Forensic Archives - Confer

Objective
This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.

Conclusions
Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.

Objective
This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.

Conclusions
Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

Abstract
Mental disorders traditionally have been viewed as distinct, episodic, and categorical conditions. This view has been challenged by evidence that many disorders are sequentially comorbid, recurrent/chronic, and exist on a continuum. Using the Dunedin Multidisciplinary Health and Development Study, we examined the structure of psychopathology, taking into account dimensionality, persistence, co-occurrence, and sequential comorbidity of mental disorders across 20 years, from adolescence to midlife. Psychiatric disorders were initially explained by three higher-order factors (Internalizing, Externalizing, and Thought Disorder) but explained even better with one General Psychopathology dimension. We have called this dimension the p factor because it conceptually parallels a familiar dimension in psychological science: the g factor of general intelligence. Higher p scores are associated with more life impairment, greater familiality, worse developmental histories, and more compromised early-life brain function. The p factor explains why it is challenging to find causes, consequences, biomarkers, and treatments with specificity to individual mental disorders. Transdiagnostic approaches may improve research.

Fazel S & Danesh J. 2002. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet 359: 545-50.

Background
About 9 million people are imprisoned worldwide, but the number with serious mental disorders (psychosis, major depression, and antisocial personality disorder) is unknown. We did a systematic review of surveys on such disorders in general prison populations in western countries.

Methods
We searched for psychiatric surveys that were based on interviews of unselected prison populations and included diagnoses of psychotic illnesses or major depression within the previous 6 months, or a history of any personality disorder. We did computer-assisted searches, scanned reference lists, searched journals, and corresponded with authors. We determined prevalence rates of serious mental disorders, sex, type of prisoner (detainee or sentenced inmate), and other characteristics.

Findings
62 surveys from 12 countries included 22790 prisoners (mean age 29 years, 18530 [81%] men, 2568 [26%] of 9776 were violent offenders). 3.7% of men (95% CI 3.3–4.1) had psychotic illnesses, 10% (9–11) major depression, and 65% (61–68) a personality disorder, including 47% (46–48) with antisocial personality disorder. 4.0% of women (3.2–5.1) had psychotic illnesses, 12% (11–14) major depression, and 42% (38–45) a personality disorder, including 21% (19–23) with antisocial personality disorder. Although there was substantial heterogeneity among studies (especially for antisocial personality disorder), only a small proportion was explained by differences in prevalence rates between detainees and sentenced inmates. Prisoners were several times more likely to have psychosis and major depression, and about ten times more likely to have antisocial personality disorder, than the general population.

Interpretation
Worldwide, several million prisoners probably have serious mental disorders, but how well prison services are addressing these problems is not known.

Fazel, S. & Seewald, K. (2012) Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. The British Journal of Psychiatry, 200 (5) 364-373

Background
High levels of psychiatric morbidity in prisoners have been documented in many countries, but it is not known whether rates of mental illness have been increasing over time or whether the prevalence differs between low-middle-income countries compared with high-income ones.

Aims
To systematically review prevalence studies for psychotic illness and major depression in prisoners, provide summary estimates and investigate sources of heterogeneity between studies using meta-regression.

Method
Studies from 1966 to 2010 were identified using ten bibliographic indexes and reference lists. Inclusion criteria were unselected prison samples and that clinical examination or semi-structured instruments were used to make DSM or ICD diagnoses of the relevant disorders.

Results
We identified 109 samples including 33 588 prisoners in 24 countries. Data were meta-analysed using random-effects models, and we found a pooled prevalence of psychosis of 3.6% (95% CI 3.1-4.2) in male prisoners and 3.9% (95% CI 2.7-5.0) in female prisoners. There were high levels of heterogeneity, some of which was explained by studies in low-middle-income countries reporting higher prevalences of psychosis (5.5%, 95% CI 4.2-6.8; P = 0.035 on meta-regression). The pooled prevalence of major depression was 10.2% (95% CI 8.8-11.7) in male prisoners and 14.1% (95% CI 10.2-18.1) in female prisoners. The prevalence of these disorders did not appear to be increasing over time, apart from depression in the USA (P = 0.008). Conclusions
High levels of psychiatric morbidity are consistently reported in prisoners from many countries over four decades. Further research is needed to confirm whether higher rates of mental illness are found in low- and middle-income nations, and examine trends over time within nations with large prison populations.

Glasser, M (1996) The Assessment and Management of Dangerousness: The Psychological Contribution. Journal of Forensic Psychiatry. 7: 271-283.

Abstract
In the difficulties in assessing dangerousness, the contribution of the psychoanalytical approach should not be overlooked: it can be of great value in diagnosis, treatment, discharge evaluation and management within an institution and in the community.

Hinshelwood, R.D. (1999) The difficult patient. The role of ‘scientific psychiatry’ in understanding patients with chronic schizophrenia or severe personality disorder. British Journal of Psychiatry. 1999 Mar;174:187-90.

Abstract
The role of ‘scientific psychiatry’ in understanding patients with chronic schizophrenia or sever personality disorder.

Main, T (1957) The Ailment. British Journal of Medical Psychology, 30: 129-145.

Abstract
Address from the Chair, to the Medical Section, British Psychological Society, on 20 March 1957, in which the author offers a psychoanalytic understanding of the dynamics within teams involved in the treatment of individuals on psychiatric inpatient hospital wards.

Mullen, P. E. (2000) Forensic mental health. The British Journal of Psychiatry. 176 (4) 307-311

Abstract
In which the author outlines what Forensic Psychiatry is, and some of the key challenges facing the discipline, such as risk assessment and management, service improvement, and workforce development.

Steadman, H.J., Mulvey, E. P., & Monahan, J. (1998) Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods. Arch Gen Psychiatry. 55(5):393-401.

Background
The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed.

Methods
We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks.Results
There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home.Conclusions
“Discharged mental patients” do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.

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Aetiology of Forensic Psychopathology

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Aetiology is “the study of the causes of disease.” (Reber and Reber, 2001)

The concept originates in a medical model that looks predominantly at biological factors, for example the genetic basis of bipolar disorder. This is broadened within the psychiatric model to include aspects of the environment, which would include psychological or social factors. There is a risk when employing the medical model of attributing the cause of a mood disorder to biology, rather than recognizing biological factors as contributing to an individual’s affective experience, alongside environmental factors. (Bartlett, 2010)

Spitzer and Wilson (1975) explored whether psychiatric disorders can justifiably be referred to as physiological dysfunction, and concluded that they cannot. Their reasons were: 1) that the aetiology of psychiatric disorders is never fully understood, and they are typically multi-factorial; 2) that features of psychiatric disorders are often part and parcel of normal experience, unlike, for example, ‘coughs’ or ‘heart pain’; 3) that there would need to be a demonstrable physical change in the individual – in fact that there are instances where this is the case, as well as more recent research into genetic pre-disposing factors in personality disorder (Tobena, 2000), and; 4) that physiological dysfunction should proceed independently of environmental influences, which is not the case.

It is important to note that Caspi et al (2014), and Patalay et al (2015) have recently elucidated a general factor for psychopathology (p-factor) in psychiatric disorders onto which all aetiological factors load. Higher p scores have been associated with greater life impairment, greater familiarity, poorer developmental histories and more compromised early brain function. The authors propose that the p-factor explains the challenges of identifying common aetiological factors associated with any specific psychiatric disorders.

In terms of the relationship between psychopathology and offending behavior, the psychodynamic perspective presents with another useful way of thinking:

“At times, the criminal act is the expression of more severe psychopathology; it is secretive, completely encapsulated and split from the rest of the patient’s personality, which acts as a defence against a psychotic illness (Hopper, 1991). On the other hand, it can be a calculated act associated with professional, careerist criminality. The forensic psychotherapist can help to clarify these difficult diagnostic issues. ” (Welldon, 2011: 174)

Welldon (2011) reminds us further on that patients with severe psychopathology have experienced profound instability and inconsistency at crucial junctures in their early lives in which both their psychological and physiological survival were in jeopardy. These experiences have effectively disrupted processes of individuation and separation through undermining the basic trust towards primary caregivers that most people are able to depend on.

This paper will examine the work carried out so far to identify the aetiologies of common forensic psychopathology that manifest specific offending behaviours, considering physiological and environmental factors, and including psychodynamic perspectives.

Violent crimes

Despite the media’s portrayal of mentally ill individuals as the common perpetrators of violent crimes, most individuals with mental illness are not violent, although there is a small but significant association. (Yakeley, 2010)

It is worth bearing in mind Estela Welldon’s (2015) observations, that the common public response to violence is rarely scrutinised as it appears on the surface to be logical and pragmatic. Projection and splitting are usually at play, and as a result perpetrators are labelled ‘bad’, with those looking on defending their ‘goodness’ in contrast, which is an example of Melanie Klein’s (1946) ‘projective identification’. As this approach to understanding the dynamics of violence is often viewed as condoning the criminal act, psychodynamic approaches can be vilified, and as a result the forensic psychotherapist has the invidious task both of trying to help their patient, whilst working through some of the painful problems that wider society contends with.

If we turn to research studies, this is what we find.

Violence in individuals with mental disorder has been correlated with a range of maladjusted behavior during early childhood, which in turn are associated with aetiological factors. (Burke, 2010)

Such maladjusted behaviours include attention and concentration problems, recurrent failure in academic settings, and truancy and expulsion from school (Harris, et al 1993), anti-social behavior at an early age (such as chronic alcohol/substance abuse, and aggressiveness) (Farrington, 2001), impulsive, reckless behavior during adolescence, problems with peer group relationships, and hostility towards authority (Melton et al, 1997).

The aetiological factors associated with these maladaptive behaviors are sexual and physical abuse and neglect (Ferguson and Lynskey, 1997; Weiler and Widom, 1996; Widom, 1989), separation from parents at an early age (under 16 years), parental rejection, low parental involvement, cruel and inconsistent parenting (Muetzell, 1995), parental alcoholism (Moffitt, 1987; Rydelius, 1994; Virkkunen et al 1996) and violence within the family (Blomhoff et al, 1990; Fitch and Papantonio 1983; Johnston 1988; Ryan, 1989).

Burke (2010) stresses that whilst these factors may not directly cause violent behavior, they may “structure potential violence” (41) and they may shape triggers to future violence. Glasser (1996) noted that an individual diagnosed with schizophrenia does not commit a homicidal act as a result of psychological malfunctioning. As Doctor (2008: 2) avers “even the most apparently insane violence has a meaning in the mind of the person who commits it. There is a need to be aware of this meaning and to learn from it in an attempt to prevent further violence.”

If we are thinking less about the root causes, and more about the moment to moment dynamics that precede violent crimes, it is helpful to remember James Gilligan’s assertion that acts of violence, and this is especially true of those acts that appear irrational, are most often preceded by subjective feelings of humiliation. (Gilligan, 1996)

For more detail on the psychodynamics underpinning violent crimes, we have learnt from De Zulueta (2006) what some consider to be a nearly ineluctable process that takes place in between mental and physical pain and its development into physical violence. Where De Zulueta makes reference to individual situations, Meloy and Yakeley (2014) apply a similar approach to the context of group and social violence, including acts of genocide and terrorism.

Violence towards women

As with any other offending behavior explored here, there is a biological theory underpinning domestic violence against women, which points to men’s average greater size and physical strength. Dobash and Dobash (1992), and Koss et al (1994), note that this implies such incidents have different meanings and physical consequences for the victims. There are also powerful discourses that make aggression, and therefore violence, as naturally masculine behavior, as well a biological sub-plot, which connects levels of testosterone and aggression. (Hearn, 1998)

From a psychological perspective, a commonly attributed cause is problematic personality types, or personality disorders (Dobash et al 2000; Hearn, 1998; Koss et al, 1994), though this has been criticized as withdrawing the agency from such men, which also makes the possibly of them engaging in transformative change of themselves difficult. (Dobash et al, 2000)

Sexual offending

The prevalence of mental ill health amongst sexual offenders is low (10% or less) (Sahota and Chesterman, 1998b), although in the region of 30%-50% for personality disorders. (Ahlmeyer at al, 2003; Madsen et al, 2006) However, there is no causal relationship between mental ill health and sexual offending. Any relationship is complex, and needs to take into account aetiological and risk factors.

It is important to bear in mind that whilst the following characteristics have been observed in men who’ve committed sexual offences, they will not be present in all individuals who offend. (Houston, 2010)

As discussed above, early attempts to understand sexual offending began with a focus on biology, such as Goodman’s (1987) theory, which concentrated on hormonal and genetic factors. Elaborating on Marshall’s (1989) observations of an interaction between deficits in the capacity to have intimate relationships, and sexual offending, Marshall and Barbaree (1990) proposed a multifactor ‘integrated’ theory. The theory included genetic factors alongside the influence of the criticial adolescent developmental task in males of distinguishing between aggressive and sexual impulses, as they emanate from the same brain structures. They recognized that hormonal factors will render this task more challenging, especially in the context of unfavorable early development.

Hudson and Ward (1997) hypothesized that men who have sexually offended against children tend to have anxious, pre-occupied and fearful styles of attachment. Attachment theory is the psychological model of the dynamics of human relationships, learnt in early childhood, and articulated especially in times of stress. (Bowlby, 1971) Smallbone (2006) later developed an ‘attachment-theoretical revision’ of the ‘integrated’ theory.

The significance of negative early childhood experiences and their contribution to the development of maladaptive patterns of attachment in later sexual offending has been increasingly examined in the last two decades. Craissati et al (2002) found that the family history of sexual offenders involved high levels of disruption, neglect and violence, and Prentky et al (1989) found a relationship between inconsistency in caregivers, and familial sexual deviation and abuse, with severity of sexual aggression within a cohort of sentenced rapists.

Higher levels of physical abuse have been identified in the family lives of rapists than other sexual offenders (Marshall et al, 1991) or non-sexual offenders (Leonard, 1993). High rates (40%) have been found amongst convicted child abusers (Craisatti and McClurg, 1996).

A history of sexual abuse has consistently been found to be more common in sexual offenders than in either non-sexual offenders or non-offenders. In men who have sexually offended against children, the rates of victimization have been found to be between 46% and 51% (Craissati et al, 2002; Craisatti and McClurg, 1996; Houston and Scoales 2008).

Studies have also examined underlying beliefs and cognitive schema of sexual offenders, for example, the work on cognitive distortions by Abel et al (1989), and implicit theories that underpin these cognitive distortions amongst men who offend against children (Ward and Keenan, 1999), and amongst convicted rapists. (Polaschek and Ward, 2002)

There are various theories that bring these things together, such as Finkelhor’s (1984) model of sexual offending against children, Wolf’s (1985) model of the influence of early childhood adversity leading to sexually deviant interests, and Ward & Siegert’s (2002) aetiological theory of sexual offenders against children, and the heterogeneity amongst them. In addition, models of sexual aggression towards women have been constructed by Hall and Hirschmann (1991), which has been critically evaluated by Ward et al (2006), and Malamuth et al (1993).

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Forensic psychotherapy – history and theoretical schools of thought

admin — Fri, 10 May 2019 19:26:34 +0000

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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, 2015b) Williams (1991) examines the difficulties in bridging these disciplines. 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”.

Forensic Psychotherapy seeks to understand the unconscious motivations of the offender’s antisocial behaviours, with the objective of preventing their repetition, which might lead to further crimes against society. The better the criminal mind can be understood, the more effectively positive action can be taken to prevent criminal acts, and the better counter-transferential responses can be understood and managed. The expectation is that in time, this should lead to more effective and economically viable treatments. (Welldon, 1994)

Typically, criminal behaviour is responded to with punishment, so a compassionate response that attempts to understand the offender and his delinquent actions in the context of self-destructive and compulsive behaviours is equated with condonement. (Welldon, 2015) As such the Forensic Psychotherapist has the invidious task of both trying to help his/her patient, whilst also trying to work through some of the painful problems that society contends with.

Unlike the dyadic relationship between therapist and patient in traditional psychotherapy, forensic psychotherapy involves a triadic relationship between therapist, patient, and society. (de Smit, 1992) Welldon (2015b) draws other triadic relationships into this work: between the social roles of ‘bully’, ‘victim’ and ‘bystander’ (Twemlow, Sacco and Williams, 1996), and; between the cultures of concern, learning and blaming. (Welldon, 2011)

The modifications of traditional psychoanalytic practice that have led to forensic psychotherapy as a model in its own right have received support from eminent psychoanalysts such as Kernberg (2014) and Twemlow (2013).

Over the years this approach has made progress, and behaviours traditionally treated as transgressions deserving punishment have been steadily recognised as being understandable, with a basis in the patients life experiences. This is evidenced by the inclusion of such behaviours in the Diagnostic Statistical Manuals, e.g. DSM – III-R ((American Psychiatric Association (APA), 1987).

Fishman and Ruscynski (2004) note that it is due to the work of the International Association of Forensic Psychotherapy and Dr Estela Welldon, that the title of forensic psychotherapist came into existence.

History

The UK has been at the vanguard of the development of forensic psychotherapy, since, in 1931, the Institute for the Scientific Treatment of Delinquency and Crime was established. This later became known as the Institute for the Study and Treatment of Delinquency (ISTD) (Cordess, 1992; Glover, 1960). The Institute identified its goal as to promote alternative and better ways of dealing with criminals than imprisoning them. It also sought to advance understanding of the causes and prevention of crime through scientific research, as well as consolidating the literature already extant, promoting cooperation between the relevant statutory and professional bodies involved in forensic work, and to advise and educate colleagues and the public. Its first chair was the eminent and influential psychoanalyst Dr Edward Glover.

The ISTD was strongly influenced by the work of the psychiatrist and psychotherapist, Dr Grace Pailthorpe, who worked in Birmingham and Holloway prisons following time as a doctor in the trenches in the First World War. Dr Pailthorpe eventually wrote Studies in the Psychology of Delinquency (1932) in which she explored her interest in the personalities of female prisoners, which attracted other like minded psychoanalysts, including Dr Glover, who had himself been expanding the literature around sexuality, criminality, and addictions.

Glover wrote in his own history of the ISTD that, as the work dealt with social phenomena, it required the involvement of a variety of disciplines, including social workers and social psychologists, but that the most vital approach to making sense of crime, was psychoanalytic. (Fishman & Ruszcynski, 2004) Welldon (2015) notes that forensic psychotherapy is typically a multi-disciplinary team approach, in recognition of the complex interconnected set of systems through which the forensic patient moves.

Due to the stigma attached to its work, the clinicians of the ISTD were prevented from working under one roof until May 1937. In 1948, with the establishment of the National Health Service, one part of the ISTD joined the NHS as the Portman Clinic, offering treatment primarily, and a part that remained the ISTD (now located at Kings College London) focused on research and training. (Welldon, 1992) In the United States during the early 20th century, Dr Karl Menninger was establishing the Menninger School of Psychiatry in Topeka, Kansas. He believed that punishment protected neither society not the criminal, and went considerably further with a psychodynamic perspective.

Dr Menninger famously critiqued the popular interpretation of Lee Harvey Oswald’s case, as an example of the alienated, little man, gaining attention and notoriety through a transgressive act directed at society (1967).

In the UK, during the mid 1960s, Dr Maxwell Jones founded a “therapeutic community” (Jones, 1953) at the Henderson Hospital for the treatment of severe personality disorders, at the time known in a pejorative sense as psychopaths. This clinic was run in such a way as to achieve greater parity and equality between staff and patients, with patients having a much greater say in the running of the institution, and even the discharge of their peers. In this way Dr Jones further eroded the stigma engrained in the treatment of such individuals.

During the 1960s the Portman Clinic continued to play a central part in the development of the field, holding conferences (in 1961), and publishing volumes (the same year, and a second edition in 1979) on pathology and the treatment of sexual deviation, such as “Sexual Deviation” (Eds Ismond Rosen, 1964)

Fishman & Ruszcynski (2004) note that a number of seminal works emanated from clinicians working within the Portman Clinic. For example “From the analysis of a transvestite” (1979a), and “On violence: a preliminary communication” (1998) by Dr Mervin Glasser, “Clinical types of homosexuality” (1989c) and “A re-evaluation of acting out in relation to working through” (1966) by Adam Limentani and Estela Welldon’s work on female perversion “Mother, Madonna, Whore” (1988). Another key publication is the twin volume edition “Forensic Psychotherapy” edited by Christopher Cordess and Murray Cox.

Having been embedded within the fabric of the NHS for some years, and established a theoretical basis, the place of forensic psychotherapy within statutory services in the UK was at risk during the mid 1980s, due to a serious review of the role of psychotherapeutic work offered through the NHS. However, the Seymour review (1985) ultimately concluded that psychotherapy did have a part to play in the NHS.

Founding of the IAFP

A pivotal moment in the recognition of forensic psychotherapy as a discipline in it’s own right, was the initiation of the International Association of Forensic Psychotherapy (IAFP). As an idea, the IAFP emerged from a conference on Law & Psychotherapy in Leuven, Belgium, in 1991.

At this time, the gap between the psychodynamic and judicial understandings of criminal behaviour was being bridged through residential weekends for judges, co-led by staff from the Portman Clinic, to enable them to become familiar with a psychodynamic understanding of unconscious motivations of offenders. (Welldon, 2015b)

The IAFP emerged, driven by Dr Welldon, from the European symposia, originating in the 1980s with annual meetings at the Portman Clinic that brought together practitioners from Holland, Belgium, Austria and Germany, along with staff from the Portman Clinic, to explore work with patients involved with the criminal justice system due to their psychopathology.

The IAFP is a robust enterprise, which marked its 25th anniversary in 2016, with its 25th annual conference in Ghent, Belgium.

Training in Forensic Psychotherapy

The most important contribution to the field emerged from the Portman’s array of workshops and conferences was the 2 year Diploma in Forensic Psychotherapeutic Studies, sponsored first by the British Post Graduate Medical Federation, and later by UCL. The course was pioneered by Dr Estela Welldon, who was appointed as clinical tutor at the Portman Clinic in 1988. Dr Welldon and Professor Michael Peckham structured the course, with a faculty of Portman Clinic staff, and other consultants delivering the teaching. The course was the first of its kind, and ran for 4 years and was the embodiment of the challenges of bridging the disciplines of forensic psychiatry, and of psychodynamic psychotherapy. In this respect, it played a crucial role in furthering understanding of the field, and creating a cohort of newly equipped clinicians, in this “evolving species”. (Adshead, 1991).

Many of the alumni have become influential figures in the sector and held leading offices within the IAFP, and since the course was multidisciplinary, books from a broad range of different professions continue to emerge, illuminating and widening the scope of this field.

These books include Toxic Couples: The Psychology of Domestic Violence (2014) and The Psychology of Female Violence: Crimes Against the Body (2008) by Anna Motz, and Dangerous Patients: A Psychodynamic Approach to Risk Assessment and Management (2003) and Murder: A Psychotherapeutic Investigation (2008) by Ronald Doctor.

The first consultant psychiatry post in forensic psychotherapy was created in 1994 by Professor Eastman and Margaret Orr, then medical director at Broadmoor Prison, which was held by Dr Gill McGauley. (McGauley, 2016)

Forensic psychotherapy is being adapted for a variety of purposes, for example, working with offenders with learning difficulties (Corbett, 2014; Sinason, 2010; Curen & Sinason, 2010), music therapy and art therapy have been shown to be effective for patients in prisons and other secure settings (Compton Dickinson, Odell-Miller, & Adlam, 2012). Group analysis has also been utilised effectively with forensic patients. (Welldon, 1993)

Despite a growing body of evidence for both the effectiveness of these treatments, and the cost-effectiveness of such an approach in comparison to penitentiary and other traditional responses to crime, there are still those who question it’s efficacy. (Altshul, 2013)

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Treatment approaches to forensic psychopathology – psychodynamic, CBT

admin — Fri, 10 May 2019 19:25:08 +0000

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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 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)

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