Program Profile: Responsive Aggression Regulation Therapy (Netherlands)

This is a responsive intervention that seeks to reduce severe aggressive behaviors of incarcerated youth at a juvenile justice institution in the Netherlands. The program is rated Promising. Intervention group youth, compared with treatment-as-usual group youth, had statistically significant higher aggression-related skills, lower cognitive distortions (such as how youth think about aggression), and a lower recidivism risk for violent and general offenses at the 3-year follow up.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals/ Target Population

Responsive Aggression Regulation Therapy (Re-ART) is a responsive intervention that integrates principles of the Risk-Need-Responsivity (RNR) model, with emphasis on the responsivity principle. The responsivity principle emphasizes the following two types of responsivity: 1) general, which refers to the use of techniques to change criminogenic needs such as impulse control and problematic substance use; and 2) specific, which refers to providing treatment that is tailored to the motivation, learning style, specific capabilities, and limitations of the individual (Andrews and Bonta 2010).

Using a cognitive–behavioral therapy approach, combined with drama therapeutic and mindfulness techniques, Re-ART is designed to reduce severe (life-course persistent) aggression regulation problems and recidivism risk of moderate- to-high-risk males and females (ages 13 to 23), who are incarcerated at a juvenile justice institution in the Netherlands. The goal of Re-ART is to increase youth’s responsivity by positively influencing interfering factors (such as demotivation, distrust, attention deficit, and poor impulse control) and increasing their beliefs in their own capacities (Bandura 1997).

Program Components

Re-ART consists of individual training sessions, combined with group modules, which are conducted by a trained therapist. The focus of Re-ART is on emotional and instrumental aggression. The program can be adjusted to the youth’s intellectual capacity, learning style, pace, preferred learning method, and needs (offering optional modules or parallel treatment such as addiction care). The length of the entire Re-ART program (combined individual and group modules) may vary from half a year to approximately 2 years.

Individual sessions are held at least once a week and last approximately 1 hour. Group modules include 12 to 14 sessions, with each session lasting approximately 1.5 hours. Although emphasis is on individual treatment, Re-ART uses group sessions to focus on cognitive distortions that are associated with several themes (such as revenge and insulting family members). Group sessions are held every other week. If there is a contraindication (e.g., a youth demonstrates bad behavior), then the group module is offered individually to the misbehaving youth. Individual sessions are always available to youth.

Both individual and group module sessions begin with the standard Influence of Thinking module. Other Re-ART standard modules include sessions on 1) Intake and Motivation, 2) Aggression Chain (psychoeducation for self-comprehension and relapse-prevention plan), 3) Controlling Skills, and 4) Handling Con?icts. Additionally, Re-ART offers optional modules on 1) Stress Reduction, 2) Impulse Control, 3) Emotion Regulation, 4) Observation and Interpretation, 5) Assertive Behavior, and 6) a module for the family system.

Re-ART emphasizes that the therapist must consider the personality, intellectual capacity, cognitive and social skills possibilities, motivation for treatment, and learning style of the youth (i.e., client). The therapist can then use several treatment techniques to increase the youth’s responsiveness to treatment of Re-ART and minimize obstructive factors such as demotivation, distrust, attention de?cits, and low-impulse control. However, there is no established manualized treatment used.

Key Personnel

School or living group staff (i.e., mentors or tutors) are involved and responsible for youth’s treatment. Specifically, mentors are central in the execution of the signaling plan, the completion of home or living group assignments, and the evaluation of progress.

Program Theory

Re-ART uses an integrative explanatory model, which is based on the transaction theory (Sameroff and Fiese 2000) and the Social Information Processing (SIP) theory (Crick and Dodge 1994). The transaction theory suggests that an individual’s development is the product of the ongoing bidirectional in?uences on them and their environment (Sameroff and Fiese 2000). Based on this theory, youth’s aggression problems are thought to stem from a transactional process in which cognitive factors (particularly cognitive distortions) and socialization factors such as attitudes, values, and morals, play an important role (Granic and Patterson 2006).

SIP argues that antisocial behavior is the result of inadequate or disturbed social information processing, through which children and adolescents receive and read information from their environment and prepare to respond to social cues. This process consists of ?ve steps 1) encoding cues, 2) interpreting cues, 3) clarifying goals, 4) generating responses, and 5) making decisions. Each step of the process transacts with the individual’s environment (Crick and Dodge 1994; Fontaine 2006). From a transactional point of view, the displayed reaction or behavior leads to social consequences that inform the individual’s future SIP (Hoogsteder et al. 2014).

Study 1

Hoogsteder and colleagues (2014) conducted a quasi-experimental design to evaluate the efficacy of Responsive Aggression Regulation Therapy (Re-ART) on reducing severe aggressive behaviors and recidivism risks. The study sample included serious violent youth who were incarcerated at a secure juvenile justice institution (JJI) in the Netherlands. Youth were assigned to the treatment conditions based on the following criteria: 1) they scored moderate or high on risk for recidivism; dealing with anger, stress, and poor coping; and negative attitude, as measured by the Structured Assessment of Violence Risk in Youth (SAVRY) assessment tool; and 2) they had been placed in a JJI because of severe aggression problems and behaviors in different areas of life (such as school, work, and home). All youth in the study were between the ages of 15 and 21.

Of the total sample of 91 youth, 63 were assigned to the Re-ART intervention group, and 28 were assigned to the treatment-as-usual (TAU) comparison group. Youth in the Re-ART intervention group received individual training (at least one session per week), combined with biweekly group session modules, which were conducted by a Re-ART therapist. Youth in the TAU group received the standard treatment that was provided at all judicial residential locations in the Netherlands. Of the total study sample, 28.6 percent of the youth were of Dutch background, 25.3 percent were Moroccan, 14.3 percent were Surinamese, 7.7 percent were Turkish, 6.6 percent were Dutch Antillean, 3.3 percent identified as “other: western,” and 14.3 percent identified as “other: non-western.”

Of the 63 youth in the Re-ART group, 93.7 percent were male. More than half (52.4 percent) had committed a type 1 offense (ability, possibly with violence), 27 percent had committed a type 2 offense (medium-to-high violence crime), and 7.9 percent had committed a type 3 offense (attempted murder). The average age of youth in the intervention group was 17 years. Of the 28 youth in the TAU group, 71.4 percent were male. Exactly half (50 percent) had committed a type 1 offense (ability, possibly with violence), 21.4 percent had committed a type 2 offense (medium-to-high violence), and 14.3 percent had committed a type 3 offense (attempted murder). The average age of youth in the TAU group was 16.6 years. At pretreatment, the intervention and TAU groups differed significantly in 1) length of stay at the residential setting (Re-ART youth stayed an average of 20 months, whereas youth in the TAU group stayed an average of 11.9 months); and 2) gender (the Re-ART group was 6.3 percent female, and the TAU group was 28.6 percent female). These differences were not statistically significant; however, the study authors controlled for length of stay and gender in the overall analysis.

Pre- and posttreatment data were collected between January 2007 and February 2011, using the SAVRY assessment, which provided an estimation of the risk for reoffending with a violent offense. The SAVRY was collected as part of the Routine Outcome Monitoring and was filled in (blind) by prison staff members (i.e., psychologists, and not the therapists) who had a background in child studies and finished a special training in administering, scoring, and interpreting the SAVRY.

Posttreatment data were collected approximately 13 months after the intervention was implemented in September 2009 for Re-ART youth, compared with 10 months for the TAU group. At posttreatment, the outcomes of interest were recidivism risk, aggression-related skills (such as self-control and assertiveness), and cognitive distortions related to sub-assertiveness, aggression, physical aggression, and opposition-defiance behavior. Recidivism risk was measured using the total risk score on the 24-item SAVRY, which comprised three risk domains: 1) historical risk factors (10 items; e.g., abused as a child); 2) social/contextual factors (6 items; e.g., experiencing stress and poor coping), and 3) individual dynamic risk factors (8 items; e.g., negative attitude). Self-control and assertiveness were measured using youth- and mentor-reported scores on the Re-ART List Self-Control Scale (10 items) and Assertiveness Scale (8 items), using a 5-point Likert scale that ranged from 1 to 5 (1 = This is not true at all; 5 = This is completely true). The Brief Irrational Thoughts Inventory, a self-report questionnaire that consisted of 18 statements describing different kinds of irrational thoughts, was used to measure sub-assertiveness (“I think that people get angry with me because I often say ‘No’”; 5 items) and aggression (“If someone touches me, I should hit him”; 9 items), using a 1–6 Likert scale (1 = I totally agree; 6 = I totally disagree). The How I Think questionnaire was used to measure behavioral cognitive distortions of physical aggression (10 items) and opposition-defiance behavior (10 items), using a 1–6 scale (1 = I totally agree; 6 = I totally disagree).

An analysis of covariance (ANCOVA) was used to determine differences between youth in the Re-ART and TAU groups, at posttreatment. The study authors did not conduct subgroup analyses.

Study 2

Hoogsteder and colleagues (2018) conducted a quasi-experimental design, using the same study sample as in Study 1 (Hoogsteder et al. 2014), to evaluate the long-term effects of the Re-ART intervention on risk of recidivism. This study evaluated data at the 3-year follow up, which started after the youth were dismissed from the secure JJI in the Netherlands.

As in Study 1, the total sample consisted of 91 serious violent persons (Re-ART n = 63; TAU n = 28) who were incarcerated because of severe aggressive behaviors and scored medium-to-high on risk of recidivism for a violent offense. Youth demographics (i.e., ethnic background, gender) were also the same as in Study 1.

Recidivism data were collected from the official Judicial Registration System, in which data were edited and conformed to standard procedures set by the Dutch Ministry of Justice. Files contained the number of arrests, severity of arrests (violent versus nonviolent), and dates of arrests and convictions. Recidivism outcomes of interest were the average number of violent offenses, property crimes (including offenses related to drugs and smuggling), property crimes with violence, and general offenses.

An ANCOVA was used to determine differences between the Re-ART and TAU groups on recidivism risk at the 3-year follow up. The study authors did not conduct subgroup analyses.

A major assumption of the Responsive Aggression Regulation Therapy (Re-ART) intervention is that youth with multiple static risk factors (e.g., previously violent behavior), cognitive distortions, or with comorbid mental disorders need more time to learn speci?c skills (Hoogsteder et al. 2014). Thus, all therapists (n = 7) had higher vocational education levels and completed the “Train-the-Therapists” course, which included cultural sensitivity training. Furthermore, therapists attended supervision meetings every other week, as they were expected to meet the caseload requirement of at least three clients and provide Re-ART treatment for at least 12 hours a week (Hoogsteder et al. 2018).

Additionally, a multidisciplinary indication team (including a psychiatrist, social worker, and supervisor of Re-ART) met every 2 weeks and discussed which treatment was indicated for (new) youth at the institution. This indication team also checked which youth met the substantive criteria for inclusion in Re-ART.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Following are CrimeSolutions-rated programs that are related to this practice:

Treatment in Secure Corrections for Serious Juveniles Who Have Committed Serious or Multiple Offenses

This practice includes interventions targeting serious (violent and chronic) juveniles sentenced to serve time in secure corrections. The overall goal is to decrease recidivism rates when juveniles are released and return to the community. The practice is rated Effective for reducing general recidivism and serious recidivism of violent and chronically offending juveniles.

Evidence Ratings for Outcomes

	Crime & Delinquency - Serious recidivism
	Crime & Delinquency - Multiple crime/offense types

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?