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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%
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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%
- 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
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