Why prisons should be run on therapeutic lines. 1. Rates of childhood trauma and personality...

Why prisons should

be run on

therapeutic lines

1. Rates of childhood trauma and personality pathology in prisoners are equivalent to

those of psychiatric in-patient populations

Psychosis – 4-10%

Major depression – 10-12%

Neurotic disorders – 6-60%

Substance use disorders – 21-73%

US studies – serious mental illness in 10-25% of prisoners

Childhood trauma HMP Cornton Vale (Hooks, Perrin,

Treliving, 2011) Emotional abuse/neglect – 80% (33%

severe/extreme) Physical neglect – 92% Severe/extreme CSA – 33% All types of severe/extreme abuse – 25-33%

Female prisoners US – physical or sexual abuse in 38% Canada – CSA in 50%

Personality disorder Community – 4-16% Psychiatric out-patients – 25-31% Psychiatric in-patients – 65-90% Prisoners

Antisocial PD – 13-37% Female US prisoners – BPD – 35%, ASPD – 44% HMP Cornton Vale – PD – 90%, BPD – 53%, ASPD –

52%, both – 37%

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2. Therapy works

1793 – Philippe Pinel unchained his patients at Bicetre 1801 – “le traitement moral” 1874 – “the rest cure” – Weir Mitchell

Relationship between therapist and patient as a therapeutic tool

1896 – “psychoanalysis” – Sigmund Freud 1942 – “therapeutic communities” – Tom Main 1967 – cognitive therapy – Aaron Beck 1969 – attachment theory –John Bowlby 1993 – dialectical behaviour therapy – Marsha Linehan 2003 – schema therapy – Jeffrey Young 2004 – mentalisation based treatment – Bateman and

Fonagy

this is no longer something we can do nothing about!

Therapeutic communities 4 principles (Rapoport, 1960):

Democratisation Permissiveness Communalism Reality confrontation

Effectiveness Lees, Manning Rawlings (1999)

Meta-analysis, 29 studies (10 RCTs) OR 0.57 (upper 95% CI 0.61) “very strong support to the effectiveness of

TCs”

HMP Grendon 1962 – experimental project 235 cat. B male prisoners 5TCs, 1 assessment unit Prisoners tend to be ‘high risk’ Minimum 24 month stay, go

voluntarily Large and small group work Inmates organise and run groups

2 studies: Marshall (1997) Taylor (2000) 700 prisoners 2 control groups

Waiting list General prison group

Reconviction rates lower for those who had >18 months Rx

Reduction in violent and sexual reconviction rates Low rates of violence and self-harm in the prison

3. Workable therapeutic models are possible in secure settings

In prisons, some modification of the traditional TC model is required HMP Grendon (Cullen, 1997)

Inmates have the power to make or influence certain decisions, but not those that would compromise security

Deviant behaviour is addressed by the small group and fed into the therapeutic process (instead of being tolerated or punished)

Communalism remained largely intact Confrontation is often done in a more direct

way

Now several prison based TCs in England HMP Dovegate (200 men,

4TCs, 1 assessment unit) HMP Gartree (23 men, 1 TC) HMP Aylesbury (22 young

offenders, 1TC) HMP Blundeston (40 men,

1TC) HMP Send (40 females, 1TC)

Modified approaches (“TC light”?) Milieu approaches

Psychologically informed environments (PIEs) No set definition The approach of the staff is informed

by a psychological theory which feeds into the social environment

More flexible than a traditional TC Based around reflective practice Staff training and supervision required

• Psychologically Informed Planned Environments (PIPEs)• Specifically planned environments (e.g.

prisons) where staff have additional training to develop an increased psychological understanding of their work

• Recognise the importance of relationships and interactions between staff and prisoner

• Allows opportunity for all interactions to be considered in a psychological way

• Currently 6 pilot PIPEs across English prisons