CBT Proves Its Value in an Unusual Setting

Cognitive-behavioral therapy (CBT) has been found to benefit the mental health of Iranian prisoners, new research shows.

The study was conducted by Gregory Hamot, Ph.D., director of the University of Iowa Center for Human Rights, in conjunction with two Iranian colleagues who are associate professors of psychology at the University of Tehran.

Results were published online August 31 in the International Journal of Offender Therapy and Comparative Criminology.

The study's goal was to learn whether individual or group CBT could improve the psychological status of Iranian prisoners. The type of CBT offered was called Reasoning and Rehabilitation (R & R), a corrective intervention that is already being offered to prisoners in a number of countries, including the United States. The main objective of the intervention, which involves 36 two-hour sessions, is to develop cognitive skills in a progressive (accelerated) manner. The program covers topics such as interpersonal problem-solving, stress-coping skills, anger control, risk-taking skills, and positive thinking.

A random sample of 180 male inmates was studied. About a third of the inmates had committed robbery, about a fourth assault and battery, and about a fifth murder. Nine percent had committed fraud, 8 percent rape, and 8 percent drug dealing. Nearly a third had mental disorders prior to conviction (notably anxiety, depression, somatization, and obsessive-compulsive disorder), and nearly half had a history of illicit drug use. A number of the subjects were receiving psychotropic medications prescribed by psychiatrists for their mental disorders.

Subjects were randomly assigned to one of three groups. One group received individual R & R, the second group received both individual and group R & R, and the third group served as controls. Subjects were evaluated psychologically both before and after the intervention periods with the General Health Questionnaire, Symptom Checklist-90-Revised, and diagnostic interviews based on DSM-IV. The researchers compared outcomes for the three groups.

Individual and Group R & R Ideal

Subjects who received individual R & R or individual plus group R & R improved significantly more psychologically than control subjects did, and especially as far as somatization, depression, anxiety, and hostility were concerned, the researchers found. However, subjects who had received individual and group R & R improved even more than did subjects who had received individual R & R only.

The reason why, the researchers speculated, may have been because “by attending group therapy sessions and being exposed to other participants' experiences and contributions to group dynamics, the inmates started to analyze and scrutinize their own problems. In addition, the participants in this group might have benefited from individual therapy, which provided an opportunity for them to discuss the problems and issues that they did not or could not discuss in group settings.”

In any event, the study's results are not surprising to psychiatrist Cassandra Newkirk, M.D., vice president of Correctional Mental Health Services and chief medical officer of GEO Care Inc. The reason, she told Psychiatric News, is because CBT has already been demonstrated to benefit American prisoners.

For example, she said, “CBT is widely used in substance abuse programs that are prison-based with very good results … . The programs focus on thinking prior to acting and understanding how thinking affects one's actions … . From personal experience I have [also] noted that many inmates in [CBT] groups that teach them how to think have often said that they wished they had learned such skills in school. Educational systems teach ‘theories and facts,’ but not much about feelings and the influence that thought has on those feelings.”

CBT May Also Reduce Recidivism

The Iranian study also suggests that CBT—or more specifically R & R—can reduce recidivism once prisoners are released from prison. In a one-year follow-up after inmate release, recidivism in the individual R & R subjects and in the individual-plus-group subjects who received R & R was zero, whereas it was 15 percent in the control group.

Other studies have also implied that R & R CBT can reduce recidivism, Hamot and his coworkers noted in their paper. In one study, for instance, one group of subjects had received R & R, a second had been given life-skills training, and a third had received no training. Results showed that whereas the rate of recidivism was 48 percent and 70 percent in the second and third groups, respectively, it was only 18 percent in the R & R group.

But even though psychological group therapy is offered to American prisoners, it's not clear how much of it is CBT based and what impact CBT therapy might have on American prisoners' overall recidivism rates, Newkirk pointed out. “It would be well worth the effort of psychiatrists working in correctional settings,” she suggested, “to note the models of group therapy that are being provided, usually by psychologists and master's-level clinicians, and review recidivism rates for inmates living with mental illnesses and having been exposed to CBT-type groups while incarcerated.”

The study was funded by the University of Tehran and the Tehran Prisons Organization.

An abstract of “Effects of Individual and Group Cognitive-Behavioral Therapy for Male Prisoners in Iran” is posted at <http://ijo.sagepub.com/cgi/content/abstract/0306624X09344840v1>.