be noted. First, the small sample size and low base rates of violent behavior may have led to our inability to detect an effect of treatment on this outcome. The limited sample size also prevented us from examining possible site differences. Second, randomization occurred within sites, which may have led to contamination across treatment groups (i.e., the group being inadvertently taught R&R skills). A further limitation relates to selection bias. It is likely that patients who declined to participate were more unwell and/or antisocial, and these factors might potentially influence treatment outcomes. Another limitation is the possibility of bias arising from the fact that it was not possible to blind researchers to allocation status (more pertinent for outcomes such as verbal aggression where there is some degree of ambiguity). Finally, the post hoc analyses lost the benefits of randomization and were underpowered to detect a treatment effect. Our findings demonstrate that participation in R&R is associated with a reduction in incidents of antisocial behavior, particularly for those who complete treatment. 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