Forensic Interventions for Therapy and Rehabilitation

Case Studies and Analysis

Belinda Winder, Nicholas Blagden, Laura Hamilton, Simon Scott

• Publisher: Routledge
• Year: 2021
• ISBN:
  9780429557163
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Forensic Interventions for Therapy and Rehabilitation: Case Studies and Analysis provides an up-to-date overview of the latest therapeutic ideas being used for forensic service users and prisoners in both custodial and community settings.

The field of forensic work is increasingly being recognised for its importance, both in terms of the value of the work in reducing reoffending and in terms of the salience given to it by the media, the public, and politically. This text reflects current policy and practice, and furthermore considers the therapeutic encounter from a broad perspective, which incorporates individual, group, and systemic interventions. Forensic Interventions for Therapy and Rehabilitation includes chapters on a range of therapeutic models, issues pertinent to specific groups of people with criminal convictions, and discussion on the various contexts in which interventions take place.

Forensic Interventions for Therapy and Rehabilitation is essential reading for all students of Forensic or Clinical Psychology, as well as practitioners in the field.

1

Health meets justice

Transformation in forensic practice

Naomi Murphy and Michael Underwood

DOI: 10.4324/9780429262074-1

Introduction

Forensic practice is broadly defined as the scientific field pertaining to courts and the law; it extends into both the prison and health systems, as well as the work of those in non-custodial settings such as community forensic teams or approved premises (under section 13 of the Offender Management Act, 2007). Anyone working within these settings might describe their work as being encompassed within forensic practice. However, the scope of forensic interventions is more restricted. For many years, it has been most closely associated with prisons, where forensic interventions aimed to change “the thinking, attitudes and behaviours which may lead people to re-offend … to help people develop new skills to stop their offending … (and) … to encourage prosocial attitudes and goals for the future” (GOV.UK, 2021).

Whilst those working in secure hospitals or approved premises could legitimately define their work as forensic in nature, there was inconsistency in how practitioners incorporated attention to the individual’s risk of re-offending into their therapeutic endeavours. Undoubtedly, it is assumed that some individuals’ risk of violence would diminish if medication addressed some of the symptoms of their poor mental health; thus, risk reduction was often not directly addressed. Other practitioners in health settings used models such as psychodynamic psychotherapy and schema-focused therapy. Still, they varied in the degree to which, during the course of treatment, they focused on those factors empirically identified as underpinning physical and sexual violence. At times, risk reduction probably wasn’t clearly expounded upon in end-of-treatment reports as practitioners tried to balance the dual requirements of alleviating distress whilst reducing risk. However, practitioners working in the health system also tended to address causal factors underpinning risky behaviour rather than just targeting the manifest behaviour (which was perceived as a “symptom” of underlying distress). Consequently, the language in reports generated within the health service perhaps masked the endeavour to reduce risk that drove much hospital-based treatment. Indeed, “interventions” is in itself language that is synonymous with the work of prison-based staff; those working within the health sector are more inclined to talk about “therapy”. Thus, it was assumed for many years that “forensic interventions” were available predominantly within the criminal justice system, as they lacked visibility within health contexts.

Forensic psychological interventions and the dominance of accredited offending behaviour programmes

Most interventions within the UK’s criminal justice system (CJS) have been based on the risk–needs–responsivity model (Andrews & Bonta, 2010) and predominantly draw on cognitive behavioural approaches, which were argued to be the most effective (Landenberger & Lipsey, 2005; McGuire, 2002). Typically, these offending behaviour programmes (OBPs) are delivered in a stand-ardised fashion to ensure programme integrity and provide psychoeducation to target problem-solving (McGuire, 2002), help participants recognise and define maladaptive patterns, and then plan and execute solutions (McMurran, Egan, Blair & Richardson, 2001). Hospitals sought to import these programmes into their services in an attempt to ensure they were more explicitly addressing risk; sometimes, these were adapted to take into account the individual’s differing mental health needs; at other times, delivery was consistent with a prison format to maintain programme integrity, but with little or no adaptation to accommodate the mental health needs of patients. When delivered following the successful treatment of mental health conditions, this might have been appropriate, but this requirement was not uniformly applied to their application.

In the UK government’s Offending Behaviour Programmes and Interventions (2021) documentation depicting the work they commission to help individuals reduce their risk, the omission of any explicit reference to relationships or emotion and affect is symbolic of the neglect of these domains in the types of interventions that have been delivered. Affect is the visceral feeling which occurs in every moment (interoception); emotion is a more complex construction that includes, amongst other things, attribution and physiological and expressive changes (Panksepp & Biven, 2012; Russell, 2003). The UK government’s documentation also fails to suggest that work on an individual’s self-concept and the social context within which their offending originated might be relevant. The emphasis upon improving left-hemisphere, rational brain functioning to reduce thinking errors and cognitive distortions can be really useful. It can help people “analyse what went wrong and identify situations which may make them vulnerable to offending” (Murphy, 2017). Whilst OBPs in prison do include reference to emotion, e.g., the CALM programme (Controlling Anger and Learning how to Manage it), they tend to be predominantly concerned with anger and to be focused (since they derive mainly from cognitive behavioural theory [CBT]) on recognising one’s thoughts and enhancing control over one’s emotional state in order to reduce the likelihood of offending behaviour. There is very little attention to the felt visceral affect that is incorporated within our concept of emotion. As Murphy (2017) points out,

many people who commit violent crime aren’t in a rational state of mind when offending. Instead, they find themselves overwhelmed by strong affect that restricts their capacity to think logically, their ability to draw on the intellectual knowledge they may have about themselves and their functioning or think rationally about the consequences of possible behaviours.

(p. 181)

Lynch (2018) also observes that for some people, too much self-control can be as problematic as too little and highlights the relationship of overcontrol to personality dysfunction. Contact with forensic populations indicates that a significant proportion of the population relies on maladaptive over-control to manage their emotions. Hamilton, Winder, Norman and Baguley’s (submitted for publication) systematic review found 50% of patients in secure hospitals and one in three prisoners could be identified as overcontrolled. Placing such individuals on programmes to bolster their self-control is likely to be iatrogenic. These ideas are explored more in Chapter 5 of this book, together with a potentially new intervention offered to address the needs of this population.

Additionally, Drennan, Cook and Kiernan (2015), Knight (2014) and Rossner (2013) conclude that the neglect of emotion has been a significant deficit in conceptualising criminal behaviour and thus devising appropriate interventions to more effectively reduce risk. The work of Canton (2017), Knight (2014) and Murphy and McVey (2010) goes further by drawing attention to the reduced impact of rehabilitation efforts when staff are unable or unwilling to authentically discuss their own emotional reactions to the person they’re working with and the person’s violent and/or sexual offending. Knight (2014), in particular, highlights how emotion and emotional literacy (the ability to work actively with emotion) is undervalued within the criminal justice sector and may thus impact the delivery and quality of interventions aimed at enhancing emotional regulation. She suggests this may be a consequence of the preponderance of men in the senior power structures of the prison system. However, Fox (2010) discusses prison service culture as one in which operational staff understood they were tasked with maintaining control to ensure there were no crises.

One could argue that within such a culture, emotion and the expression of affect might be perceived as more dangerous than a culture in which emotion appeared relatively absent. Thomas (1972) observes that prison officers are often perceived as agents of punishment and barriers to change. It is likely that the anxiety that generally accompanies change would be perceived as possibly signalling impending crisis and thus stifled before it could become out of hand. Within such a context, it is perhaps unsurprising that a somewhat repressed, “macho” culture prevailed for many decades, which perhaps made it very difficult for emotion, affect, and relationships to be discussed or expressed.

The culture of an organisation tends to be fairly stable over time without an intentional strategy and resources to implement systematic change and “unlearn” elements of the existing culture (Hanna, 1988; Moos & Moos, 1974; Schein, 1990). Whilst many staff who didn’t fit the cultural norm would have worked within the prison system during this period (e.g., staff labelled “civilian” such as probation officers, forensic psychologists, and primary care nurses), they were in a small minority and would have found it hard to resist the human tendency to assimilate in order to belong. Gelfand (2020) suggests that individuals tend to desire increased autonomy when they feel safe but that a sense of threat increases their propensity to conform, so it is perhaps unsurprising that affect, emotion, and relationships have been so neglected. Similarly, operating within such a threat-conscious system is not conducive to the free expression of individual staff members, so it seems unremarkable that developers of OBPs have been so little preoccupied with facilitating the expression of an authentic self.

Both McMurran (2002) and McGuire (2013) acknowledge that relationships have an influential effect on the success of interventions. In particular, they highlight the benefits of staff members’ role-modelling of prosocial attitudes and behaviour through their interpersonal skills, but initially, the What Works movement and its “adherence to a prescriptive programme manual for a time shifted the emphasis away from the significance of the relationship in promoting engagement and change” (Knight, 2014). More recently, the risk–needs–responsivity model has emphasised the importance of “collaborative relationships between clinicians and offenders” (Andrews & Bonta, 2010) and, in the organisational principles, give value to being human and having respect for the person. They continue to say that effectiveness is “enhanced when delivered by therapists and staff with high-quality relationship skills”, and Serran, Fernandez, Marshall and Mann (2003) also highlight how programme facilitators who exhibited “empathy, warmth and being directive and rewarding” encouraged greater beneficial changes in participants. Despite this, such values, particularly respect for the person, have been observed to be more widely lacking in criminal justice settings (Hulley, Liebling & Crewe, 2012), and in general, much less attention has been given to relationships beyond those with the immediate programme facilitators. The absence of a milieu in which OBPs were embedded will perhaps inevitably also have reduced the capacity of OBPs to focus on elements over which course facilitators will have had little control, such as the wider culture of the criminal justice sector.

Therapeutic communities (TCs), such as HMP Grendon, represented a divergence from most standard OBPs and are often cited as exceptions to the earlier observation since they prioritise the importance of social relationships and the community as a vehicle for change (Bennett & Shuker, 2018). The approach adopted has produced “extraordinary outcomes” (p. 48), including increased self-esteem and a reduction in anxiety (Shuker & Newton, 2008), improved psychological health and well-being (Gunn & Robertson, 1982; Newton, 1998), improved relating (Birtchnell, Shuker, Newberry & Duggan, 2009), and reduced offending levels (Taylor, 2000). Working therapeutically in this manner promotes autonomy, emphasises the value of relationships and of the person, and assists “the residents” in reconfiguring their identity into a more prosocial one whilst dealing with trauma in a proactive way (Bennett & Shuker, 2018). Perhaps significantly, this relationally focused work proved possible in TCs because several of the staff were trained as psychological therapists and specifically in models that attended to the transaction between patient and therapist, such as psychodynamic or psychoanalytic psychotherapy. This is unlike other forms of OBPs, which are based on cognitive behavioural treatment where affect, emotion, and relationships tend to be less of a priority. There have been calls for emulation of the democratic therapeutic community as a model for other parts of the prison estate (Her Majesty’s Inspector of Prison reports, 2004, 2009, 2014; Cretenot, 2013).

Additionally, many of the individuals delivering OBPs did not have formal training as therapists, which may have made it more difficult to prioritise the kind of idiosyncratic adaptations that are necessary when working with visceral feelings and relationships. Those trained in psychodynamic and psychoanalytic therapies are also required to undergo therapy as part of their training, which could be argued to give the therapist a different perspective on the importance of emotions, the relationship, and power than one might have if trained in other models with different priorities. Perhaps of most importance is that TCs employed staff to act as therapists, which meant expecting them to use their own clinical judgement and tailor the delivery to the various people they happened to be working with. This was in distinct contrast to OBPs, which had strict adherence procedures designed into the system to enable elimination of variability as part of the means of maintaining interventions of a certain quality. Services that are delivered by accredited therapists can, to some degree, be assured of competence due to the need for the therapist to maintain their professional registration, and this enables flexibility of delivery. However, OBPs could not rely on this assurance due to the variability in experience and knowledge of the staff delivering the intervention and so needed to ensure that safeguards against threats to the integrity of the programme were built in. Whilst this had advantages for the mass scale of delivery of these programmes (such as ensuring participants received programmes delivered to a reasonable standard), it may have had the unfortunate effect of stymying the creativity of some of the more experienced and skilled professionals delivering these programmes. Crucially, the success of TCs may have proved possible because an emphasis upon visceral affect, emotion, and relationships was something the whole prison had agreed should be a priority; the task of the operational staff was therefore extended beyond maintaining control, and they were given tacit permission to develop therapeutic relationships with prisoners and talk explicitly about feelings. This approach ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication Page
• Contents Page
• Contributor list Page
• Foreword Page
• Acknowledgements Page
• 1 Health meets justice: transformation in forensic practice
• 2 Statistical analysis of intervention studies in forensic psychology
• 3 Therapeutic communities and facilitating change
• 4 Boundaries and boundary setting in clinical practice
• 5 Radically Open-Dialectical Behaviour Therapy: a new treatment of people with maladaptive overcontrol who offend
• 6 A healthy sex programme for individuals with paraphilic interests convicted of sexual offending: biopsychosocial processes and intervention procedures
• 7 The importance of being earnest: rethinking the “problem” of categorical denial in men with sexual convictions
• 8 Deaf treatment programmes
• 9 Compassion-focused therapy as an intervention for sexual offending
• 10 Mindfulness for individuals with a violent and/or sexual conviction
• 11 Apollo: an intervention to improve psychological flexibility for young people displaying sexually harmful behaviour
• Index