Working with women in Prison Settings

Working with people with multiple and complex needs in HMP Edinburgh

HMP Edinburgh

A Clinical Problem

Available resources

4.5 mental health nurses2 sessions of consultant psychiatristTherapeutic skills available in Forensic Psychology colleages, but pressed for prison functionsOffending behaviour programs-limited for women in HMP EdinburghNo Clinical PsychologySome third sector possibilities

No access to NHS based clinical psychology with no nursing staff trained in psychological

interventions

Split teamsPoor communication

Unhappy staffPoor outcome

The second attempt…

Second time around…• Joined up multi-disciplinary

working across prison• Across SPS/NHS

• Focus on management rather than just treatment

• Appropriate information sharing

• Close working with prison officers to improve their psychological understanding and confidence

• Senior involvement and buy-in

Concept test

HMP Edinburgh

3 strands: Staff training

MBT-I groups for women with BPD

IPT groups for women with depression

Co-ordinated by Willow

Working with women in prison settings

2 year concept test to increase access to psychological interventions for women in prison settings

The team: Co-ordinated Suzie Black

1 session Alex Quinn

1 session Jon Patrick

2 days Assistant Psychologist – Amy Forman

10 ish hours of admin support

New Clinical Psychologist post – Alana Davis

Training and supervision

Staff training

2 types: MBT Skills – 2 days

Understanding PD – 2.5 hours and full day

PD Training

73 delegates

Range of staff working in prisons

Statically significant change in staff’s knowledge and

understanding of PD t (70), = -12.74, p<.001.

MBT Skills Training

2 courses delivered – co-delivered with Claire Maclean, NES

Prison officers (Ratho and SRU), Unit manager, whole mental health team, Forensic Psychologists, Willow staff

Excellent feedback

Statistically significant increase in knowledge of mentalizing

Another course in December

Case consultation groups for officers started last month

What is Mentalizing?

Why is Mentalizing important?

1. Self-awareness and a sense of identity.2. Meaningful and sustaining

relationships.3. Self-regulation and self-direction.

Good Mentalizing

• In relation to others’ thoughts and feelings– Opaqueness– Contemplation and reflection– Absence of paranoia– Perspective-taking– Genuine interest and open to discovery– Forgiveness– Predictability

Why is MBT helpful?• Characterised by complex relationship difficulties

• “Giving a language” as difficulties include inability to name affect, thus often get confused and emotional

• Mentalizing as a natural process for all!!

• Teaching a skill, not a concept or theory

• Dual focus/components of our MBT programme

1. Psychoeducation (MBT-i)

2. Therapy group

Emerging evidence …• Bateman, A., and Fonagy, P., (1999). Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial. Am J Psychiatry 156:10. • Bateman, A., and Fonagy, P. (2001). Treatment of Borderline Personality Disorder With Psychoanalytically Oriented Partial Hospitalization:• An 18-Month Follow-Up. Am J Psychiatry 2001; 158:36–42 • Bateman, A., and Fonagy, (2003). Health Service Utilization Costs for Borderline Personality• Disorder Patients Treated With Psychoanalytically Oriented Partial Hospitalization Versus General Psychiatric Care. Am J Psychiatry 2003; 160:169–171.• Twemlow, S. W., Fonagy, P., Sacco, F. C. (2005). A developmental approach to mentalizing communities II: The peaceful schools experiment.• Twemlow, S. W., Fonagy, P., Sacco, F. C. (2005). A developmental approach to mentalizing communities: I A model for social change. 9, 4, 265-281. • Fonagy, P., and Bateman, A. (2006). Progress in the treatment of borderline personality disorder. British Journal of Psychiatry, 188, 1-3. • Fonagy, P., and Bateman, A. (2006). Mechanisms of change in mentalization based treatment of BPD. Journal of Clinical Psychology, Vol. 62(4), 411–430.• Bateman, A. W., Ryle, A., Fonagy, P., Kerr, I.B. (2007). Psychotherapy for Borderline Personality Disorder: Mentalization Based Therapy and Cognitive Analytic Therapy Compared. International Review of Psychiatry, February 2007; 19(1): 51–62• Bateman, A., and Fonagy, P. (2008). Comorbid Antisocial and Borderline Personality Disorders: Mentalization-Based Treatment. Journal of Clinical Psychology, vol 64, 2, 127-230.• Bateman, A., and Fonagy, P. (2008). 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual. Am J Psychiatry 2008; 165:631–638.• Fonagy, P. and Bateman, A. (2008). The development of borderline personality disorder: A mentalizing model. Journal of Personality Disorders, 22(1), 4–21, 2008• Choi-Kain, L. W., and Gunderson, J. G. (2008). Mentalization: Ontogeny, Assessment, and Application in the Treatment of Borderline Personality Disorder, Am J Psychiatry 2008; 165:1127–1135.• Fonagy, P., Twemlow, S.W., Vernberg, E. M., Mize Nelson, J., Dill, E. J., Little, T. D. and Sargent, J.A. (2009). A cluster randomized controlled trial of child-focused psychiatric consultation• and a school systems-focused intervention to reduce aggression. Journal of Child Psychology and Psychiatry 50:5 (2009), pp 607–616• Meehan, K. B., Levy. K. N., Reynoso, J. S., Hill, L. L., & Clarkin, J. F. (2009). Measuring Reflective Function With A MultidimensionalRating Scale: Comparison With Scoring Reflective• Function On The AAI. Ebsco Electronic Journals Service (EJS) on July 8.• Söderström, K., and Skårderud, F. (2009). Minding The Baby: Mentalization-based treatment in families with parental substance use disorder: Theoretical framework. Nordic Psychology, Vol. 61(3), 47-65• Brent, B. (2009). Mentalization-Based Psychodynamic Psychotherapy for Psychosis. J Clin Psychol: In Session, 65, 803–814.• Bateman, A. and Fonagy, P. (2009) Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder. American Journal of Psychiatry, 166:1355–1364.• Bateman, A. and Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry 2010;9:11-15• MacBeth, A., Gumley, A., Schwannauer, M., and Fisher, R. (2010). Attachment states of mind, mentalization, and their correlates in a first-episode psychosis sample. Psychology and Psychotherapy: Theory, Research and Practice (2011), 84, 42–57.• Fonagy, P., Bateman, A. (2011). The widening scope of mentalizing: A discussion. Psychology and Psychotherapy: Theory, Research and Practice, 84, 98-110.• Bales, D., van Beek, N., Smits, Maaike., Willemsen, S., Busschbach, J.J.V., Verheul, R., and Andrea, H. (2012). Treatment outcome of 18 month day hospital mentalization based treatment (MBT) in patients with severe borderline personality disorder in the

Netherlands. Journal of Personality Disorders, 26, 568-582.• Jakobsen, J. C., Gludd, C., Kongerslev, M., Larsen, K.A., Sorensen, P., Winkel, P., Lange, T., Sogaard, U., and Simonsen, E. (2012) ‘Third wave’ cognitive therapy versus mentalization-based therapy for major depressive disorder. A protocol for a randomized clinical

trial. BMC Psychiatry, 12, 232• Hausberg, M. C., Schulz, H., Piegler, T., Happach., C.G., Klopper, M., Brutt, A. L., Sammet, I., and Andreas, S. (2012). Is a self-rated instrument appropriate to assess mentalization in patients with mental disorders? Development and first validation of the

Mentalization Questionnaire. Psychotherapy Research, 22, 6, 699-709.• Bevington, D., Fuggle, P., Fonagy, P., Target, M., nd Asen, E. (2012). Innovations in practice: Adolescent mentalization-based integrative therapy (AMBIT) –a new integrated approach to working with the most hard to reach adolescents with severe complex mental

health needs. Child and Adolescent Mental Health, 18, No 1, 46-51. • Rossouw, T.I., and Fonagy, P. (2012).Mentalization-Based Treatment for Self-Harm in Adolescents: A Randomized Controlled Trial. J. Am. Acad. Child Adolesc. Psychiatry; 51(12):1304-1313.• Asen, E., and Fonagy, P. (2012). Mentalization-based Therapeutic Interventions for Families. Journal of Family Therapy, 34: 347–370.• Luyten, P. Van Houdenhove, B., Lemma, A.,Target, M., and Fonagy, P. (2012). A mentalization-based approach to the understanding and• treatment of functional somatic disorders. Psychoanalytic Psychotherapy, Vol. 26, No. 2, June 2012, 121–140 • Rutimann, D. D. and Meehan, K. B. (2012). Validity of a brief interview for assessing reflective function. J Am Psychoanal Assoc 2012 60: 577.• Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K (2012). Psychological therapies for people with borderline personality disorder (Review). The Cochrane Library 2012, Issue 8• Jorgensen, C. R., Freund, C., Boye, R., Jordet, H., Andersen, D., Kjolbye, M. (2013). Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial. Acta Psychiatrica Scandinavica, 127, 305-317.• Biskin, R.S. (2013). Treatment of Borderline Personality Disorder in Youth. J Can Acad Child Adolesc Psychiatry, 22:3, 230-234. • Rossouw, T. I. (2013) Mentalization-Based Treatment: Can It Be Translated Into Practice in Clinical Settings and Teams? Journal Of the American Academy Of Child & Adolescent Psychiatry. 52, 3, 220-222. • Ensink, K., Maheux, J., Normandin, L., Sabourin, S., Diguer, L. Berthelot, N. & Parent, K. (2013). The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial. Psychotherapy Research, vol. 23, No. 5, 526-538.• Bateman, A. and Fonagy, P. (2013). Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. The British Journal of Psychiatry, 203, 221–227.• Taubner, S., White, L.O., Zimmermann, J., Fonagy, P., and Nolte, T. (2013). Attachment-related mentalization moderates the relationship between psychopathic traits and proactive aggression in adolescents. Journal of Abnormal Child Psychology, 41, 929-938.• Ha, C., Sharp, C., Ensink, K., Fonagy, P., Cirono, P. (2013). The measurement of reflective function in adolescents with and without borderline traits. Journal of Adolescence 36 (2013) 1215–1223.• Sadler, L.S., Slade, A., Close, N., Webb, D. L., and Simpson, T. (2013). Minding The Baby: Enhancing Reflectiveness To Improve Early Health And Relationship Outcomes In An Interdisciplinary Home-Visiting Program. Infant Mental Health Journal, Vol. 34(5), 391–405.• Katznelson, H., Reflective Functioning: A review, Clinical Psychology Review (2013), doi: 10.1016/j.cpr.2013.12.003

Why choose MBT?

System-wide approach

Existing pilots

• Simple• Easy to understand• Common-sense• Jargon-free • Not discipline specific• Highly acceptable (90%)

Foundation model that could underpin other work

Treatment and Psychoeducation

MBT-I

2/3 facilitators

1 pre group individual + pre group assessment

1 pre group group session (!) + 12 weeks

post group assessment

First group on week 4

What is MBT-i?• 12 session psychoeducational programme

– Pre and post measures (inc PDQ-4)– Focus on -

• Attachment• what is PD?• anxiety/depression• what are thoughts and feelings?• Treatment etc

– Mainly explicit education focus but implicit mentalizing focus with modelling of this for patients also

IPT – G

First IPT group in Scotland, first in prison outside USA

Group for female prisoners with depression

2 facilitators

18 week model

First group just finished

Outcome data and group member interviews this week. Anecdotal evidence improved women’s depressive symptoms and understanding of relationships

SummaryTraining73 officers through PD training

2 MBT training for officers (20 delegates each training)

SupervisionReflective practice started 2 weeks ago on Ratho Hall

(Lots of informal discussion with officers and managers)

TreatmentIPT-G completed (1 cycle, 5 completers from 8 beginners)

MBTi session 4 this week

Summary

• 6 months into project• Not complete in scope • Pilot to increase access to psychological

therapies• Major unaddressed area's of need• Need for wider access to broader range of

evidence based psychological therapies.

Summary

• “push it where it moves”• Hope to reflect into male estate if effective• Should allow us to argue for further

development as unmet need identified