Immigration, antisocial behaviour and psychopathology: assessment and treatment

By Alfio MAGGIOLINI.
1 Jul, 2007

Summary:

In this paper I will present some data and I will share some thoughts regarding the mental health problems and the psychological treatment of young offenders, with some data about the problems of unaccompanied under 18s immigrants, a group causing great concern in Italy today.

I would then like to describe an integrated model of intervention, based on a developmental understanding of psychotherapy, according to which it is essential to aim at developing a sense of responsibility, while working with antisocial adolescents.

Finally, I would like to show that a psychoanalytic prospective may be compatible with an intervention within the penal system, while cognitive-behavioural interventions tend to be generally deemed more effective.

Our understanding of the issue comes from interventions with antisocial adolescents carried out by our team in the community and within the Juvenile Justice Services. Such provisions have been funded by the Ministry of Justice, the Lombardia Region, the Milan Hall and the Cariplo Foundation amongst others. Our experience led to the foundation of a Centre for the assessment and the treatment of antisocial behavioural disorders, funded by Milan Hall. The Centre is the result of a long standing relationship between the Minotauro, a trust working within the social field, and the Juvenile Justice Centre in Milan.

Juvenile delinquency in Italy

In Italy the number of young offenders is low, in comparison to other European Countries. In Italy for every thousand adolescents, only 9,7 are charged; this figure rises to 43,4 in Finland, 43,5 in France, 81,9 in Germany, 24,3 in Greece and 32,5 in the United Kingdom (Year 1998, National Centre for Childhood and Adolescence, 2004).

Considering the proportion of under 18s amongst offenders reported to the Authorities, the situation in Italy is also positive.

There is a relatively stable trend over time in the number of charges involving under 18s, with a tendency towards a lessening.

Juvenile reported to the Authorities 1991-2001 (Source: ISTAT, 2001)

The most common offence amongst under 18s is burglary.

In the past few years mayor changes have occurred with regards to under 18s charged with an offence, especially in the North, where the number of non Italian adolescents entering the penal system is increasingly high.

Number of young offenders detained in prison in Italy 1991-2002 (Italian Department of Juvenile Justice)

The percentage of non-Italians in juvenile prisons is now higher than the percentage of Italians.

Not Italian adolescents entering the penal system come prevalently from Rumania and Morocco.

NUMBER OF UNDER 18s CHARGED WITH A CRIMINAL OFFENCE IN 2003, BY COUNTRY OF ORIGIN (National Centre for childhood and adolescence's documentation and analysis, Ministry of Labour and Social Security)
COUNTRY OF ORIGIN	N OF UNDER 18s CHARGED IN 2003

Italy	29.747
European Union	338
Of which: France	96
Germany	148
United Kingdom	23
Spain	21
Other European Country	7.363
Of which: Albania	1.051
Bosnia	267
Croatia	545
Serbia	1.605
Rumania	3.323
Africa	2.968
Asia	297
America	497
Total	41.212

Most immigrants under 18s are unaccompanied. Some of them are sent to Italy by their family, some others take the personal decision to leave a problematic family behind. After an expensive and adventurous journey, most of them fail to find financial means to survive. They then get in touch with adults, coming from the same Country, who involve them into offending.

Youths coming from Morocco tend to commit drug dealing, while Rumanians tend to commit burglary.

Mental health problems in young offenders

The discussion on the relationship between mental health problems and delinquency is still ongoing and research on psychopathology in juvenile delinquency still in its infancy.

Antisocial behaviour by youths is a normative phenomenon, but in persistent offenders vulnerability interacts with adverse or criminogenic environment, thus resulting in a stable and persistent pattern of offending. The definition of offending may vary, covering offences ranging from minor delinquencies to serious assault. Measures of prevalence vary depending on self-reports or court convictions, with rates as high as 70% in self-report and when minor delinquencies are included (Farrington 1995). In the adolescent population about 5% show an early onset and persistent pattern of antisocial behaviours (Vermeiren, 2003; Moffitt, 2003; Vermeiren, Jespers, Moffitt, 2006).

In addition to that, prevalence rates of mental health problems in young offenders depend on the definition of mental illness employed and on what measures are used to assess it.

The prevalence of psychiatric disorders in community samples is around 15-20%. The literature reports rates of mental health problems in young offenders varying from 4% to 70%. Higher rates are likely to be reported when the definition includes 'antisocial personality disorder or conduct disorder', for symptoms of that diagnosis can be detected in most people with a delinquency history. Excluding conduct disorder more than half of detained adolescents are diagnosed with at least one other psychiatric disorder. Lower rates are reported mainly when the definition is limited to serious psychiatric illnesses, such as psychoses.

Of course, detention itself may influence one's psychological condition, but youth at a pre-juvenile justice level (namely those in contact with the police) have higher levels of both internalizing and externalizing problems, compared to non-arrested youths.

Prevalence of mental health disorders within the under 18s population and within the young offenders population

MENTAL HEALTH PROBLEMS	GENERAL POPULATION% (Boesky, 2002)	JUVENILE JUSTICE% (Boesky, 2002)	INCARCERATED YOUNG OFFENDERS % (Vermeiren, Jespers, Moffitt, 2006)
Conduct disorder	1 - 10	10-88	66-75
Attention deficit	3 - 7	2 -76	1-34
Substance abuse	5.5- 9	46 -88	33-50
Mental retardation	1	13
Learning disorders	2 - 10	17 -53
Mood disorders	5 - 9	10 -88	1-20 (more suicide attempts amongst delinquents)
Anxiety disorder	3 - 13	6 - 41	20-59
Post Traumatic Stress Disorder	6	5-49	16-32
Psychosis & Autism	0,5 - 5	1 - 16	1-2 (psychotic symptoms in 25 %)
Any other disorder	18 - 22	80

Prevalence of mental health problems within the young offenders population of the Juvenile Justice Services in Milan

We have carried out an epidemiologic research on the prevalence of mental health problems in a sample of 214 young offenders within the Juvenile Justice Services of Milan (65% not Italians either from other Countries or gipsy, 35% Italians; 87% males and 13% females). The research assessed the youths when entering the penal system in 2005, either in prison or in the community - if alternative provisions where put in place.

We have used the following assessment tools:

A re-offending risk scale
The Global Assessment Functioning Scale (GAF, DSM-IV-R)
The Youth Self Report Form (Achenbach, 2001)
The Teacher Report Form (Achenbach, 2001)

The global functioning, as assessed with the GAF Scale, has a medium score of 63 (range 0-100). Gipsies and adolescents coming from Rumania and ex-Yugoslavia Countrieshave the lowest scores (Italians has a medium score of 67, not Italians a score between 50 and 60).

This global functioning assessment overlaps with the re-offending risk assessment (number and types of offences committed, age at the first offence and indicators of a supportive environment). Adolescents coming from Rumania show a high score in re-offending risk index.

Risk index percent. Young offenders Juvenile Justice Services, Milan, 2005

		Country
	Total	Italy	Rumania	Morocco	Ex Yugoslavia	Other
Low risk	24,6	38,2	0,0	33,3	0,0	0,0
Medium risk	24,6	32,4	9,1	0,0	16,7	60,0
High risk	50,8	29,4	90,9	66,7	83,3	40,0
Total	100,0	100,0	100,0	100,0	100,0	100,0

Medium score	48	39	65	47	72	46
Number	65	34	11	9	6	5

Rumanians' scores in behavioural problems are higher, in comparison to Italian young offenders'.

Behavioural problems index. Young offenders Juvenile Justice Services, Milan, 2005

	Medium score	Number of offenders
Italy	27	31
Rumania	52	4
Morocco	21	4
Ex Yugoslavia	50	4
Other	52	4
	33	47

The assessment by the staff through the TRF (Achenbach, 2001) of the total problems show that 66% of young offenders are in a clinical range, 16% in the borderline range, and 18% has a normal score.

Total problems' score is higher for non Italians:

Young offenders within the clinical range of the TRF problems scales

Total problems Externalized Internalized

Italians 50 46,4 28,6

Not Italians 92,9 78,6 62

Total problems at TFR. Juvenile Justice Services, Milan, 2005

Non Italians tend to be more rule-breaking (percentages in clinical range: 62,5% gypsies, 50% non Italians, 45,5% Italians). 80% of the scores of young offenders from Romania is within the clinical range.

Rule- breaking: YSR percentage rates. Young offenders Juvenile Justice Services, Milan, 2005

		Normal	Borderline	Clinic	Total
Nationality	Italians	54,5	15,2	30,3	100,0
	Not Italians	25,0	25,0	50,0	100,0
Total		42,1	17,5	40,4	100,0
Country	Italy	50,0	14,7	35,3	100,0
	Rumania	0,0	20,0	80,0	100,0
	Morocco	28,6	28,6	42,9	100,0
	Ex Yugoslavia	33,3	33,3	33,3	100,0
	Other	33,3	0,0	66,7	100,0
	missing	60,0	20,0	20,0	100,0
Total		42,1	17,5	40,4	100,0

The cross informant information (TFR - YSR) shows a difference with regards to the young person's and the staff's assessment of the adolescent's problems.

Cross informant information (TRF-YSR: DSM scales).Juvenile Justice Services 2005

The Juvenile Justice's guidelines

Penal response can either take place in prison, in a residential community or it can involve diversion projects. In Italy, the Penal Proceeding Code for young offenders aims at keeping the adolescent in his environment, thus avoiding disruption, and promoting the acknowledgement of one's responsibility with regards to the offence. Both aims are promoted through interventions held in the community, in residential communities or in prison. The goal is declaredly making prison a residual response for young offenders.

The number of non-Italian young offenders detained in prison is getting higher than the number of Italians. In the North, this trend has already taken place. However, the number overall is still relatively low.

In probation, an alternative to prison, the trial is suspended, while a project aiming at taking on responsibility and commitments is agreed upon with the young person. However, Italian adolescents tend to be mostly the target of such alternative responses, due to their having a home and a family.

Once in Italy, the first Institution many immigrant unaccompanied adolescents come across with is the penal system. Some probation projects, with special allocated founding, have only recently been put in place. The aim is a reduction in prison rates, not differently from the aim informing responses to Italian young offenders. In particular, we have recently put in place a provision for unaccompanied young offenders, mainly from Romania and Morocco, with a strong psychological and educational support.

Models of psychological interventions with young offenders

Psychological and psychotherapeutic intervention within the penal system can be thought in two different ways.

A first model of intervention is based on the assumption that if young offenders are "psychopathological", they should be treated. If they are not deemed so, they are to be punished. The psychologist assesses and treats the former group. In this scenario the psychotherapist tries to be as little involved with the penal system as possible.
According to a second model of intervention, the psychologist works in team with the other professionals and, depending on the available resources, deals with all the young offenders. However, the psychologist is more involved in cases where a higher risk has been assessed and he is more needed.

These models clearly depend on the available resources, but they are also underpinned by the assumed relationship between mental health problems and juvenile delinquency.

On the effectiveness of the penal response

Until 1970s-80s there was a widespread pessimism that treatment of juvenile delinquency could be effective; such opinion arose from a survey on the results of different types of treatment (Martinson, 1974). New meta-analyses carried out, together with a gradual improvement of the provisions, encouraged a more positive attitude (McGuire, 1995; Lipsey, 1995).

The issue today is no longer on whether psychological treatment works overall, but on finding what treatment, by whom, is most effective for which individual, with which specific problems and under which set of circumstances. Punitive interventions have negative effects and worsen recidivism rates; moreover, psychotherapy results are not encouraging, and the same is true with regards to pharmacological treatment when not associated with psychosocial interventions. Meta-analyses show that any treatment, compared to criminal sanctions, works. Effect size of treatment for young offenders is 0.13 (a 13% reduction in recidivism) compared with a negative effect (-0.02) of criminal sanctions (Dowden, Andrews, 1999, Latessa, 1999).

Multimodal interventions seem to be a particularly effective strategy in reducing juvenile antisocial behaviour, when psychotherapy is combined to social and educational provisions (Fonagy, Target, Cottrell, Phillips, Kurtz, 2002); Bleiberg, 2001; Henggeler, Schenwald, Borduin, Rowland, Cunningham, 1998).

Effectiveness evaluation of programmes carried out in Europe

Redondo, Sanchez-Meca, Garrido (2001) carried out a meta-analysis including the treatments addressed to young and adult offenders in Europe for youth and adults.

The study explored the effectiveness of a set of programs involving the treatment of offenders, carried out in European countries in the course of a decade.

The general result was that treated groups showed an improvement 12% greater than control groups (as assessed by a decrease in re-offending rate).

Cognitive and behavioural programs were found to be the most effective ones, with an average reduction of 23% in re-offending rates (Redondo, Sánchez-Meca, Genovés, 2001).

Treatment cluster: theoretical models and effectiveness (r )(Redondo, Sanchez-Meca, Garrido, 2001)

What makes a program effective

Providing appropriate and effective mental health services is a critical factor in building a positive Juvenile Justice system, along with making employment a realistic possibility and avoiding as much as possible placing the young people in situations where they form close bonds with other offenders (Maxwell, 2003).

In young offender treatment some principles are important in effective treatment. The first principle is the introduction of human service in a justice context (Andrews, Zinger, Hoge, Bonta, Gendreau, Cullen, 1990; Dowden, Andrews, 1999; Gendreau, Andrews, 1990). The application of the risk principle helps identify who the treatment should be targeted at. The service has to be delivered to the high risk subgroup of offenders: indiscriminate targeting is counterproductive in re-offending rates. Medium-to high-risk offenders should be selected for treatment and programs should focus on criminogenic targets.

The criminogenic need principle focuses on what should be treated: criminogenic needs are the key when developing effective correctional treatments. Criminogenic needs are pro criminal attitudes, substance abuse, antisocial personality, problem-solving skills and the expression of hostility-anger. Non-Criminogenic needs are self-esteem problems, anxiety, feelings of alienation and psychological discomfort, group cohesion or neighbourhood improvement. The responsivity principle focuses on how the treatment should be delivered and its methodology. The type of treatment is important, with stronger evidence for the effectiveness of structured behavioural and multi-modal approaches, rather than less-focused ones. The most successful programs, while behavioural in nature, include a cognitive component that focuses on attitudes and beliefs. Provisions carried out in the community have a stronger effect than the residential ones. Indeed, residential programs can be effective only if they are structurally linked with community based interventions. The most effective programs show a high treatment integrity, i.e. they are carried out by trained staff and the treatment initiators are involved throughout the operational phase of the treatment (Hollin,1995; 1999).

Mean Effect Sizes and Number of Contributing Tests of Treatment for the Principles of Human Service, Risk, Need and Responsivity (**p < 0.05; ***p < 0.001,) (Dowden, Andrews, 1999)

Variable label Adheres to principle

No Yes Eta

Human service -0.02 (54) 0.13 (175) 0.31***

Risk 0.03 (61) 0.12 (168) 0.20**

Criminogenic need -0.01 (126) 0.22 (103) 0.55***

General responsivity: Behavioural 0.04 (169) 0.24 (60) 0.42***

Criminogenic needs targeted and treatment effectiveness (Bonta, 1997) Rank Ordered by Frequency and Their Correlation with Effect Size
Criminogenic needs
Targeted need	Frequency	r
Academic 51 0.23***	51	0.23***
Other criminogenic needs	47	0.36***
Anger/antisocial feelings	41	0.28***
Self-control	40	0.29***
Family: affection	24	0.33***
Pro-social model	19	0.19**
Antisocial attitudes	17	0.13*
Family: Supervision 17 0.35***	17	0.35***
Vocational skills	17	0.09
Barriers to treatment	12	0.30***
Substance abuse treatment: Any	11	0.04
Vocational skills + job	9	0.26***
Reduce antisocial peers	8	0.11
Relapse prevention	7	0.07 *
Noncriminogenic needs
Vague emotional/personal problems	59	-0.06
Physical activity	36	-0.03
Family: Other interventions	22	-0.11
Fear of official punishment	15	-0.18**
Increase cohesive antisocial peers	15	-0.12
Target self-esteem	14	-0.09
Increase conventional ambition	12	-0.00
Respect antisocial thinking	7	-0.05 *
p < 0.05; p <0.01; *p < 0.001

Can a psychoanalytic understanding inform effective interventions with young offenders?

A psychoanalytic approach, namely psycho-dynamically oriented counselling, is generally deemed ineffective, when opposed to interventions of a cognitive-behavioural nature. The results of meta-analytic researches rather show that so called "Freudian approaches" are not effective, while multi-systemic and cognitive-behavioural approaches are (Fonagy, Target, Cottrell, Phillips, Kurtz, 2002).

Our model of intervention with young offenders is based on:

A developmental view of psychopathology, framing mental health problems in a developmental paradigm, rather than a psychiatric one based on categories (Cicchetti, Cohen, 1995; Cummings, Davies, Campbell, 2000; Achenbach, 2001; Fonagy, Target, 2003).
An attention for the developmental needs and tasks of the adolescent, together with their symbolisation (Maggiolini, Pietropolli Charmet, 2004; Maggiolini, Riva, 1998).
The importance of the becoming a subject in adolescence (Richard, Wainrib, 2006), seen more as a capacity to integrate different aspects of the self (the motivational systems underpinning interpersonal relationships: attachment, exploration, sexuality, competition, Lichtenberg, 1989; Lichtenberg, Lachmann, Fosshage, 1992; Liotti, Migone, 1997) rather than the development a reflective capacity.
The importance of an intervention on the environment, either supporting the family or creating an alternative positive environment when this is not possible.
The importance of taking responsibility, of developing a sense of agency - not only controlling one's impulses and promoting reparation. From a psychological viewpoint responsibility implies the ability to commit oneself in relation to acknowledged social bonds, to acknowledge the consequences of one's behaviour, whatever one's intentions are and to be prepared to make up for one's mistakes. This concept refers to the ability to recognize a bond, inside a social relationship; it does not relate to a specific cognitive ability nor with maintaining reality exam or with controlling impulses. Such a notion of responsibility underlines its relational rather than intra-psychic feature.

Methods

The intervention specifically aims at:

Understanding the subjective meaning of the offence (in relation to the adolescent's intentions and motivations).
Relating symbolically the offence with adolescence developmental tasks (e.g. separation, autonomy, need to feel of a value).
Detecting the developmental need underpinning the offence.
Working with the adolescent and his family on a project that involves commitment either to school, work, with the professionals or in reparative activities.
Designing an individual project, according to the needs, skills and problems of every single adolescent.
Providing psychological, social and educational support, in order to achieve the agreed goals.

The psychological intervention addressed to all young offenders within the Juvenile Justice System of Milan is carried out in cooperation with social workers, educators and the police, both during the assessment stage and the treatment stage that follows.

In the assessment phase, while the consultation with the adolescent and his family takes place, the aim is helping the patient and his environment (first of all family and school) modify their representation of needs and resources. The developmental needs can then be seen in a positive way. This phase usually ends with a report to the judge. The consultation leads to the formulation of a project that integrates a psychotherapeutic intervention addressed to the adolescent and his family with an educational provision.

Re-symbolizing means, for instance, helping the adolescent acknowledge and support the fact that separation needs are positive, while the young person and his environment may be denying it. This may imply trying to increase the adolescent's narcissistic value, and in doing so changing the value that the adolescent and his environment attribute to him.

A positive representation of the separation or an increase in the adolescent's narcissistic value can be gained in parallel works on his self image, on helping the family acknowledge these aspects in their child, through educational interventions, or by helping the adolescent get a job.

A behavioural intervention, such as helping the adolescent get a job, is important for two different reasons. Firstly, it prevents the adolescent from getting involved into dangerous situations meanwhile it gives him the opportunity to earn money, thus reducing his need to steal. Secondly, and more importantly, it changes the adolescent's representation of himself, making him feel adequate and giving him hope of developing towards the achievement of an adult status (Kammerer, 2000).

Therefore, interventions should be aimed at giving meaning to antisocial behaviour, not only relating it to the context it comes from, but primarily reading such meaning in relation to the developmental needs of the offender.

Developmental psychotherapy

A new paradigm is emerging in psychopathology as well as in treatment (developmental psychotherapy). It implies a reformulation of goals and methods of psychotherapy (Greenspan, 1997). Actually, this conception of treatment is not far from suggestions made by Anna Freud, who argued that the goal of psychoanalysis was basically to redirect the adolescent back to his natural developmental path (Fonagy, Target, 2003).

From our point of view, developmental psychotherapy is promoting the development of one's social identity and a sense of agency, underpinned by a better understanding of the young person's developmental needs, an adequate response to such needs and an intervention on the environment.

Treatment does not need to take place in the traditional setting of a consultation room. If the problems experienced by the adolescent come from a maladjustment between individual developmental needs and environment, it follows that it could be just as useful to work with the individual in his environment. Home, school and the community may equally be the setting of an effective intervention. Our perspective does not emphasize an increase in insight, but considers the symbolic meaning of the intervention more important than behavioural and impulses regulation.

Conclusion

Mental health problems are widespread amongst young offenders. Interventions within the Juvenile Justice Services can be effective, but psychological work with the young offenders has to be integrated with social and educational provisions.A psychoanalytic frame can be useful, helping the adolescent and his environment achieve developmental tasks. A strong support should be given, not only in promoting a reflective function, but also a capacity to act, to commit and to take on responsibility for one's behaviour.

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