The biopsychosocial model-the multidisciplinary approach towards illness that

encompasses biological, psychological and sociological determinants -proposed by

pathologist and psychiatrist George Engel(1913-1999) has been valued as one of the
most important developments in medicine and psychiatry in the late 20th century;
George Engel initially formulated the biopsychosocial model so as to expand the
diagnostic process and understand the patient’s suffering adequately. (Borell-Carrio,
Suchman & Epstein,2004). Its broad applicability has also been extended in the area
of criminal justice.

As cited in Abrahamsen (2013), neurobiological deficits impacting self-regulation

may lead to signs of antisocial and aggressive behaviour (Beaver & Wright, 2005;
Calkins & Keane, 2009); early age low birth weight may lead to the emergence of
neurophysiological deficits or contribute to dysfunctions of the central nervous system;
a low activity genotype of the enzyme monoamine oxidase (MAOA-L) (McSwiggan,
Elger and Appelbaum, 2017) and the CDH13 gene (coding for neuronal membrane
adhesion protein) (Tiihonen et al. 2015) have been suggested to increase the risk for
aggressive, extreme and antisocial behaviour; polymorphisms in the transporter gene
of serotonin have been associated with aggressive behaviour at both infancy and
adolescence. (Beitchman et al.,2006). Gao, Raine, Venables, Dawson and A Mednick
(2010) connected fear conditioning which arises through the amygdala and ventral
prefrontal dysfunction with impeding criminal behaviour. Moreover, the age of
offending onset is considered of primary importance for the explanation of the
criminal act and the prediction of its repeat. (Loucks, 2002). Another biological factor,
gender, plays a vital role in the emergence of violent behaviour; according to Sheikh,
Hafizur, Rahman and Karzon 2008(as cited in Rahman, 2015)different behaviour
pattern in males and females stems from different biological structures; Worldwide,
approximately 85 to 90 per cent of crimes are being committed by males. Low
intelligence has also been consistently associated with increased criminal activity
(Frissell, Pawitan &Langstorm, 2012).

Mental disorders like antisocial personality disorder and psychopathy are linked to
criminal behaviour. Offending is included in the antisocial personality spectrum as a
prevailing syndrome; According to Tuvblad and Beaver, (2015), antisocial behaviour
is a term that “encompasses many facets of destructive behaviour, most of which
bring harm to another person or involve the violation of the rights of others” (p.273).
Characteristics of antisocial disorder often involve breaking the law, incidents of
disruptive behaviour, manipulation and deception. It is often accompanied by
substance abuse, pathological gambling and psychiatric illnesses.
When referring to criminals, and especially the ones committing despicable crimes,
the word “psychopathy” emerges at surprising rates. The symptoms of psychopathy
include “shallow affect, lack of empathy, guilt and remorse, irresponsibility, and
impulsivity” (Kiehl & Hoffman, 2011,p.356). While initially addressed as a biological
phenomenon(aberrant neuronal activity in specific regions of the brain ), an
interactive model has been adopted by scholars; genetically predisposed individuals
blossom into psychopaths when interacting with the inappropriate environment(Kiehl
& Hoffman, 2011). The unique cluster of affective and individual characteristics of a
psychopath makes their identification in court challenging, while the deceptive nature
of the disorder leads to earlier incarceration release. According to Laurell and
Daderman(2005), “the ability to identify psychopathy gives us, to a certain extent, the
ability to predict serious crime”(p.256).
Individual differences play a major role in criminal behaviour; for example, Tseloni
and Pease (2014) found that “pensioners living alone in densely populated areas face
disproportionally high numbers of personal crimes” while “ethnic minority
individuals experience fewer personal crimes than whites” and “frequent club and pub
visits are associated with more personal crimes only for males and adults living with
young children.”(p.3) Personality traits theories have been linked with the
manifestation of criminal behaviour; As cited in Simane-Vigante, Plotka and
Blumenau(2018), personality models such as the Five factor model, Eysenck’sPEN
model (Psychoticism, Extraversion, neuroticism), three-factor model, C.R.
Cloninger’s temperament and character model have been used in order to explain
criminal acts. Psychological developmental theories have also been addressed;
originally developed by J. Bowlby (1984), the attachment theory surfaces in incidents
of emotional distress for the baby which seeks proximity in order to be comforted.
(Bowlby, 1988, as cited in Simane-Vigante, Plutka & Blumenau, 2018).The
attachment formation can be divided into secure or insecure attachment; According to
the theorist, criminal violence is a repercussion of attachment dysfunction; disordered
attachment-children who are mostly emotionally distanced or ignored by their parent
figure-leads to the emergence of aggressive behaviour (Levy & Orlans, 2000).

It should be noted that a child’s growing environment might be of enormous

importance in the effort of predicting the possibility of criminal engagement.
According to the socio-environmental theories, violence and aggressiveness are
acquirable attributes; the social learning theory essentially states that children adopt
values and norms from the social group to which they belong because they imitate the
group’s actions (Abrahamsen, 2013). Akers and Jensen(2006) underline the
importance of social learning theory in relation to the possible development of
conduct disorder and emergence of delinquency; continuous exposure to domestic
violence elicits the increase of stress in children that witness of becoming victims of
said violence. Through different mechanisms of the hypothalamus and the
hippocampus, chronic childhood stress results in deficient self-regulation, an attribute
linked to criminal behaviour. According to the spillover hypothesis, the disruption of
inter-parental relationship and high levels of conflict between parental figure leads to
general dysfunctionality between all family members (Benson, Buehler, & Gerard,
2008). Negative parental practices have been characterized at potentially causative to
children’s externalizing problems and namely, antisocial behaviour. (Abrahamsen,
2013). Additionally, environmental factors affect the expression of gene
predispositions; gene-environment interplay is evident in the framework of crime
causality. While 50% of the total variance in antisocial behaviour is explained by
genetic influences (Tuvblad & Beaver, 2015), 20 % of the population variation in
antisocial personality disorder stems from shared environmental factors (Moffitt,
2005). The genetic predisposition to aggression induced by the MAOA gene can be
regulated or triggered by social and environmental factors; According to Sohrabi
(2015) individuals with deficiencies in MAO-A activity have shown similar results
with other subjects in the low provocation, while displaying significantly higher levels
of aggression in high provocation conditions. In the study by Raine, Brennan,
Mednick, & Mednick, (1994), subjects revealed an interaction between birth
complications and early maternal rejection in the prediction of violent crime. In their
own words:” the critical importance of integrating biological with social measures to
fully understand how violence develops and also suggest that prenatal, perinatal, and
early postnatal health care interventions could significantly reduce violence(p.984)”.

Two of the most researched type of offenders(serial killers and sex offenders) can be
approached through the lens of the biopsychosocial model: Morisson and
Goldberg(2009) suggested that in brain scans examining the brain morphology of
convicted serial killers, a similarity pattern of decreased orbit cortex activity was
revealed. Hormonal imbalances and previous head trauma have also been found to
contribute to the formation of a serial killer; Attachment theory and social learning
theory have been suggested as methods of interpreting the mentality of a serial killer;
According to the first theory, our early life experiences are so crucial that they are
able to affect an individual’s tendency to violent behaviour (Lee, 2014). Social
learning theory (Yarbrough et al., 2012)(as cited in Abrahamsen,2013) is based on the
individual’s ability to learn through observation and mimicking; e.g.children with a
predisposition to psychopathic traits which are raised in violent environments are
prone to developing violent tendencies. As mentioned in Reis, Cavalvcante and
Valiente(2019) attributes of sex offenders are related to attributed such as
physiological arousal, age, sex, social conditions, dysfunctional family dynamics,
personal affiliations, age and gender of the victim, self-esteem, alcohol and/or drug
abuse and cognitive distortion. The contribution of paraphilic disorders is a robust
predictor of the emergence of deviant behaviour;(Thibaut et al.,2016). The authors
underline however that while frequently associated with the existence of paraphilias,
sex offences do not always stem from the existence of paraphilic disorders and most
importantly, not all paraphilics are potential sexual offenders. In the depiction of
sexual violence against women, sociological factors such as cultural view of gender
plays a vital role; according to Kalra and Bughra, (2013) while sexuality is genetic,
our understanding of sexuality depends heavily on cultural background; “Sexual
violence is likely to occur more commonly in cultures that foster beliefs of perceived
male superiority and social and cultural inferiority of women”(p.244).

While biopsychosocial factors contribute to the manifestation of criminal behaviour,

is the model adequate for the prevention of recidivism?
Recidivism is prevented when an offender desists from crime. “Desistance” is defined
as the circumstance where offenders cease to engage in criminal conduct. As
aforementioned, psychopathy is a psychological disorder, considered one of the most
contributing factors to criminal behaviour while psychopaths are significantly
represented among chronic offenders. Langstrom and Grann (2002) explored violent
crime recidivism among young offender using the PCL-r test for psychopathy and
concluded that there is a robust connection between psychopathy and recidivism.
Results of recidivism concerning psychopathy range from disappointing to alarming;
As Kiehl and Hoffman(2011) put it ”Psychopaths compose that small but
embarrassing cohort whose very resistance to all manner of treatment seemed to be its
defining characteristic.” (p.355).
Oueslati et al. (2018) explored recidivism risk factors among schizophrenic offenders;
factors that range between sociological, biological and psychological frameworks
were identified; living in poor urban neighbourhoods, having been unemployed, and
not having lived with the family, alcohol and cannabis use related disorders or a
hospitalization shorter than six months. Additionally, a combination of conventional
antipsychotics and poor adherence to treatment were considered as recidivism risk
factors. Krona et al. (2017) concluded that in a study among mentally disordered
offenders, childhood adversities and early onset of criminal offences increase the
chances to criminal relapse, while reinforced supervision tactics and intense
psychiatric monitoring seem to decrease recidivism rates. Interestingly, in a pilot
study conducted by H M Peek and Nugter (2009) it is revealed that psychotic
offenders susceptible to one-year mandatory hospital order tend to relapse shortly
after their discharge in spite of the psychiatric treatment provided, a result that
questions the validity and effectiveness of the one-year hospital order tactic imposed
to the offenders. The programs of the United Nations Office on Drugs and Crime
(2018) that focus on desistance theory emphasize long-term change over short-term
control, recognizing that progress is unlikely to be direct or continuous. In subsequent
replication research conducted in 2014 (Nowak & Nugter, 2014) 43,5 % of the
research subjects relapsed shortly after their release. Results indicate that “recidivism
among patients subject to a one-year hospital order is relatively high compared to the
rate among patients who had received a longer-term detention order.” (p.237) .The
duration of the forced hospitalization may be the catalyst for explaining the adverse
effects of the length of conviction on the decrease of recidivism. At misdemeanour
level of offences, Alarid and Rubin (2018) investigated mentally ill offenders or
offenders with co-occurrence of mental health problems and substance abuse who
voluntarily agreed to stabilize on medication and report to community-based
outpatient mental health clinic; both groups showed decreased signs of recidivism
compared to their pro-diversion period. In contradiction, on research conducted by
Shafer, Arthur and Franczak (2004) on jail diversion, individuals charged with a
misdemeanour displayed insignificant signs of recidivism limitation.

Biologically, gender differences affect criminality between males and females;

subsequently they can affect recidivism; Mannerfel and Hakansson (2018) reveal that
while females recidivate less than males (62 % to 71%) while they tend to suffer from
psychiatric symptoms and substance abuse at more significant rates than males
post-incarceration; having a substance abusing-partner is related to female recidivism.
On the other hand, a prison term is likely to induce substance abuse behaviour in
males; (Mears, Cochran and Bales, 2012); According to the authors, “a large literature
suggests that the causes of offending may differ for females and that traditional
correctional interventions may have different effects for them”(p.376). Additionally,
the quality and nature of peer relationships play a crucial role in recidivism; according
to Khachatryan, Heide, Rad ,V. Hummel (2016), group juvenile offenders face a
higher possibility of re-offending rather than lone juvenile offenders.; Juvenile
homicide offenders are more prone to re-offending if they maintain relationships with
other delinquents (M Vries & Liem, 2011).

Ter Beek et al. (2018) explored the effects psychological treatment holds on levels of
recidivism among young sex offenders. The authors concluded that treatment causes
reduction at rates of recidivism in comparison to the absence of treatment. Mpofu,
Athanasou, Rafe and Belshaw (2018), based on their research on sex offenders who
have been treated with cognitive-behaviour therapy presented lower recidivism rates
than those who did not accept CBT, marking this type of treatment as efficacious on
preventing offending relapse. Perrin (2019), in a qualitative analysis among
incarcerated sex-offenders, reveals the importance of individuals holding a
meaningful-role inside prison supported by peer support. Piche, Mathesius, Lussier,
and Schweighofer. (2016) revealed that the majority of the sex offender subjects in his
study indicated that preventative interventions such as individual and group treatment
would prove beneficial, “but inaccessibility of interventions and fear of arrest
prevented them from seeking services”. It could be argued that psychosocial factors
such as public stigmatization and fear of rejection play a vital role in the emergence of
criminal acts. Hamilton(2018) finds that incorporating narrative roles into
conceptualization and treatment of sexual offenders may benefit the treatment of sex
offenders while Davey, Day and Balfour (2015) reveal the positive outcome prison
theatre has on incarcerated sex offenders by enabling them to acquire skills positively
related with desistance ability. The beginning of the rehabilitation process pro-release
seems to enhance the mental stability of the offender and prepare him for his
resistance to re-offending.In the case of sex offenders against children, a research by
Kingston, Fedoroff, Firestone,Curry and Bradford (2008) indicated that between
high-risk and low-risk molesters, child pornography consumption was revealed as a
risk factor of recidivism for both groups while frequent use of pornography with legal
content has been estimated as a risk factor for the former group. Johnson (2018)
recommends strongly “that anyone convicted of a sex offence be prohibited from
owning, viewing, making, or in any way accessing erotica that relates in any way to
the theme or content of their sex or violent offence behaviour” during their probation
or offender registration(p.2).
Exploring agencies that address to mentally ill/addicted ex-offenders, Ray, Grommon
and Waatson (2017) suggested that “agencies with more resources and a focus on
prisoner reentry had better recidivism outcomes than those that focus only on
substance abuse services.”(p.874), underlining the targeted areas of each agency
program as crucial to the course of post-release behaviour. T.Cullen, Jonson and
Nagin (2011) concluded that prison does not in fact reduce recidivism and suggest
that prison has a criminogenic effect. The feedback from researches on mental health
courts-a developed strategy designed to address the overrepresentation of adults with
mental illnesses in the U.S-has provided mixed results; the incident of the
involvement of criminal justice authorities stands out as unfavourable and potentially
causative of a recidivism rates increase.A review examining the applicability of
criminogenic risk assessment to mentally ill offenders suggests that addressing both
mental health problems and criminogenic risk factors simultaneously will enhance the
prevention of recidivism (Skeem, Steadman and Manchak, 2015, as cited in Lamberti,
2016). On a study concerning the effectiveness of jail diversion programs(J Steadman
& Naples, 2005), results showed that while time served is prone to decrease; public
safety risk remains stable. Sirotich (2009) confirms the findings of J Steadman and
Naples(2005); while jail diversion programs proved effective on the limitation of time
served among the mentally ill offenders, jail diversion services did not decrease
recidivism rates. Leutwyler, Hubbard and Zahnd (2017), suggest that case
management is able to alleviate recidivism problems in individuals suffering from
severe mental illness. The authors propose that funding should be granted to case
management, and the goal of facilitating the access of mentally disordered
ex-offenders to case management should be achieved. According to Breetzke and
Polaschek (2018), a significant number of studies have proved that residential choice
after incarceration release plays a crucial role in the offender’s tendency to recidivate.
S Kendler, L Lönn, Sundquist and Sundquist (2017) investigated how marriage
contributes to the appearance of recidivism; it appears that marriage after the
commitment of the first crime reduces the rates of recidivism while marriage to a
former offender increases the rates of recidivism. According to Chamberlain et al.
(2018), the communication between paroles and parolee contributes to recidivism
rates of the latter; ex-offenders who have a positive relationship with their parole
office present lower chances at re-engaging in criminal acts. Lastly, according to
Nally, Lockwood, Ho and Knutson (2014), researches have supported that
ex-offenders frequently encounter multiple financial challenges after their release;
uneducated or unskilled ex-convicts were likely to be unemployed post-release and
unable to sustain their living financially; in turn, they were expected to become
recidivist offenders.

The majority of offenders face significant social adaptation issues-family

stigmatization and social ostracism, unemployment or difficulty finding a residence,
inability to return to formal education or formulate healthy relationships. Unless they
receive the appropriate help to address these issues, they risk getting entangled in a
vicious cycle of failed social re-integration, re-offending, re-conviction and social
rejection(United Nations Office on Drugs and Crime, 2018). Prevention strategies
should be formed, taking into consideration the biological, psychological and
sociological background of the offender. Biological factors as gender and age, social
factors like the nature of marriage or peer affiliations, psychological reasons as the
existence of a mental disorder or sense of worthiness overlap and affect the course of
an individual’s life post-incarceration. A multifaceted rehabilitation process should,
therefore, be among the fundamental objectives of criminal justice systems.

(2995 words)
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