Tag: therapy

 Task

Write a report that evaluates the specific challenges and issues that might be faced by prison staff planning to implement a therapeutic service (as described in a hypothetical scenario provided by The Open University, to the Author of this paper). The report should be suitable for reading by a non-academic audience.

Written by Róisín Pitman as the End-of-Module essay (3rd level) for the Psychology portion of the BA (Hons) in Criminology and Psychology (2024).

IMPLEMENTING A THERAPEUTIC SERVICE AT YOUNG OFFENDERS’ INSTITUTE

1. SUMMARY AND RECOMMENDATIONS

The following report will identify, as well as recommend, several psychological interventions that have been addressed within this report (recommendations / observations can be seen in full in Section 6 below), and suitable for the needs of the young men within this institute. The recommendations will include relevant intervention theories, some in group settings and others in one-to-one meetings, and one, where it is hoped that those leaving the institute can continue with if transferred or ultimately within their own community upon release. This report will identify Attachment-Based Theory as a useful tool when first interacting with a client, Cognitive Behavioural Therapy (CBT) which is seen as excellent in group settings and Mindfulness / Dialectical Behavioural Therapy (DBT) for both group and one-to-one sessions when encouraging inmates to self-regulate their behaviour. Finally, Systemic Therapy may useful when back in one’s own community as it draws on other influences within that person’s life.

2. INTRODUCTION

Offering any level of psychological and/or well-being programmes in a forensic setting, whether that be a Youth Offenders Institute (YOI), adult prison or secure psychiatric unit, carries with it a layer of required security and safety, compared with delivery of similar interventions within community-based programmes.

The British Association of Counselling and Psychotherapy’s ethical structure requires its practitioners to maintain a patient’s privacy and confidentiality (Open University 2023, W2; S2.1). This comes with some caveats within a prison structure. In the main body of this report are sections coveringthis as well as identifying several interventions available to you, for individual and/or group dynamics, discussing the benefits and challenges that may arise.

3. THERAPY PROVISION IN FORENSIC SETTINGS

The predominant issue when delivering therapeutic programmes in a forensic setting is security. Inmates are incarcerated to porotect the public from their crimes and to punish them accordingly. Aiding inmates with their mental health and associated issues has, until now, generally been of lower priority than the main reason for their incarceration. Therapists must balance the needs of their patient while being mindful of the overall security of the premises, and manage good risk assessment protocols (Smedley, 2010) cited in Vossler et al. (2017, p.13 & 15). In a community setting, confidentiality is sacrosanct however, dynamics change within a prison system. Any therapists working in a prison setting must be able to discuss concerns about clients with a supervisor and prison authorities, if they believe that what has been disclosed by the client, may lead to issues with their safety and the security of inmates, staff, or the prison itself. In the next section, this report will outline the four main types of therapy intervention commonly used in one-to-one encounters and/or as part of a group structure.

4. THERAPEUTIC APPROACHES

(a) Attachment-Based Theory

This type of therapy was based on a theory by John Bowlby, who concentrated on the type and quality of early relationships, primarily with how our mental and physical health needs are fulfilled within our infancy and early childhood. He claimed that the way we were cared for and nurturedis likely to have a major effect on our adult development (Holmes, 2001) cited in Haley (2017). As the inmates in this YOI are aged between seventeen and twenty-one, there is a chance that many of them will have originated from a lower socioeconomic area, within a one-parent, or socially dysfunctional family unit, or brought up in the care system. One criticism of this theory is that it concentrates primarily on our early childhood without exploring further influences such as peer pressure ((Open University, 2023, W17; S2).

Based on Mary Ainsworth’s ‘Strange Situation Test’ (SST) (1973) cited in Haley (2017), infants were used in a controlled experiment with their primary caregiver and a stranger, to gauge the reactions and interaction of the infant within a series of scenarios. This led to a conclusion of the type of attachment the infant had, i.e., Secure, insecure-ambivalent and insecure-avoidant. Later a fourth was included; disorganised-disorientated. This new category was found to have been identified in children most at risk of abuse or neglect (Main & Soloman, 1986, 1990) cited in Haley (2017).

There is also an adult version, ‘Adult Attachment Interview’ (Hesse, 2008) cited in Haley (2017) with similar categories to the SST. The interview, during counselling, explores relationships with family and other caregivers with the ability to identify a type of attachment in the way the client answers the questions, rather than the actual answers given.

Revisiting childhood experiences often helps the client understand their emotional needs and identify how their current behaviours and emotions are merely linked to repeating their unmet childhood needs (Bowlby, 1988) cited in Haley (2017). The therapist attempts to meet these needs by ‘empathic attunement’, mirroring how a caregiver would meet those of a young child, by taking, what are often bleak and jumbled feelings, and returning them to the client in a more moderated form.

A caution in the delivery of attachment-based therapy is that of ‘transference’ and ‘countertransference’. Transference is when a client recognises feelings expressed about a previous person or situation in their life but attaches them to someone in the present (Grant & Crawley, 2003) cited in Haley (2017). This recognition can be helpful to the client in relation to past and present relationships. However, ‘countertransference’ can emanate from the therapist when they notice a strange feeling themselves, when a client recalls a memory which triggers the therapist personally. This can aid the therapist in feeling empathy with the client and allowing them to be more open (Rowan & Jacobs, 2002) cited in Haley (2017). A further caution would be to be careful that any triggering of oft buried childhood trauma may re-trigger the client, which could lead to an escalation of their mental health problems, which, if they include violence or self-harming, may have to be shared with prison authorities for the safety of the client, other inmates, and staff.

(b) Cognitive Behavioural Therapy (CBT) aka `Cognitive Behavioural Modification’

This is a form of therapy where a client is taught to change their negative, destructive speech and understanding by being offered more positive alternatives. It is helpful in dealing with controlling anger, dealing with stress and anxiety and assists in teaching new coping skills (Colman, 2015, p.142).

In the prison estate, group programmes drawn from CBT dynamics are popular. It is seen as being very influential in helping to reduce reoffending by teaching the inmates new social skills, aiding their ability at problem solving and reasoning and, instead of expressing their frustration through anger and violence, it helps them to develop self-control and makes them feel better about themselves (Landenberger & Lipsey, 2005) cited in Bruce (2017). Another positive regarding CBT in a forensic setting, is that the group therapy teaches inmates to exist more harmoniously with each other and engenders positiveness within that society (Milkman & Wanberg, 2007) cited in Bruce (2017). There are also more CBT based programmes that can be extremely useful, such as “Aggression Replacement Training, Reasoning and Rehabilitation, Enhanced thinking skills, Relapse prevention (for behaviour, drugs and alcohol), Anger management etc.” (Clarke 2010) cited in Bruce (2017).

There are, however, certain challenges with CBT in a forensic setting. While CBT is known to work extremely well in group settings, there is a distinct lack of proof or research that CBT is currently successful when those programmes are used for one-to-one therapy (Bruce, 2017, p.210/11). Those sent to prison, often possess much higher instances of negative physical and mental health conditions than the public. They are more likely to have issues with drugs and alcohol, have a disrupted or absent education, are prone to self-harm and attempted suicide and have lived and suffered within a low socio-economic community (Fazel & Baillargeon, 2011) cited in Bruce (2017). Because of the disruption in, or lack of education, it has been observed that inmates in the United Kingdom often have a reading age of an eleven-year-old child. This is often an obstacle when therapists are requesting the client express their emotions in words (Morrisroe, 2014) cited in Bruce (2017, p.217).

There is a balancing of issues, to be achieved, when providing any sort of therapy in a forensic setting. Whether it is in a one-to-one consultation or a group dynamic, those settings must be viewed as ‘safe spaces’, while in general, prisons are seen as places of punishment and separation from the population. Prisons can be violent, oppressive, and often dehumanising (Peters & Wexler, 2005) cited in Bruce (2017). There is also the difference in a wider power dynamic between therapist and client in a forensic setting than in the community (see Section 5 below).

Warning – There are a multitude of factors that could disrupt CBT, or in fact, any therapy provision at your facility. These include budget restraints, lack of space to deliver these protocols, access to qualified staff, and the fact that an individual prisoner may be unexpectedly transferred to another facility or released into the community, thus ending the therapy prematurely. One idea would be to arrange a continuation of therapy for that inmate whether he is in another facility or back in the community (Bruce, 2017, p.220). This is where a therapy, such as Systemic Therapy, described in the next section, may be a solution.

(c) Systemic Therapy
Providers of ‘Systemic therapy’ promote the view that a person who is suffering from mental illness is not solely responsible for the development of that condition but that it is the result of a combination of relationships, such as personal, family, employment, and wider social interactions (Vossler et al., 2017, p.224). As well as the family unit, systemic therapists now explore all avenues from family to school, peer influence, local community, gang affiliations and drugs and alcohol abuse. In forensic settings, systemic therapy can be more difficult to explore with a client, if the therapist has limited or no ability to reach family members and other community-based evidence affecting the client. However, systemic therapy has been used in some secure settings, and reports show that there have been improvements. While there is limited success in a small number of secure units, mainly adult, where family therapy was offered, a 2014 report showed that sixteen out of forty-nine medium secure units were using systemic therapy as their main offering, showing that 72% of inmates were regularly in family contact (Absalom et al., 2010) cited in Vossler et al. (2017, p.222). There are no studies regarding the offering in YOI’s, however, systemic therapy may be of assistance in the continuation of therapy upon the release of the offender into a community setting, if that were possible.

(d) Mindfulness & Dialectical Behaviour Therapy – (DBT)
Mindfulness has been a major influence within counselling and adapts ancient Buddhist philosophy with westernised psychotherapy (Gilbert, 2010) cited in Barker & Cooper (2017, p.240). Mindfulness can be practised in group therapy or in a one-to-one consultation (Crane, 2009) cited in Barker & Cooper (2017, p.240) and can also be practised away from the therapy room in solitude or in a group. Most mindfulness delivery is manifested in breathing practice and meditation. Mindfulness is believed to aid personal insight, leading a person to new information and new ways to deal with psychological and mental health difficulties (Colman, 2015, p.463). Mindful therapies, which can aid anxiety and depression among inmates, seek to address and confront ‘frightening experiences’ rather than seeking avoidance.

It is known that, in the early 1980s, an incarcerated American prisoner, Fleet Maul, started meditating in a small area of his prison, mainly for his own well-being and ‘something to do’, but it soon spread and in 1989 Maul, while still behind bars, founded the ‘Prison Dharma Institute’. Many argue that mindfulness training reduces the risk of reoffending, reduces substance abuse, all by self-regulation when provided with the skills and tools to do so. It is believed that this type of therapy can improve health, forge greater self-awareness and be able to assist in regulating one’s emotions and build a resilience to stress (Hilert & Haskins, 2022).
One form of mindfulness that has proved successful is Marsha Linehan’s (1993) Dialectical-Behaviour Therapy (DBT) cited in Barker and Cooper (2017). DBT seeks to enquire about the client’s deep seated emotional and developmental background. Linehan observed that CBT tries to alter a client’s thoughts and actions without being acceptive of, or exploring their personal emotions, experiences, and historical self. (Barker and Cooper, 2017, p.246/7).

DBT however, has four areas that are worked on together with the therapist, i.e. Distress tolerance, coping with negative emotions, to build a coping mechanism so that emotional challenges do not escalate to more suffering; Mindfulness, concentrating on the present and not the past and attempt to learn not to allow negative self-judgement; Emotional regulation, recognising when one is having experiences that might overwhelm them and addressing those feelings in a more positive way and Interpersonal effectiveness, by dealing with issues and problems that arise, while protecting existing relationships and retaining respect for oneself and others (Barker & Cooper, 2017, p.247).

DBT is believed to be the only intervention that can successfully treat borderline personality disorder (BPD), although children are not usually diagnosed with such, as they are in transit from child to adult where their personality goes through a major biological and psychological change (Hill, 2001) cited in McDougall and Jones (2007). Rather than BPD, with children and adolescents, it would be more prudent to refer to their changes as personality and interpersonal traits. In McDougall and Jones (2007) they explore DBT within Echo Glen, a young offenders centre in the United States. The primary belief is to lead the inmates to accept their behaviour and not to avoid, deny or resist that it has happened. Many inmates at Echo Glen have a low opinion of themselves and have difficulty making and retaining relationships with others, which often leads to harming themselves or having suicidal ideation. Regardless of whether an inmate is a serious or regular offender, DBT can be used equally well in a one-to-one or group setting, to realign their personal emotions and aid a reduction in aggressive or self-destructive traits.

In England and Wales, the responsibility for the mental health needs of inmates in young offenders institutes come under the Department of Health and the Youth Justice Board and currently, the offering of those services to incarcerated young people is deficient. DBT is known to be successful. (McDougall & Jones, 2007).

5. CHALLENGES OF WORKING IN A FORENSIC SETTING
(a) Power dynamic between therapist & client in a forensic setting
A prison therapist is seen as being part of the prison staff, with the authority that this entails. They are openly seen to have keys that allow access to all areas and have the power to report issues when they arise, which ordinarily might remain confidential (OU, W2, S3). Therapy is often set up through Prison Officers and it is difficult to retain any privacy (Harvey & Smedley, 2020) cited in Vossler et al. (2017, p.20). Sometimes, therapist-inmate relationships can appear intense and, without strong supervision and solid boundaries, could be in danger of crossing well defined protections. It is not uncommon for inmates and therapists to embark upon inappropriate relationships, just as it can be a problem between prison officers and inmates (Vossler et al. 2017, p20). Two examples of this can be found in articles about notorious Liverpool drugs baron, Curtis Warren who had an affair at HMP La Moye, Jersey, with the senior manager of the drug and alcohol counselling service (Gallagher, 2014) and an affair with a female prison officer, more recently, at HMP Whitemoor, UK (Kirkham and Edrich, 2023).

(b) Age related issues – Gang membership
Young males are the highest percentage of youth inmates incarcerated in the UK and those between 16 and 24 years of age are also more likely to have personally suffered violence (OU, 2023, W9, S3). The age group catered for in this establishment are extremely vulnerable to being drawn into the criminal world and children from socio-economically deprived areas and broken families are drawn to gangs as a way of finding a ’family’ that will not let them down, as they may feel that they have been by their natal relatives. Gang members may be persistently resistant to any form of therapy as they have formed a solid group identity that boosts their self-esteem and gains them a reputation (OU, W9, S5).

(c) Staff training
It is important for correctional staff to understand the young people in their care and, where possible, assist therapists by receiving training in various treatment areas, for example in DBT. This will allow for prison staff to assess problematic behaviour when it presents itself and feel able and confident enough to form an intervention that may assist in resolving an inmate’s behaviour outside of the therapy room. This may also include self-harm and suicidal ideation. It is also imperative that the therapists and staff have a supervisor to filter and share the burden placed on the staff when difficult situations present themselves (McDougall & Jones, 2007).

6. RECOMMENDATIONS / OBSERVATIONS

• While Attachment-based Therapy was originally used with infants, there is now an adult version of that scale, the Adult Attachment Interview, which may be useful as an initial exploration of an inmate’s past familial history and may unearth conditions such as child sexual abuse and neglect which could lead to other interventions.
• Cognitive Behavioural Therapy works well in groups settings, less well in one-to-one encounters. Group settings are popular in helping to reduce reoffending by teaching coping methods, and, as a group, inmates learn to exist in harmony with others.
• Systemic Therapy relies on involving not just the inmate but also a belief that their family and community environment is a contributing factor to their offending and mental health issues. While it is difficult to involve many different agencies while the client is incarcerated, my recommendation would be that it may be suitable as a continuation of therapy, ideally with the current therapist, when the inmate is released. Continuation of therapy outside the prison would reduce reoffending.
• Mindfulness is very adaptable and can be practised in group settings, one-to-one’s and inmates can be encouraged to use meditation in their own time, to aid behaviour regulation. DBT aids a person’s ability to build personal resilience, concentrate on the present and eliminate negative self-judgement.
• Correctional staff, wherever possible, should be encouraged to take courses that will assist in the mental well-being of those they oversee and act as a bridge between therapist and client when the therapist is not available.
• It is important that whatever therapists you employ, you have a hierarchical support system that they can refer to if needed in times of stress and support, related to the services they provide.

References
Barker, M-J. & Cooper, T. (2017) ‘Mindfulness’ in Vossler, A., Havard, C., Pike, G., Barker, M-J. and Raabe, B. (eds), Mad or bad? A critical approach to counselling and forensic psychology, London, Sage Publications Ltd. pp.237-250.

Bruce, M. (2017) ‘Cognitive behavioural therapy’ in Vossler, A., Havard, C., Pike, G., Barker, M-J. and Raabe, B. (eds), Mad or bad? A critical approach to counselling and forensic psychology, London, Sage Publications Ltd. pp.205-222.

Colman, A.M. (2015) ‘Cognitive behaviour therapy’, Oxford dictionary of psychology, 4th edition, Oxford, Oxford University Press. p.142.

Colman, A.M. (2015) ‘Mindfulness’, Oxford dictionary of psychology, 4th edition, Oxford, Oxford University Press. p.463.

Gallagher, I. (2014) ‘Prison manager two-year affair with Britain’s biggest gangster’ [Online] Mail Online. Available at:
https://www.dailymail.co.uk/news/article-2560282/Prison-manager-two-year-affair-Britains-biggest-gangster-jail-cell-But-allowed-away-it.html
(Accessed: 23 May 2024)

Haley, M. (2017) ‘Attachment based approaches’ in Vossler, A., Havard, C., Pike, G., Barker, M-J. and Raabe, B. (eds), Mad or bad? A critical approach to counselling and forensic psychology, London, Sage Publications Ltd. pp.189-204.

Hilert, A.J., & Haskins, N. (2022) ‘Teaching mindfulness in prison settings: a grounded theory of strategies to promote engagement and empowerment’ [Online] Journal of Offender Rehabilitation, 10509674, Jan 2022, Vol.61, Issue 1.

Kirkham, J and Edrich, P (2023).’Inside Curtis Warren’s sordid affair with prison officer which saw her jailed,’ [Online] Liverpool Echo. Available at: https://www.liverpoolecho.co.uk/news/liverpool-news/inside-curtis-warrens-sordid-affair-27270887
(Accessed 25 May 2024)

McDougall, T. and Jones, C. (2007) ‘Dialectical behaviour therapy for young offenders: lessons from the USA, Part 2’ [Online] Mental health practice,11(2), pp.20-21. Available at: https://doi.org/10.7748/mhp2007.10.11.2.20.c4324
(Accessed: 27 May 2024)

Open University (2023) ‘Confidentiality’, Tensions between therapeutic and forensic settings – Week 2: Section 2.1 [Online] Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=2134616&section=2.1
(Accessed: 27 May 2024)

Open University (2023) ‘Working in therapeutic and forensic settings – Part 2’,Tensions between therapeutic and forensic settings – Week 2: Section 3 [Online] Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=2134616&section=3
(Accessed: 27 May 2024)

Open University (2023) ‘Age in the mental health and criminal justice systems’ Age – Week 9: Section 3 [Online] Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=2134624&section=3
(Accessed: 27 May 2024)

Open University (2023) ‘Teen gangs’ Age – Week 9: Section 5 [Online] Available at: https://learn2.open.ac.uk/mod/oucontent/view.php?id=2134624&section=5
(Accessed: 27 May 2024)

Vossler, A., Havard, C., Barker, M-J., Pike, G., Raabe, B and Walkington, Z. (2017) ‘Working therapeutically in forensic settings’ in Vossler, A., Havard, C., Pike, G., Barker, M-J. and Raabe, B. (eds), Mad or bad? A critical approach to counselling and forensic psychology, London, Sage Publications Ltd. pp.9-22.

Vossler, A., Squire, B. & Bingham, C. (2017) ‘Systemic approaches’ in Vossler, A., Havard, C., Pike, G., Barker, M-J. and Raabe, B. (eds), Mad or bad? A critical approach to counselling and forensic psychology, London, Sage Publications Ltd. pp.223-236.