Week 3 ACT: A Systematic Review PDF

Aggression and Violent Behavior 46 (2019) 45–55 Contents lists available at ScienceDirect Aggression and Violent Behavior journal homepage: www.elsevier.com/locate/aggviobeh The application and adoption of four ‘third wave’ psychotherapies for mental health difficulties and aggression within correct...

Aggression and Violent Behavior 46 (2019) 45–55 Contents lists available at ScienceDirect Aggression and Violent Behavior journal homepage: www.elsevier.com/locate/aggviobeh The application and adoption of four ‘third wave’ psychotherapies for mental health difficulties and aggression within correctional and forensic settings: A systematic review T Gary Byrne , Áine Ní Ghráda ⁎ Health Service Executive, Dublin, Ireland ABSTRACT Objective: The prisoner population have substantially higher mental health needs than those reported in community samples. A number of third wave therapies have accrued varying levels of evidence in clinical and community samples for a range of psychological difficulties. Methods: This review, using PRISMA guidelines, reviewed four third wave therapies, Acceptance and Commitment Therapy (ACT), Compassion Focused Therapy (CFT), Metacognitive Therapy (MCT) and Functional Analytic Psychotherapy (FAP) and their respective effectiveness in addressing psychological difficulties and aggression for those incarcerated in a number of forensic settings. Results: A total of nine studies were included in the review, 8 studies for ACT, 1 for CFT and none for MCT or FAP. The study provides very tentative evidence for the use of ACT with addiction issues and anger/aggression with a prisoner population but that this is significantly tempered by methodological shortcomings and small sample sizes. Conclusions: ACT shows some potential promise as a treatment with a prisoner population but the general lack of methodologically sound studies greatly limits any conclusions that can be made. At present other treatments such as Cognitive Behavioural Therapy (CBT) and other third wave therapies, most notably, Dialectical Behaviour Therapy (DBT) have accrued more evidence as a result of greater amount of research. 1. Introduction The prisoner population have substantially higher mental health needs than those reported in community samples (Prins, 2014). Research indicates heightened levels of anxiety disorders (Falissard et al., 2006), psychotic symptoms (Fazel & Danesh, 2002), depression (Fazel & Seewald, 2012) and personality disorders (Fazel & Danesh, 2002; Trestman, Ford, Zhang, & Wiesbrock, 2007) amongst those incarcerated. These mental health difficulties have been found to be risk factors for serious issues such as suicide (Haglund et al., 2014) and violence within prisons and correctional settings (Goncalves, Goncalves, Martins, & Dirkzwager, 2014). Focused offence-specific programs and general rehabilitative treatments are now in most jurisdictions. In attempting to draw from best practice, forensic psychology has utilized the theory and research from neighbouring fields in both psychiatry and clinical psychology. Cognitive behavioural programs, adhering to Risk-Need-Responsivity principles (RNR, Andrews & Bonta, 2006) have garnered much research, although the effectiveness of such approaches in reducing recidivism rates is still subject to much debate (Landenberger & Lipsey, 2005; Lösel & Schmucker, 2005; Rice & Harris, 2003). Research is somewhat clearer in delineating the positive effect that cognitive behavioural approaches ⁎ can have on mental health needs within prisoner populations (Kouyoumdjian et al., 2015; Yoon, Slade, & Fazel, 2017). However the long-term effectiveness of cognitive behavioural therapy (CBT) has been called into question (Johnsen & Friborg, 2015) and a recent systematic review found limited efficacy for CBT-based programs for reducing prison violence (Auty, Cope, & Liebling, 2017a). Other treatments that utilise differing strategies are therefore important in clarifying the question of what works for whom. 1.1. Third wave psychotherapies Over the last 15 years, the so-called ‘third wave’ therapies have grown not only in popularity amongst clinicians but have also garnered an increasing evidence base within the clinical literature with evidence suggesting the possible effectiveness of such approaches (Churchill et al., 2013; Kahl, Winter, & Schweiger, 2012), despite some questioning what substantial theoretical differences lie between more traditional cognitive behavioural approaches as compared to ‘third wave’ therapies (Hofmann & Asmundson, 2008). While no one factor unites these disparate approaches, Luoma, Hayes, and Walser (2017) posit that third wave therapies are sensitive to the context and functions of psychological states rather than form and content that would usually be Corresponding author at: Primary Care Psychology Department, Churchtown, HSE, Dublin 14, Ireland. E-mail address: [email protected] (G. Byrne). https://doi.org/10.1016/j.avb.2019.01.001 Received 22 August 2018; Received in revised form 28 November 2018; Accepted 7 January 2019 Available online 14 January 2019 1359-1789/ © 2019 Elsevier Ltd. All rights reserved. Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda the focus of treatment in more traditional cognitive behavioural approaches. Third wave therapies seek to construct effective and flexible repertories of behaviour in the client, drawing from both mindfulness and acceptance strategies. Such treatments are cited as more contextual than mechanistic and place an emphasis on learning through experiential means (Hayes, 2004). Several concepts key to third wave therapies such as acceptance, defusion, clarification of values and psychological flexibility may be especially useful in working with forensic populations (Roberton, Daffern, & Bucks, 2012). For example a focus on valuing and acceptance of anger, trauma, and shame may provide an alternative to a search for the criminal cognitive errors that traditional cognitive behavioural models would attempt to restructure. Gardner and Moore (2008) in developing an Anger Avoidance Model, have also drawn upon the role of experiential avoidance in maintaining impulsive and aggressive behaviours (behavioural avoidance) and rumination (cognitive avoidance). Experiential avoidance has been found to be related to interpersonal problems (Gerhart, Baker, Hoerger, & Ronan, 2014). Such findings lend further credence to the potential of third wave therapies in addressing anger without the need to reduce, eliminate or suppress such emotions and thoughts. Within the forensic field, Dialectical Behaviour Therapy (DBT) has accrued the most evidence of its applicability and effectiveness of the third wave therapies in forensic settings (Tomlinson, 2018). DBT (Linehan, 1993) is a cognitive behavioural approach that was originally developed to target emotional dysregulation (i.e., mood disturbance, affective liability, uncontrolled anger) and behavioural difficulties (i.e., self-harm, violent aggression) that can be associated with chronic, severe emotion dysregulation seen in Borderline Personality Disorder (BPD). Two recent review articles have cited the potential benefit of DBT within the forensic setting and for difficulties associated with anger and aggression. Frazier and Vela (2014) reviewed the effectiveness of DBT in relation to reducing anger and aggression. Amongst the 21 studies reviewed, seven were RCTS. Five were set in correctional or forensic institutions. Of these five studies, four indicated that, even when modified for use with specific forensic populations, DBT demonstrated a positive impact on the reduction of anger and aggressive behaviours (Evershed et al., 2003; Long, Fulton, Dolley, & Hollin, 2011; Shelton, Kesten, Zhang, & Trestman, 2011; Shelton, Sampl, Kesten, Zhang, & Trestman, 2009), with one study reporting mixed findings in relation to behavioural change (Trupin, Stewart, Beach, & Boesky, 2002). A more recent review by Tomlinson (2018) included 23 studies evaluating DBT and DBT derived programs in forensic settings. The review reported preliminary evidence that DBT programs can be effective in reducing recidivism, not withstanding issues in relation to the heterogeneity of samples studied and methodological limitations. A number of other reviews have indicated that various differing mindfulness practices may be useful with both incarcerated youth (Himelstein, 2010) and adult offenders (Shonin, Van Gordon, Slade, & Griffiths, 2013). The question remains if other third wave therapies, namely Acceptance and Commitment Therapy (ACT), Compassion Focused Therapy (CFT), Metacogntive Therapy (MCT) and Functional Analytic Psychotherapy (FAP) may also be useful alternatives to more traditional cognitive behavioural approaches in reducing aggression and alleviating psychological distress with a prisoner population. defusion, self-as-context, committed action and clarity of values (Hayes, Strosahl, & Wilson, 1999). These processes are underpinned by the overarching aim of increasing psychological flexibility by reducing rigid, inflexible behavioural repertories and being in contact with the present moment in order to pursue a valued life (Luoma et al., 2017). Strategies such as metaphor, paradox, and experiential exercises help to manage psychopathology by diminishing their deleterious behavioural consequences (Arch & Craske, 2008). A number of early review articles have noted that ACT is more effective than control conditions (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Öst, 2008) for a number of psychological difficulties. A more recent review article has found that mean effect sizes on primary outcomes significantly favoured ACT over CBT in depression and quality of life measurements (Ruiz, 2012) and that ACT demonstrates largely equivalent effects relative to traditional CBT (Twohig & Levin, 2017). Further reviews (A-Tjak et al., 2015; Swain, Hancock, Hainsworth, & Bowman, 2013) also provided preliminary support for ACT in the treatment of anxiety and physical health problems but other reviews have suggested that ACT is not a well established treatment for any one disorder but probably efficacious for a number of disorders including depression, obsessive compulsive disorder and substance misuse (Öst, 2014). The evidence for ACT in reducing aggression has garnered a limited evidence-base that provides tentative support of its utility. Harvey, Henricksen, Bimler, and Dickson (2017) reported that a one week ACT program completed by 262 military personnel demonstrated significant reductions in aggression and alcohol use and an increase in emotional management strategies. Similarly, Donahue, Santanello, Marsiglio, and Van Male (2017) reported on a sample of 23 male military veterans undergoing ACT for anger dysregulation. The study reported that those who had completed the program reported significant decrease in physical aggression and greater psychological flexibility. Interestingly, the study also found no reductions in the areas of verbal aggression and overall anger reactivity. A randomised controlled trial measured the effectiveness of ACT compared to supportive treatment amongst a male community sample who endorsed at least two incidents of partner aggression. Findings indicated that those in the ACT group demonstrated significantly greater reductions on a number of self-report measures of physical and psychological aggression compared to those in a control group (Zarling, Lawrence, & Marchman, 2015). Interestingly, reduction in aggression was mediated by reduction in emotional avoidance, a key mechanism of change within the ACT model. A further study examined the effectiveness of a 24 session ACT-based protocol (ACTV) for domestic violent offenders receiving treatment in the community. The intervention was delivered over the course of 6 months, across the entire state of Iowa. The results from the study reported that those offenders in the ACTV programs (n = 843) compared to those in the mixed Duluth and CBTbased programs (n = 2631) accrued significantly less new charges including domestic violence charges. ACTV participants also had significantly fewer charges one year after treatment end compared to those in the other treatment condition (Zarling, Bannon, & Berta, 2017). The study provides preliminary evidence of acceptance and commitment strategies for domestic violent offenders although others have highlighted a number of significant methodological concerns that limit firm conclusions (Gondolf, Bennett, & Mankowski, 2018). 1.2. Acceptance and Commitment Therapy (ACT) 1.3. Compassion Focused Therapy (CFT) ACT, founded upon the theory of contextual functionalism (for review see Hayes, 2004), is an evidence-based contextual cognitive-behavioural approach. Within the ACT framework, historic and wellconditioned psychopathology is not the focus of treatment. Instead the ACT therapist focuses on loosening the grip of the literal verbal content of cognition and avoidant behaviours in helping the individual make space for such emotions and thoughts. ACT employs six core connected therapeutic processes; mindfulness, acceptance of experience, cognitive Compassion, at its core, is a basic kindness and awareness of suffering in self and others and a wish to alleviate it (Gilbert, 2009a, 2009b). Borrowing from evolutionary psychology, attachment theory and neuroscience, Compassion Focused Therapy (CFT) is a multimodal approach that was developed specifically to build capacity to experience compassion in high shame and self-critical individuals (Gilbert, 2009a, 2009b; Kolts, 2016). Individuals prone to high-self criticism and shame find it very difficult to generate feelings of safety and comfort in 46 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda both themselves and others. CFT puts an emphasis on the way differing emotions and basic systems have evolved to serve differing functions. Research into the neurophysiology of emotion suggests that we can distinguish at least three types of emotion regulation systems (Depue & Morrone-Strupinsky, 2005): threat and protection systems; drive, resource seeking and excitement systems; and contentment, soothing and safeness systems. Treatment strategies include the use of compassionate reasoning, cultivating compassionate feelings and behaviours, mindfulness and compassionate letter writing in helping the client develop an internal compassionate relationship with oneself instead of a punitive, harsh self-critical one (Beaumont & Hollins Martin, 2015; Gilbert, 2009a, 2009b). Investigators have begun to research CFT as a useful treatment for a number of psychological disorders. Beaumont and Hollins Martin (2015) completed a narrative review of the CFT literature and included 12 studies, one of which was an RCT, in their review. The authors highlighted that there is some evidence that CFT may be useful for a variety of psychological difficulties including eating disorders, schizophrenia, brain injury and chronic mental health difficulties. However the significant methodological shortcomings of many of the studies as well as seven of the twelve studies having sample sizes of less than twenty individuals limited conclusive findings. A broader meta-analysis which included differing types of compassion based therapies by Kirby, Tellegen, and Steindl (2017) included 12 randomised controlled trials. Significant moderate effect sizes were found for a range of variables including mindfulness, self-compassion, and measures of anxiety and depression. Although providing evidence for the use of compassion based programs one of the drawbacks of the review was the lack of substantive details about the differing compassion based programs. This was somewhat remedied in a later review by Kirby (2017) which focused on a number of interventions utilizing compassion based interventions. In this review, CFT specifically, was found to have the greatest evidence base of the compassion based treatments and shows preliminary evidence as a treatment for mood disorders in individuals high in self-criticism. This is similar to the findings reported in a prior systematic CFT review by Leaviss and Uttley (2015) however this review noted a high number of studies that focused on psychological wellbeing amongst those from a non-clinical population. 1.5. Functional Analytic Psychotherapy (FAP) FAP, developed by Kohlenberg and Tsai (1991) is a behavioural contextual approach that places an emphasis on the therapist-client relationship and delineates the steps therapists may take to facilitate intense and curative relationships in the pursuit of evoking change in clients' problematic behaviours. In particular, the FAP therapist focuses on the special opportunities for therapeutic change that occur when the client's daily life problems are manifested within the therapeutic relationship. Five functional rules guide the treatment protocol and central to this the in vivo occurrences of the clients' problems referred to as Clinically Relevant Behaviour (CRB). CRB's are divided into CRB1s, which are in-session manifestations of clinically relevant behaviour and CRB2s, which are improvements or behavioural progress. There have been longstanding criticisms of the lack of efficacy research (Corrigan, 2001) into FAP. An early review article indicated that much of the evidence was characterised by narrative case studies focusing on a diverse range of clinical presentations, with the most prevalent presenting problem being depression (Mangabeira, Kanter, & Del Prette, 2012). The review provided recommendations for the need of further well-designed and controlled trials but significant questions still remained regarding FAP as an efficacious intervention. A recent comprehensive review by Kanter et al. (2017) found evidence supporting the mechanisms of change posited by FAP but again the research base was characterised by single case studies and only six publications of uncontrolled and controlled clinical trials of FAP were found suggesting that FAP lags behind the evidence base of other third wave therapies. Taken together, while a number of reviews have been conducted regarding the effectiveness of third wave approaches, the literature lacks a comprehensive review of the efficacy of ACT, CFT, MCT and FAP approaches in the forensic and correctional field. Given the particular and specific challenges faced by prisoner populations, it should not be assumed that interventions that have proved effective for non-incarcerated populations will be equally as effective for those who are incarcerated. To address this, the current article aims to provide a broad systematic review of the empirical evidence for the aforementioned approaches within the forensic field covering both published and unpublished articles. The current study aims to comprehensively identify summarize, and critically evaluate the existing literature and to draw conclusions about the use of ACT, CFT, MCT and FAP for a range of presenting psychological difficulties as well as aggressive behaviour with prisoners or individuals in secure forensic settings. 1.4. Metacognitive Therapy (MCT) MCT, which evolved from classical cognitive therapy, has been classed a novel form of therapy that can provide a transdiagnostic approach to psychopathology (Wells, 2009). MCT suggests that the maintenance of psychological difficulties is linked to a particular thinking style known as the cognitive attentional syndrome (CAS), which includes rumination, suppression, repetitive thinking and unhelpful avoidant behavioural strategies (Wells, 2009). The CAS is then maintained by metacognitive beliefs about the nature and level of control that the individual feels about the nature and appraisal of worry. A key element of MCT is helping promote attentional flexibility which in turn strengthens executive control which impacts on the CAS (Normann, van Emmerik, & Morina, 2014). MCT is not a content orientated intervention. Instead therapeutic techniques include attention training, detached mindfulness, and behavioural experiments targeting metacognitions. There is a growing evidence base for metacognitive therapy. A meta-analysis completed by Normann et al. (2014) included 16 studies (eight of which were randomised) including 384 outpatients with psychological difficulties including posttraumatic stress disorder (PTSD), depression, generalized anxiety disorder (GAD) and comorbid mood disorders. The analysis showed that MCT was significantly more effective than waitlist controls (between-group Hedges' g = 1.81) and CBT (between-group Hedges' g = 0.97). Over half of the studies included in the meta-analysis were controlled. 2. Method 2.1. Search and screening procedures A comprehensive literature review was completed using PsychoInfo, Medline, Science Direct and Google Scholar up to October 2018. To locate eligible unpublished doctoral dissertations Proquest was also searched. A number of key words were developed and used for each of the databases (see Appendix A). Non-English studies were included. The online research profiles of several researchers were also searched to identify additional studies. Citation searches were also completed on Google Scholar. The title and abstract of each of the articles was examined by the first author and subject to inclusion and exclusion criteria. Where an article met inclusion criteria, the full paper was retrieved and reviewed by both the first and second authors. 2.2. Inclusion criteria The inclusion criteria for the current review included the following: a) Intervention studies that used ACT, CFT, MCT or FAP with a forensic population. This population could include adult or juvenile offenders and was not restricted by offence category. Regarding ACT, 47 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda included studies had to include at least two treatment strategies under the ACT rubric to ensure that not only one specific strategy (i.e. mindfulness) was employed. Compassion interventions were limited to CFT and did not include other compassion based programs such as Cultivating Compassion Training (Jazaieri et al., 2013). Metacogntive Therapy was limited to the model proposed by Wells (2009) and did not cover other metacognitive therapies such as Metacognitive Training (Moritz et al., 2014) or Metacognitive Insight and Reflective Therapy (Lysaker & Dimaggio, 2014) b) Studies that focused on mental health difficulties including anxiety, depression, psychosis, personality disorders and substance misuse. Interventions that focused on anger, aggression and offence focused work were also included c) Psychometrically sound outcome measures designed to measure the change of psychopathology symptoms were used in the intervention. This was defined as an outcome measure that had at least one study published attesting to its psychometric properties articles (n = 7; 77.7%), with the remaining two unpublished doctoral theses (n = 2; 22%). Eight of the nine studies reported on adult offenders with the remaining one study reporting on juveniles. Of the eight ACT studies, two studies focused on addiction, three focused on aggression/anger and impulsivity and two on general psychopathology. One study (Malouf, Youman, Stuewig, Witt, & Tangney, 2017) focused on general post-release risky behaviours that also included drug use and broader mental health issues. The one CFT study focused on a range of mental health difficulties for patients in a secure hospital with a diagnosis of schizophrenia. Of the eight ACT studies, six used the Acceptance and Action Questionnaire II (AAQ-II, Bond et al., 2011) to measure mechanisms of change specific to ACT. No MCT or FAP studies met inclusion criteria for this review. 3.2. Study design and treatment conditions Of the nine studies, four were randomised trials. The other studies included three within group and two between group designs. One of the eight ACT studies used a program called The Re-entry Values and Mindfulness Program (REVAMP; Malouf et al., 2017) which comprised of a number of differing types of treatments but specifically focused on mindfulness and clarity around personal values identification to reduce defensiveness and increase motivation for treatment. The majority of studies involved group intervention (n = 8; 88.8%) with the other study providing both individual and group therapy. Group therapy ranged from 8 sessions to 20 sessions. Three studies did not utilise a control comparison group. Of the six that did, four compared ACT with CBT. One compared ACT to treatment as usual and one to a control group. Six of the studies took place in a prison, one in a low security facility, one in a juvenile correctional centre and one in a secure hospital. Retention rates within active treatment conditions varied across the studies, ranging from 100% (Malouf et al., 2017) to 37% (Plambeck, 2015). See Table 1 for overview of the included studies. 2.3. Exclusion criteria a) Studies that focused solely on mindfulness interventions such as mindfulness based stress reduction or mindfulness-based cognitive therapy. Studies that used mindfulness with other therapies (e.g. Byrne, Bogue, Egan, & Lonergan, 2016). b) Single case design studies and research with less than 5 individuals per group/condition. 2.4. Eligible studies The initial search produced 298 citations. Examination of reference list produced another 14 citations. Nine papers met initial inclusion criteria and full papers were retrieved for these. See Fig. 1 for a breakdown of the study selection process. 2.5. Data extraction 3.3. Assessment of methodological quality A coding sheet was developed and data was extracted for studies. Two reviewers independently extracted data. In the event of reviewers disagreeing, the two reviewers discussed the difference and determination was then met. Data extraction included setting, research design, population, gender, treatment conditions and duration. Outcomes of interest included reduction in either clinician or self-report measure of psychopathology (depression, anxiety, psychosis etc.), anger, aggression and impulsivity. The quality of the studies was assessed using the Individual Attributes of Methodological Quality measure for methodological rigour (Becker & Curry, 2008). This scale examines 14 criteria including sample size, power analysis, sequence generation, allocation concealment, primary and secondary outcome measures and active comparison. Criteria were rated as met (1) or not met or unclear (0). One item, Intention to Treat (ITT) analysis had a possible rating of 0–2. These ratings provide a Quality of Evidence Score (QES) with higher scores indicative of greater methodological rigour. Scores can range from 0 to 15. The second reviewer independently assessed five of the articles. A very high level of inter-rater agreement between reviewers was observed (ICC = 0.943; Koo & Li, 2016). Assessment of methodology quality revealed a low level of variability amongst the studies included. Overall scores on the Individual Attributes of Methodological Quality measure ranged from 3 to 8 out of a possible total score of 15, with the average score being 5 (SD = 1.92; see Table 2). Only two studies (Lanza, Garcia, Lamelas, & GonzálezMenéndez, 2014; Orengo-Aguayo, 2016) emerged with a score of 7 or above translating to a relatively low level of methodological rigour. Only one of the nine studies (Orengo-Aguayo, 2016) provided information about the process of how sample size was reached and no study provided adequate information about allocation concealment. Three studies provided information about sequence generation (González-Menéndez, Fernández García, Rodríguez Lamelas, & Villagrá Lanza, 2014; Lanza et al., 2014; Malouf et al., 2017). Regarding treatment fidelity although most studies provided information about supervisory arrangements, only the Malouf et al. (2017) study outlined treatment adherence that was monitored by independent evaluators rated on a fidelity checklist. Only one study provided adequate information as to whether follow-up assessments were completed by treatment blind evaluators. All nine studies used at least one psychometrically sound outcome measure. Three studies used objective outcome measures; two using urinary analysis (González-Menéndez et al., 2014; Lanza et al., 2014) and one using review of official rates of recidivism (Malouf et al., 2017). 3. Results 3.1. Sample characteristics Nine studies were deemed eligible for the current review. Table 1 provides an overview of the nine studies included. Studies included a total of 288 participants and covered the full spectrum of mental health difficulties including mood disorders, schizophrenia, anxiety, anger/ aggression, substance abuse and comorbid conditions. The sample size ranged from 17 to 50. The majority of studies were published journal 3.4. Outcomes Study outcomes are shown in Table 2. Outcome date includes effect sizes where available. The following review will provide a narrative synthesis of the results by clinical disorder. 48 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda Records from database screened n = 298 Additional records identified n = 14 Records and abstracts screened n = 312 Articles excluded n = 303 Non-forensic population n = 62 Mindfulness interventions n = 77 Theoretical/review articles n = 112 Government/technical reports n = 15 Other n = 37 Publications reviewed in study n = 9 ACT (n = 8) CFT (n = 1) Fig. 1. PRISMA flow chart depicting literature screening process. 3.4.1. Addiction Three studies examined addiction issues. Of these, two examined the effectiveness of a 16-week group ACT intervention (GonzálezMenéndez et al., 2014; Lanza et al., 2014). In a sample of 50 incarcerated women with substance abuse disorder, randomised to either ACT, CBT or a re-educational control group, those in the ACT group demonstrated an abstinent rate (defined as 3 months without drug use) of 27.8% compared to 15.8% in the CBT group and 7.7% in the control group at post-treatment monitored by both self-report and urinary analysis (Lanza et al., 2014). At six months post-treatment, ACT abstinence rates increased to nearly 44% in the ACT group compared to 26.7% in the CBT group. González-Menéndez et al. (2014) compared the effectiveness of both ACT (n = 18) and CBT (n = 19) in addressing addiction issues amongst incarcerated females. Findings indicated that abstinence rates for ACT were 27.8% at post-treatment, 42.8% at 6 months, 84.6% at 12 months and 85.7% at 18-months. This compared 49 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda Table 1 Overview of included studies. Study N Age Mean Age Conviction %f Population Country Design Control R/A Treatment Format Length ACT Eisenbeck et al. (2016) Lanza et al. (2014) 17 50 18–41 21–49 26 33.2 VO VO 0% 100% Prison Prison Hungary Spain RCT RCT TAU CG Y Y G G 10 × 90 min 16 × 90 min Malouf et al. (2017) 40 18–81 37.2 VO 0% Jail USA RCT TAU Y G 8 × 90 min 37 22–49 33.5 DR 100% Prison Spain RCT TAU Y ACT vs CBT ACT vs CBT vs CG REVAMP vs TAU ACT vs CBT G 16 × 90 min 30 33 41 21 Juveniles 22–55 – – – 38 – 49 – IPV/DV VO DV 0% 0% 0% 0% JCC Prison Jail Min Sec Prison Iran USA USA Spain BG WG WG BG CG – – CG – – – – ACT vs CG ACT ACT ACT vs CG G G G I/G 8 × 90 min 12 × 120 min 8 × 90 min 14 sessions 19 – 36.9 – 0% State Hospital UK BG – – CFT G 20 sessions González-Menéndez et al. (2014) Mohammadi et al. (2015) Orengo-Aguayo (2016) Plambeck (2015) Sahagun-Flores and SalgadoPascual (2013) CFT Laithwaite et al. (2009) Note: Percentage female (%f), Random Allocation (R/A), Violent Offence (VO), Randomised Controlled Trial (RCT), Treatment as Usual (TAU), Acceptance Commitment Therapy (ACT), Cognitive Behaviour Therapy (CBT), Group (G), Individual/Group (I/G), Control Group (CG), Re-Entry Values and Mindfulness Program (REVAMP), Drug Related (DR), Juvenile Correctional Centre (JCC), Intimate Partner Violence/Domestic Violence (IPV/DV), Between Group (BG), Within Group (WG), Compassion Focused Therapy (CFT). to abstinence rates in the CBT group of 15.8% at post-treatment, 25% at 6 months, 54.5% at 12 months and 50% at 18 months. Results also indicated a significant difference in favour of ACT at 18 months. One of the strengths of this particular study was the 18 month timeframe for collection of post data although the relatively small sample size limits conclusive findings. Malouf et al. (2017) assessed for frequency of drug and alcohol use amongst prisoners assigned to the REVAMP program (n = 21) compared to those in TAU (normal jail treatment, n = 19). Results indicated no statistically significant difference between substance misuse rates at Table 2 Individual attributes of methodological quality and outcomes for included studies. Study N Quality score Outcomes ACT Eisenbeck et al. (2016) 18 3 Lanza et al. (2014) 50 6 Malouf et al. (2017) 40 7 Gonzaléz-Menéndez 37 5 Mohammadi et al. (2015) 30 3 Orengo-Aguayo (2016) 33 8 Plambeck (2015) 41 3 Sahagun-Flores and Salgado-Pascual (2013) 21 5 No significant difference between those in ACT and TAU group on BDI, BAI and at post-treatment. Similar results found at 3-month follow-up. At post-treatment, 15.8% of the CBT and 27.8% of the ACT groups were abstinent versus 7.7% of the CG. A significant difference was found between ACT and CG, in favour of the ACT condition, χ2(1, N = 50) = 20.48, p =.000. At the 6-month follow-up, CBT and ACT conditions increased the percentages of abstinence to 26.7% and43.8%, respectively, versus 18.2% of the CG. Those in CBT experienced bigger declines in 3 of the 4 subscales of the ASI compared to those in ACT and CG. ACT group decreased the percentage of psychopathology associated with major depressive disorder, Q(16) = 5.42, p =.06, and panic disorder, Q(16) = 5.33, p =.069 on MINI. CBT and control groups showed no significant changes. REVAMP group medium effect sizes for willingness (d = 0.72) increasing at 3-month follow-up (d = 1.05) as measured by Mindfulness Inventory. Marginally significant trend for REVAMP group to have reported engaging in less criminal activity. TAU group recidivated earlier than REVAMP (d = 0.62). No significant between-group difference at 3-month follow-up for substance misuse on TCU-CRTF. No changes found on BPD symptoms as measured by PAI. At 18-months, a statistically significant difference was found in favour of ACT compared to CBT in relation to abstinence rates as measured by UA. Significant therapy effect in favour of ACT on three subscales of the ASI-6 however CBT improved more than ACT on measure of anxiety as measured by Anxiety Severity Index (ASI). Reductions on all subscales of primary outcome measure Aggression Questionnaire, medium effect size (eta squared 0.52). Moderate effect size on secondary outcome GAD scores (η2p = 0.128) for those high on criminal severity. No impact on other secondary depressive, aggressive and impulsive symptoms as measured by Aggression Questionnaire and UPPS-S Impulsive Scale. Significant decrease in trait anger (STAXI-2, primary outcome measure) and in the number of problematic behaviour associated with anger. Problematic behaviour continued to decrease at 1-month follow-up as measured by Anger Consequences Questionnaire. Significant changes pre to post compared to a no-treatment control group, on impulsivity as measured on Plutchik Impulsivity Scale, and valued-based behaviour using Daily Willingness Diary (effect sizes ranged from 0.31 to 3.89, with an average effect size of 1.66). 19 3 CFT Laithwaite et al. (2009) Significant changes on primary outcome measure of depression as measured by BDI (r = 0.38) at post-treatment increasing at 6- week follow-up (r = 0.47). PANSS (secondary outcome measure) general Psychopathology that were maintained at follow-up (r = 0.41). No changes found on positive or negative scales of PANSS. Note: Outcome measures- Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Anxiety Sensitivity Index (ASI), Mini International Neuropsychiatric Interview (MINI), Addiction Severity Index-6 (ASI-6), Generalized Anxiety Disorder questionnaire (GAD), State-Trait Anger Expression Inventory- Second Edition (STAXI-2), The Positive and Negative Symptom Scale (PANSS), Acceptance and Commitment Therapy (ACT), Treatment as Usual (TAU), Cognitive Behaviour Therapy (CBT), Control Group (CG), Personality Assessment Inventory (PAI), Borderline Personality Disorder (BPD), Texas Christian University: Correctional Residential Treatment Form (TCU-CRTF), Urinary Analysis (UA). 50 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda 3 months post-release. Effect sizes for substance misuse improvement in the REVAMP group were found to be in the small to medium range (d = −0.37 to −0.46). found between the two groups on the BDI. Lanza et al. (2014) found that compared to CBT and control group, the ACT group decreased the percentage of psychopathology associated with major depressive disorder, (p =.06). The study by Orengo-Aguayo (2016) reported no significant changes in depressive symptoms. In another study, 19 males diagnosed with psychosis residing in a high security hospital setting completed a 20-session group therapy that was based on Compassionate Mind Training (Laithwaite et al., 2009). Results indicated that participants who completed the group demonstrated a significant reduction on the primary outcome measure of depression, as measured by the BDI (p <.05, r = 0.38) which increased further at 6-week follow up (p <.01, r = 0.47). It is difficult to draw any firm conclusions due to the conflicting findings regarding ACT's effectiveness in targeting depressive symptomology for incarcerated men. The only study focusing on CFT suggests that it may be a useful treatment in targeting depression for individuals with a diagnosis of psychosis but the small sample size and lack of a control group limits findings. 3.4.2. Anger/aggression/impulsivity Five studies examined the utility of ACT delivered interventions for anger/aggression/impulsivity. One of the studies was a randomised controlled trial (Malouf et al., 2017), two utilized a between-group design (Mohammadi, Farhoudian, Shoaee, Younesi, & Dolatshahi, 2015; Sahagun-Flores & Salgado-Pascual, 2013) and a further two within-subject design studies (Orengo-Aguayo, 2016; Plambeck, 2015). The Malouf et al. (2017) study compared an ACT intervention with TAU (normal jail treatment), the Mohammadi et al. (2015) study compared ACT with a control group and Sahagun-Flores and Salgado-Pascual (2013) compared an ACT intervention with a no-treatment control. Malouf et al. (2017) found no significant difference between the REVAMP program and TAU on measures of self control and impulsivity. Sahagun-Flores and Salgado-Pascual (2013) conducted a pilot ACT intervention that lasted 3.5 months with 18 incarcerated domestic violence offenders in Spain. The study found that on a measure of impulsivity, those offenders in the ACT group demonstrated marked reduction in impulsivity with a large effect size reported (d = 1.06). The small sample size and the lack of both randomization and symptom outcome measures limit the generalizabilty of these results. In the only study to focus on juvenile offenders, Mohammadi et al. (2015) found that compared to juveniles assigned to a control group, those in the 8session ACT group demonstrated significant reductions on the primary outcome of physical aggression, verbal aggression, hostility and anger as measured by the Aggression Questionnaire (Buss & Perry, 1992). Two studies involved unpublished doctoral theses. One of the studies, which achieved the highest Attributes of Methodological Quality score, Orengo-Aguayo (2016) found that 33 court-mandated Intimate Partner Violent offenders who participated in a 1 month ACT skills group demonstrated no statistically significant improvements or main effects on secondary outcome measures for self-reported aggressive behaviours as measured on the Aggression Questionnaire and impulsivity on the UPSS-S Impulsive Scale (Whiteside & Lynam, 2001). The other unpublished thesis study by Plambeck (2015) found that an 8-week group ACT program for violent offenders was effective in reducing primary outcome measures of trait anger as measured by the Anger Consequences Questionnaire (Dahlen & Martin, 2006) and StateTrait Anger Expression Inventory (Spielberger & Sydeman, 1994). Anger scores continued to reduce at 1 month follow-up and the reduction in trait anger indicated that treatment not only reduced anger but positively impacted on the of the offenders experience of anger. The low methodology rigour of the study and the high attrition rate (41 offenders completed pre-treatment questionnaires, only 15 completed 1-month follow-up) pose difficulties in terms of the validity of this finding. In summary, results of ACT studies conducted with incarcerated offenders on anger/aggression/impulsivity provide a somewhat mixed picture as to their effectiveness. There is limited evidence that groupACT may be effective with juvenile offenders. Three of the studies report that ACT was effective in reducing anger/impulsivity, with two studies noting no beneficial impact on these difficulties. 3.4.4. Anxiety Three randomised trials and one within group design study examined the effectiveness of ACT in treating anxiety. Eisenbeck et al. (2016) found no significant improvements for those in either the ACT or CBT group on measures of anxiety at either post-intervention or three month follow-up. It should however be noted that the very small sample size and the fact that novice therapists delivered treatment are factors that need to be considered when evaluating the study. Lanza et al. (2014) found statistically significant differences in favour of group CBT and ACT compared to control group although greater decreases were found for those in the CBT group on the Anxiety Sensitivity Index (ASI, Peterson & Reiss, 1992). Significant change observed in the CBT group at post-treatment assessment faded after 6 months. However, the posttreatment reduction in the cognitive domain of the ASI of the ACT group was maintained at follow-up. González-Menéndez et al. (2014) reported that participants in both the CBT and ACT group demonstrated significant reductions on the ASI but that improvement was more pronounced in the CBT group. Also general decreases were found in general psychopathology in both groups but ACT demonstrated significant tendencies in anxiety disorders (77.8% of ACT group meeting DSM-IV-TR at intake compared to 21.4% at 18 month follow-up). Orengo-Aguayo (2016) reported that there was a significant main effect of time with a moderate-magnitude effect size on secondary outcomes for anxiety as measured by the GAD-7, F (1, 32) = 4.57, (p.041 η2p = 0.128) but this score was qualified by an interaction with criminal history severity, with those with a higher criminal activity ratings showing a non-significant but descriptive decrease in anxiety symptoms. 3.4.5. Psychosis Only one study focused on individuals diagnosed with psychosis. Laithwaite et al. (2009) found that group CFT was effective in reducing general psychopathology on The Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) at the end of treatment with small effect sizes noted (p <.05, r = 0.38). No significant changes were reported on the PANSS negative, positive and depression subscales. 3.4.3. Depression Three studies examined the effectiveness of ACT on depressive symptoms (Eisenbeck, Scheitz, & Szekeres, 2016; Lanza et al., 2014; Orengo-Aguayo, 2016) and one group focused on the effectiveness of CFT (Laithwaite et al., 2009) on depression with two of the above using the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) as an outcome measure. In a randomised controlled study, Eisenbeck and colleagues compared the effectiveness of ACT to CBT for violence-prone inmates. Both interventions comprised of ten 90 min sessions. At postintervention and at 3-month follow-up no significant difference was 3.4.6. Recidivism rates Only one article looked at recidivism rates following therapy. Malouf et al. (2017) relied on both offender reported incidents of rearrest for 16 specified categories of offending 3-months post release. The study also used official criminal records to assess recidivism rates at four time periods: the first three months, three months to one year, one to two years, and two to three years post-release. Although not significant, results favoured the REVAMP group regarding engagement in risky behaviour post-release. According to official records of arrest, on 51 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda average participants in the REVAMP group were not only arrested later (d = −0.62) but also during fewer time periods (d = −0.73) over the three year period when compared to the control group. Although only marginally statistically significant, effect sizes were in the medium to large range. finding was found in relation to ACT's impact on anxiety symptoms. Of the four studies, two reported more favourable results for CBT over ACT (González-Menéndez et al., 2014; Lanza et al., 2014) for internalizing difficulties. This finding runs contrary to other research. For example, it appears that clients with an anxiety disorder alone may benefit more from traditional CBT than ACT, while those with co-morbid mood disorders may do better with ACT than traditional CBT (WolitzkyTaylor, Arch, Rosenfield, & Craske, 2012). However, it does seem that the positive trends tended to focus on tangible behaviours such as reductions in drug use and recidivism rather than private experiences and emotions. This may be in keeping with ACTs view that symptom reduction is not a key outcome of therapy (Orsillo & Batten, 2005). It should also be noted that a number of review articles have found that ACT is superior to control conditions and broadly equivalent to active treatments for anxiety difficulties (Ruiz, 2010; Swain et al., 2013). The findings from the current study suggest that further studies identifying moderators are required in specifying what specific methods work best for this population and if methods such as mindfulness, acceptance, sense of self, values and attentional control work can complement other more traditional approaches in targeting internalizing difficulties (Hofmann & Hayes, 2018). The current review attests to the relative dearth of evidence of CFT, MCT and FAP for a prisoner population. Only one study was found for CFT which indicates that it is possibly an effective intervention in decreasing depressive symptoms in incarcerated males diagnosed with psychosis in a secure hospital setting. However the CFT study was completed in 2009 and it is somewhat puzzling as to why this has not led to further research into the effectiveness of CFT with a prisoner population. Regarding MCT, during the search and screening phase of this review, a number of metacognitive skills treatment studies were found focusing specifically on forensic populations (Kuokkanen, Lappalainen, Repo-Tiihonen, & Tiihonen, 2014; Naughton et al., 2012). There is some debate within the literature as to what constitutes a ‘true’ metacognitive therapy (Capobianco & Wells, 2018; Moritz & Lysaker, 2018). This debate is beyond the scope of this review but it is interesting to note that other metacognitive approaches are showing promise when used specifically with individuals incarcerated with a diagnosis of schizophrenia. This could suggest that MCT may be a good fit for this population but at this stage this assertion cannot be stood over. The only clear conclusion regarding MCT and FAP from this review is a complete lack of research. It is hoped that this review may act as a catalyst in developing the possible use of these interventions within correctional settings. 3.4.7. Personality Only one study (Malouf et al., 2017) reported on the effectiveness of an ACT informed program on symptoms of Borderline Personality Disorder (BPD) as measured on the Personality Assessment Inventory (PAI; Morey, 1991). No significant differences were found at posttreatment on measures of affective instability, identity problems, negative relationships, and impulsivity. 4. Discussion The current review aimed to describe and assess the effectiveness of four third wave therapies, ACT, CFT, MCT and FAP for common mental health problems and offender specific factors (aggression, recidivism) in forensic and correctional settings. A total of nine studies met inclusion criteria. To put this number into perspective a recent review of DBT, another third wave therapy, within forensic institutions reported on 34 studies (Tomlinson, 2018). DBT's applicability with this population may be due to the fact that its therapeutic focus has historically been with emotional regulatory problems and personality difficulties; traits that have been readily reported within forensic populations. This and the prevalence of CBT based interventions in correctional and forensic institutes may go some way in explaining the paltry number of studies focusing on other third wave therapies with this population. In contrast, although this review provides some encouraging findings, it is difficult to draw particularly firm conclusions about the utility of ACT and CFT in treating and addressing common presentations due to the relatively small number of studies included in the review and the significant methodological shortcomings inherent in many of the studies. Indeed, only four studies included in this review employed randomised controlled trials, further attesting to the methodological limitations. This review provides tentative evidence for the effectiveness of ACT with a prison population for addiction issues but this finding is only based on two relatively small studies. Bolstering this finding however is the fact that the studies (González-Menéndez et al., 2014; Lanza et al., 2014) compared ACT to CBT and that abstinence rates favoured ACT even at 18 months post-treatment. This does not suggest treatment equivalence but it nonetheless a noteworthy finding, especially regarding the maintenance of such treatment effects. Similar positive findings for substance abuse have been reported for ACT amongst nonincarcerated samples for both polysubstance abuse (Hayes et al., 2004) and marijuana (Twohig, Shoenberger, & Hayes, 2007) suggesting that ACT may be a valid treatment option for incarcerated female drug users. The current review is more mixed regarding ACTs possible use in targeting aggression/anger and impulsivity, with three of the five studies reporting favourable outcomes produced by ACT. This may suggest that ACT is superior to waitlist control but it is difficult to summarize if it is broadly equivalent to other active treatment interventions that address aggression. However the evaluations included in this review did not specifically focus on reducing criminogenic need. Indeed it does not seem that the research included attempted to implement ACT or CFT in accordance with RNR principles and a number of studies that focused on anger/aggression and impulsivity provided no information as to the level of risk of the population included. No specific risk assessments were used in any of the studies. This is a significant short-coming that requires addressing and it would be interesting if outcome measures that focused on dynamic risk factors for both violent and sexual offenders were included in future research. The evidence for ACT as a treatment for internalizing disorders is somewhat more conflicted. Of the three studies included, two reported minimal effects of ACT on depressive symptoms. A similarly mixed 4.1. Limitations While the above findings provide tentative empirical evidence for ACT for certain presentations there are a number of serious limitations that permeated much of the reviewed literature. The sample size of reviewed studies is small with only nine studies meeting inclusion criteria. However, other reviews focusing on interventions with this population have been completed with a similar number of suitable studies included (Auty, Cope, & Liebling, 2017b; Shonin et al., 2013). Although four of the included trials used a randomised controlled design, much of the literature reviewed was characterised by low N and high heterogeneity. Review of the methodology also indicates that the majority of studies comprised of a number of design errors or omissions many of which have been cited in other reviews (Öst, 2008; Swain et al., 2013). Many studies also lacked the reporting of ES that would further help delineate the effectiveness of interventions and assist in the comparison of treatment modalities. The review also included many studies (n = 8) that did not include any form of treatment adherence scales or similar safeguards that would likely impact on clinical outcomes. Similarly the focus of studies on male violent offenders, while understandable, limits the generalizability of such findings to other offender groups and female populations. All of the studies included also focused mainly on 52 Aggression and Violent Behavior 46 (2019) 45–55 G. Byrne, Á. Ní Ghráda groups. Almost all of the studies varied regarding treatment length, content and intensity. Given this heterogeneity it was not possible to complete a meta-analytical analysis. A further limitation of the current study is the fact that only one reviewer completed the search procedure. Although every effort was made to search for unpublished studies through Proquest and Google Scholar it is entirely possible that other relevant research was not found. ACT; 4. compassion; 5. compassion focused therapy; 6. CFT; 7. metacogntive therapy; 8. MCT; 9. functional analytic psychotherapy; 10. FAP.; 11. forensic; 11. prisons; 12. mental health; 13. aggression; 14. psychosis; 15. anxiety; 16. depression; 17. substance abuse; 18. drugs. References1 Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis/Anderson. Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science and Practice, 15, 263–279. A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. Auty, K. M., Cope, A., & Liebling, A. (2017a). Psychoeducational programs for reducing prison violence: A systematic review. Aggression and Violent Behaviour, 33, 126–143. Auty, K. M., Cope, A., & Liebling, A. (2017b). A systematic review and meta-analysis of yoga and mindfulness meditation in prison: Effects on psychological well-being and behavioural functioning. International Journal of Offender Therapy and Comparative Criminology, 61(6), 689–710. Beaumont, E., & Hollins Martin, C. J. (2015). A narrative review exploring the effectiveness of compassion-focused therapy. Counselling Psychology Review, 30(1), 21–32. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory-II. San Antonio, TX: Psychological Corporation. Becker, S. J., & Curry, J. F. (2008). Outpatient interventions for adolescent substance abuse: A quality of evidence review. Journal of Consulting and Clinical Psychology, 76(4), 531–543. Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K.,... Zettle, R. D. (2011). Preliminary psychometric properties of the acceptance and action questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–688. Buss, A. H., & Perry, M. (1992). The aggression questionnaire. Journal of Personality and Social Psychology, 63(3), 452–459. Byrne, G., Bogue, J., Egan, R., & Lonergan, E. 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Advances in Psychiatric Treatment, 15, 199–208. Goncalves, L. C., Goncalves, R. A., Martins, C., & Dirkzwager, A. J. E. (2014). Predicting infractions and health care utilization in prison: A meta analysis. Criminal Justice and 4.2. Recommendations for future research It is clear that further high quality studies are required in order to clarify if third wave therapies other than DBT are useful in the forensic arena. Randomised, appropriately powered ACT studies are required to further delineate if ACT is potentially useful as a means of reducing psychological difficulties as well as possibly helping to decrease recidivism rates. The literature may also benefit from the study of individual ACT therapy and how this compares to group interventions regarding relative effectiveness and acceptability amongst prisoner populations. Similar requirements are needed for CFT to clarify if it is an appropriate treatment for offenders not diagnosed with a psychotic disorder. The high levels of shame and self-criticism reported in certain offender populations (Tangney, Stuewig, & Hafez, 2011: Velotti, Elison, & Garofalo, 2014) makes CFT a potentially useful treatment with this population but further high quality research is required. The paucity of research regarding MCT and FAP curtails any recommendations that can be made about these treatments with offenders and in the forensic setting. Small scale research into the effectiveness of FAP and MCT is required to help clinicians and researchers gauge the potential usefulness of these approaches as the there is no published literature on the effectiveness of these treatments in correctional settings. The application of the aforementioned therapies may benefit from integration within broader treatment packages that focus not only on mental health difficulties but also offender-focused issues adhering to RNR principles. This seems to be one of the ways in which DBT has accrued a growing evidence base with forensic populations (Tomlinson, 2018). Such reviews could also evaluate the mechanisms of change and compare these to more established treatments such as CBT. In summary we believe that methodological safeguards, such as larger sample sizes, active control conditions, treatment fidelity measures and reporting of instructor training would be further safeguards that future trials should employ. 4.3. Conclusions This article presents a review of four third wave therapies and their respective applicability and use within correctional and forensic settings. The literature is typified by low study numbers and numerous methodological shortcomings. At this time, the review provides very tentative evidence for ACT, specifically in the treatment of substance misusing female offenders. There is limited evidence for the use of ACT with aggression/violence/impulsivity and conflicting support for its use with internalizing disorders. The only study focusing specifically on recidivism, suggests that an ACT informed intervention may be effective in reducing reoffending rates. These results require further replication and need to be tested against TAU and other active treatment conditions. The only study utilizing CFT found that it was effective in reducing general psychopathology and depression for individuals diagnosed with psychosis and provides some promise. The lack of studies regarding FAP and MCT with this population requires addressing. It is hoped that this review has revealed a gap in the empirical evidence base and that it serves as an inspiration to psychotherapy researchers to establish this empirical base more firmly. Appendix A. 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