Psychotherapy in Forensic Contexts

Introduction to Psychotherapy in Forensic Contexts

• The context of prisons, young offender institutions, and high-security hospitals differs from traditional psychotherapy settings (private or agency).

• This chapter discusses the impact of institutional contexts on therapy, emphasizing the importance of the offence committed and tailored therapy for offenders.

• Main therapeutic alternatives to prison in the UK include:

  • Democratic therapeutic communities

  • High-security psychiatric hospitals

Goals of Imprisonment

• Major goals of imprisonment include:

  • Punishment: Often viewed as retribution, revenge, retaliation.

  • Rehabilitation: Seen as a primary goal in some environments, though this prioritization is not universal.

  • Incapacitation: Temporary incapacity from society to prevent further crime.

• Deterrence is often cited but lacks substantial evidence on prison effectiveness.

• In cultures such as the USA, the punitive purpose frequently overshadows rehabilitation.

Reflection on Imprisonment Goals

• Personal considerations on the justifications for imprisonment include:

  • Ethical implications of depriving someone of liberty and rights.

  • The discomfort of working in a punitive-focused system if one believes in rehabilitation.

• A disconnect between personal views on imprisonment and institutional goals can lead to professional conflict.

Reoffending and Rehabilitation

• Reoffending Statistics:

  • In the UK, about 50% of released prisoners reoffend within 12 months.

  • The likelihood of reoffending increases with shorter sentences.

  • Specific categories such as sex offenders and fraud committers exhibit lower reoffending rates (citing Ministry of Justice, 2016).

• Traditionally, rehabilitation is considered a main function of the probation service (terminology varies, especially in Scotland).

• The criminal justice system (CJS) influences the context for psychotherapy significantly, with variations across countries.

Challenges in Forensic Therapeutic Work

• The therapeutic relationship is vital for effective psychotherapy (Norcross, 2011; Wampold & Imel, 2015).

• In forensic settings, therapeutic relationships are affected by:

  • Institutional focus on punishment/security over rehabilitation.

  • Dependency on information about the client's offence, which can be problematic for psychotherapeutic epistemology.

• Therapists learn to navigate the complexities of confidentiality and institutional mandates concerning security threats.

The Role of Offence in Therapy

• Understanding an offender's crime is crucial yet complex:

  • Therapists are often required to consider previous information beyond the client's narrative.

  • Different therapeutic approaches have varying stances on guilt and the exploration of crime in therapy.

• Therapists face dilemmas when clients reveal information about their offences during therapy regarding confidentiality and security (as described in Chapter 1).

Ethical Considerations in Therapy

• Ethical responsibilities of therapists when faced with new information regarding crimes during therapy:

  • Supervisory preferences dictate the handling of this information.

  • Varying freedom in response to what the therapist can or must disclose to authorities.

• Exploration of personal responses to hypothetical scenarios involving potential information disclosures.

Significance of Offence in Therapy

• The offence committed is central to effective therapy as it ties directly to rehabilitation goals, primarily aimed at reducing reoffending.

• Research indicates that addressing the offence enhances therapeutic success.

• Historical shifts in perceptions about rehabilitation:

  • Lipton, Martinson, and Wilks (1975) argued that rehabilitation effectiveness was exaggerated, contributing to decreased funding and support.

  • Recovery of rehabilitation interest evidenced by renewed advocacy in the late 1990s (McGuire, 1995) and systematic research efforts in Canada (Andrews & Bonta, 2010).

RNR Model and Rehabilitation Strategies

• Risk-Need-Responsivity (RNR) Model:

  • Treatment intensity correlates with the risk level of the offender.

  • Treatment needs are identified and transformed into strengths to facilitate rehabilitation.

  • Responsivity emphasizes tailoring methods to individual offender characteristics and contexts.

• Despite initial success, the RNR model's influence has waned in England and Wales since 2010, with shifts toward private induction models for rehabilitation.

Alternatives to RNR: Good Lives Model

• The Good Lives Model (Ward & Maruna, 2007) complements the RNR by focusing on offender strengths and development of an attractive life plan to reduce recidivism.

• Comparison between RNR and the Good Lives Model highlights new avenues for rehabilitation.

Psychotherapeutic Approaches in Forensic Settings

• A pivotal moment occurs when choosing psychotherapy methodologies for forensic applications:

  • Numerous approaches such as CBT, humanistic, integrative, psychodynamic, and systemic therapies are presented in varying contexts.

• Evidence-based equivalence across psychotherapy methods (Lambert, 2013; Wampold & Imel, 2015) is rarely accepted in forensic settings, leading to a preference for different schools of thought.

• Insights from behavioral and insight-oriented methods contrast:

  • Behavioral techniques emphasize action-oriented results, while insight-oriented methods focus on understanding deeper issues.

• Acknowledges that drawing focus on behaviors can differ from traditional insight methods yet recommends adaptations to explore the offense's role within therapy.

Mental Health Concerns in Offenders

• High prevalence of mental health issues like:

  • Alcohol and substance abuse

  • Personality disorders (e.g., borderline personality disorder, antisocial personality disorder)

  • PTSD and dissociative disorders.

• Dual Diagnosis refers to the coexistence of distinct mental health disorders, with special therapeutic protocols necessary for treatment (Atkins, 2014; Gournay, 2016; Phillips et al., 2010).

Case Examples

• Forensic Case Example: John Smith (25)

  • History of petty offences, currently imprisoned for drug-related and violent crimes.

  • Exhibits difficulties in therapy, marked by aggressive behavior toward the female therapist despite a desire for help.

• Voluntary Case Example: Jack Smith (25)

  • University student concerned about substance abuse.

  • Similar dynamics as John but with a markedly different therapeutic environment.

Intersection of Therapy and Diagnosis

• Forensic psychotherapy poses unique challenges influenced by diagnostic criteria and healthcare management practices:

  • Personality disorders' considerations require customized therapeutic strategies and long-term engagement.

  • Treatment approaches like Dialectical Behaviour Therapy require adaptability for effectiveness with specific disorders.

Organisational Framework in Forensic Psychotherapy

• The National Offender Management Service (NOMS) manages prison and probation services in England and Wales, integrating psychotherapy services.

• Contrasting practices in Scotland where community-based social workers manage probation services.

• The prison environment imposes significant constraints, including visibility issues concerning therapy sessions and pressures on inmates.

Effects of Institutional Environments on Therapy

• Issues of privacy and confidentiality are heightened in prison, with therapists navigating complex supervisory and institutional shadows over therapy.

• Factors like shared spaces and the security presence create fluid dynamics within the therapeutic relationship.

  • This emphasizes the need for adapting standard practices to a forensic context.

Implications of Disrupted Therapeutic Relationships

• Disruption in therapy continuity negatively impacts offender rehabilitation, hindering outcomes during transfer between institutions.

• Identifying and addressing attachment issues can aid transitions and minimize separation anxiety, underscoring therapy's importance during these periods.

Socio-Cultural Factors in Forensic Psychotherapy

• Societal and cultural factors significantly impact therapy, especially regarding representation and participation by marginalized groups:

  • Black individuals are disproportionately affected within the prison system and show lower participation rates in therapeutic services.

Therapeutic Communities in Prisons

• Therapeutic Community (TC): A prison wing run democratically, emphasizing group therapy as a rehabilitation strategy, although facing scrutiny regarding efficacy and costs.

• The most recognized TC in the UK is HMP Grendon, operating with focused therapeutic intentions but critiqued for effectiveness in reducing reoffending.

High-Security Psychiatric Hospitals

• Facilities such as Broadmoor serve individuals whose serious crimes are linked to mental health issues, blending psychiatric care with stringent security protocols.

• Discontinuation of extensive individual psychotherapy, replacing it primarily with group-oriented therapeutic approaches, marks a transition in patient care.

Conclusion

• Acknowledges the complexity and multifaceted nature of psychotherapy within forensic settings, highlighting the need for appropriately adapted techniques tailored to the unique challenges.

• Calls for improved connections between rehabilitative practices and evidence-based research to enhance outcomes in these specialized contexts.

Suggested Further Reading

• Andrews, D. A., & Bonta, J. (2010). The Psychology of Criminal Conduct (5th ed.).

• Bell, E. (2013). Punishment as Politics: The Penal System in England and Wales.

• Maruna, S. (2001). Making Good: How Ex-Convicts Reform and Rebuild Their Lives.