Treatment approaches to forensic psychopathology – psychodynamic, CBT

Estela Welldon (1993) states simply that whilst society strongly supports the treatment of victims, the same does not apply to offenders.

In the Mikado, the librettist W. S. Gilbert coined the phrase “let the punishment fit the crime”, which Dr Estela Welldon transposed to “let the treatment fit the crime”. This latter approach is axiomatic of an evidence-based paradigm, which will guide the discussion of treatment approaches for this paper, though will not exclude those treatments where an evidence base is still being assembled.

In terms of the availability of treatment for offenders, a recent report by the Centre for Mental Health (Durcan, 2016) has found that only a few prisons are able to offer psychological therapies, and that primary mental health care is the weakest element for inmates needing mental health support.

In a systematic review of psychotherapeutic approaches for forensic and clinical cases, Ross et al (2013) identified cognitive behavioral treatments as the dominant paradigm for the rehabilitation of offenders, and a meta-analysis of cognitive behavioural approaches by Landenberger and Lipsey (2005) concluded that such an approach is most effective with higher risk individuals.

Eastman (1993: 28) noted that “in a specialty where there is an extraordinary level of psychopathology, as well as of childhood deprivation and abuse, it seems extraordinary that the (forensic) establishment has paid so little attention to the psychopathological understanding and psychotherapy”. Fortunately, much work has been done since then to elucidate a broad array of aspects of clinical treatment of offenders from a psychodynamic perspective, and this will be explored further down. Welldon (1988, 2011), Cordess & Cox (1996), Welldon & Van Velsen (1997), van Marle (1997).

We will begin by exploring the treatment settings, and continue on to common treatments and interventions. When considering treatment approaches, the setting is crucial, (Taylor, 1997) as it will delimit the range of treatments available. In turn patients may have self-referred, as yet undetected and be seen in an outpatient unit, or they may be in the process of being charged, or they may already be in custody.

Treatment settings

Special hospitals are the most secure settings in the UK, and take the most serious offenders, considered to pose a serious threat to the public. Nursing staff are trained in control and restraint, as well as dealing with high-risk incidents such as hostage-taking. Such hospitals may focus on treating specific disorders. Broadmoor High-Security Hospital, for example, treats substance misuse, and young offenders with psychopathy.

Medium secure units are locked, and self-contained buildings, with some internal security, and no perimeter wall. They would take prisoners who are ready for rehabilitation, or conversely, patients from psychiatric wards or prisons displaying levels of violence in the context of their illness that additional security is indicated. As security is lower, and with sufficient determination, there is some risk of absconscion, as once well and trusted enough they may be allowed leave (either escorted or unescorted).

Such units can vary in size from between 15 to 60 beds. They usually offer treatment to psychotic patients, as patients with a personality disorder are considered more difficult to treat. The size of the units limits the range of treatment offered, which would preclude occupational therapies. Once discharged, a patient would be offered outpatient follow-up, social work supervision (though these may be mandatory if discharge is conditional and a restriction order is in place) and support from a community psychiatric nursing service.

Locked wards and specialized intensive care units within general hospital psychiatric units are suited to managing patients with challenging behaviour. These are not ideal for long admissions, as they often do not have outdoor or day areas. However, they are usually more accessible for visiting partners and family.

There are also a handful of specialist services, such as the Portman Clinic, which offers outpatient psychotherapy for patients with sexually related issues, and the Henderson Hospital, which is an inpatient unit for treatment of personality disordered men and women on a voluntary basis.

Treatments and interventions

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is “designed to help the patient test certain maladaptive cognitions and assumptions” (Beck 1979), and is the dominant form of treatment in the rehabilitation of offenders. (Polaschek, Wilson, Townsend, & Daly, 2005)

Landenberger and Lipsey (2005) carried out a meta-analysis of cognitive behavioral approaches which employed elements of problem solving, victim impact/ empathy, anger control, and behaviour modification, and found them to be most effective with higher risk cases.

Specifically, CBT has been used with men who are violent towards intimate female partners, accessed either through self-referral, or through a court order. CBT attempts to change how these men view their violence, and how they manage their behaviour. However a Cochrane Review of the RCTs conducted in this area found that the data available was inconclusive in demonstrating any significant effect of the treatment. (Smedslund, et al, 2007)

Ross et al (2013) conducted a systematic review of the efficacy of a range of psychotherapeutic interventions for forensic and clinical cases. The 8 of 10 studies utilising a CBT model demonstrated reductions in aggression following CBT, however, the data was often not robust and the reductions were not found to be obdurate on follow-up. The results are also not entirely comparable as whilst most of the studies used a CBT framework, they differed in terms of delivery, some favouring individual, others group, and some a blend of the two. The treatment programmes also varied, from standard CBT, to inclusion of components of interpersonal therapy and motivational interviewing, and drama therapy. However, it was noted that other factors associated with criminal behaviour, such as problematic drinking, social functioning, and beliefs about others, did appear to be reduced. The authors also hypothesise about whether the variety of settings in which forensic patients are treated might have lead to adaptations, which is yet another confounding factor in the review.

Treatments for Personality Disorder

Approximately 5% of the population has a personality disorder (Singleton, et al, 2001). Amongst offenders this rate increases dramatically with 66% in the prison population (Singleton, et al, 1998), and there are indications that the rate is 50% in probation caseloads. (Centre for Mental Health, 2012) The Bradley Report (2009) recognised the need for significant intervention in this area.

Common treatments for personality disorders include Mentalization Based Therapy (MBT), Structured Clinical Management, and Dialectical Behaviour Therapy (DBT).

Mentalization Based Therapy

MBT is a treatment commonly offered to violent offenders, particularly those with diagnoses of anti-social and borderline personality disorder. It focuses on improving control over behaviour and emotions, improving relationships, and working towards life goals by addressing attachment difficulties, and, through mentalization. Mentalization is an approach to developing our understanding of our own and others mental states, and the interpretation of our own and others actions. Mentalizaion can be seriously disrupted in individuals whose upbringings have been characterized by violent and abusive parenting, that itself lacks mentalization. (McGauley’s Inaugural Lecture, 2016) The effectiveness of this treatment is being studied currently in a nationwide RCT led by Peter Fonagy, Antony Bateman, and Jessica Yakeley. There is already evidence that it improves outcomes and compares well with other interventions (Bateman & Fonagy, 2009), and that improvements are lasting. (Bateman & Fonagy, 2008)

Structured Clinical Management

SCM has also been developed by Bateman, Fonagy, and others, and includes regularly counselling, practical support, advocacy and case management. It ahs also been shown to be effective. (Bateman & Fonagy, 2009)

Dialectical Behaviour Therapy

DBT is an offshoot of CBT. (Dimeff & Linehan, 2001) The treatment is designed to reduce unwanted behaviours and improve emotional regulation. The development of mindfulness, founded on Buddhist meditation, is a core element, and there is a burgeoning evidence base for its effectiveness. (Feigenbaum, 2007; Verheul, R, et al, 2003))

Other approaches

Ross et al (2013) note that other forms of intervention are being trialed, for example, “Silence the Violence”, a behavioural programme described by Minnaar (2010), being tested in South Africa and the UK which operates on vicarious modeling behaviour. Other documented treatment programmes include ‘collective efficacy’ (Sabol, Coulton, & Kolbin, 2004), Aggression Replacement Therapy (Hornsveld, Nijman, Hollin, & Kraaimaat, 2007), and Social Activity Therapy (Blacker, Watson, & Beech, 2008). These are predominantly founded on behavioral or cognitive behavioral principles, though differ in delivery and structure.

Psychodynamic approach

Forensic psychotherapy “is a bridge between traditional forensic psychiatry with a major focus on diagnosis and risk, and traditional psychotherapy with a focus on understanding why things happen.” (Welldon, 2015)

“Forensic psychotherapists not only provide treatment but also apply psychodynamic thinking to the complexities and dynamics within staff teams and institutions treating this patient group.” (McGauley, 2002: 118)

Forensic psychotherapy is typically a multi-disciplinary team approach, that requires collegiate working between the psychotherapist (s), psychiatry, psychology, nursing, social work or creative arts, as well as other helpers, such as managers and administrators. (Welldon, 2015) This is in recognition of the complex interconnected set of systems through which the forensic patient moves. Most patients are treated with a combination of medication, CBT and group or individual psychodynamic work.

Individual and group psychodynamic forensic psychotherapy is increasingly available across a range of settings, but usually with little capacity, meaning only a very few of the patients who would benefit from it, receive it. (McGauley, 2002: 118)

Many authors have described their psychotherapeutic work with both men and women within prison and maximum-security units. Aiyegbusi & Kelly (2012) explore the technical challenges of working within boundaries in the forensic space, with individuals whose psychopathologies often hinge on transgressions of societal laws, organizational rules, and other’s people’s bodies and lives, which are re-enactments of violations they themselves have suffered. Kelly (2012) explores the boundary challenges of psychotherapeutic work with men who have sexually offended. Moore and Ramsden (2012) elucidate the inherent challenges of working in psychotherapeutic groups with male offenders who have histories of boundary violations whilst in detention. Guanieri (2012) explores how dramatherapy enables creative therapeutic work with individuals using non-verbal and verbal articulations of internal boundary confusion. Dickinson and Benn (2012) look at boundary issues in delivering music therapy in high security settings, and Bownas (2012) investigates boundary characteristics of family therapy in secure inpatient units. The milieu therapy reviewed by Wolf (1977) that is a characteristic of inpatient settings, that brings together containment, structure, involvement with a focus on practical matters can be beneficial to those who’ve experienced chaotic lives.

The Assessment

Any forensic intervention should begin with a comprehensive assessment of the patient that is clearly demarcated from the legalistic encounters the patient may be familiar with. It should explore developmental and family history, alongside their and context and circumstances, and will likely reveal to the psychotherapist some of what may make an offender suitable for treatment, as well as clues to early traumatic experiences. (Welldon, 1993) Assessments should be approached with the utmost honesty and transparency, which extends to the ‘structuring of time” (Cox, 1978).

Selection criteria for psychodynamic treatment

Not all offenders warrant treatment, not all want treatment, and not all can benefit from it. This may be due to careerist criminality. Obversely, the clumsily executed criminal act has become the equivalent of the neurotic symptom that emerges from the unconscious as a flag to a psychopathology needing treatment. (Welldon, 2015)

Exploring the particular psychopathologies can assist with determining whether individual or group psychotherapy will be most effective. For example, an individual with a serious personality disorder, who is unlikely to develop relationships, will not be a good candidate for group psychotherapy. (Welldon, 1993)

Individual psychodynamic treatment

The forensic psychotherapist seeks to help individuals understand their own minds better, and through this to develop a capacity to tolerate their own unpalatable thoughts and emotional states, rather than acting on them. (McGauley, 2002)

Typically treatment is over months, and sometimes years. However, this continuity that is key to a psychodynamic approach can be disrupted due to individuals being moved into different institutions depending on the status of the judiciary proceedings against them. (McGauley, 2002)

There are various characteristics that indicate an individual can make good use of individual psychotherapy. For instance, patients who’ve experienced a very close, merged relationship with one parent usually benefit from the warmer, less threatening atmosphere in a group. (Welldon, 1993)

Group therapy

Violent offenders tend to benefit more from group psychotherapy, due to the mechanism of identification with others, which, as Freud (1921) observed, tends to limit aggression towards them. Being surrounded by others who can sense hostility welling up before it is articulated gives a group the capacity to confront and defuse violent behaviour before it is enacted, and the multiplicity of the transference diversifies and softens the anger which would otherwise have focused intensely on a single target. (Welldon, 1993)

There are also those whose present circumstances preclude them from making good use of group therapy, for example, for those whose own or spouses criminal activities continue, where the rule of confidentiality would be impossible to uphold.

Group-analytic therapy is also indicated for those patients who’ve experienced abuse, both abusers and abused, since the group functions to re-create the family constellation, the violent and anti-social nature of which is at the root of many of their problems. The group setting is also a bulwark against the secrecy that has often perpetuated incestuous relations in the family, as well as the therapists being drawn into a transferential-counter-transferential dynamic that recapitulates the original traumatic experience. (Welldon, 1993)