Things of Darkness 3: The treatment of violence

1. Things of Darkness 3:The treatment of violence • Professor Gwen Adshead • June 2015 • Gwen.adshead@southernhealth.nhs.uk

2. An Overview Violence is complex Perpetrators are heterogeneous What do we know about treating violence? The Index Offence Treatment in prisons Treatment in hospitals Recovery and rehabilitation

4. First, philosophy:Can we treat violence? • Violence is not an ‘illness’ • Do we want offenders to feel ‘better’ about themselves? To go back to normal? • Do we want them to suffer? • Or do we want them to behave better? To be better people? • How would we know?

5. The index offence The offence the offender committed that led to their detention in prison or secure treatment settings or community sentence A defining offence: the index ‘points to’ identity A drunk driver, a batterer, a paedophile, a rapist, a murderer How to give up that identity?

7. Decades of research in ‘what works’? • Most offenders desist with age • Only a sub-group persist • Influenced by events in their lives: the ‘turning point’ • And attitudes towards agency and choice

8. Interventions to reduce repeat violence risk • Interventions to alter known risk factors: substance misuse social isolation and dysfunctional relationships, malignant masculinity and gang membership, unempathic attitudes towards the vulnerable Paranoia, anger and fear

9. Interventions offered in prison • Enhanced Thinking Skills: trying to reduce impulsivity and enhance the capacity for meta-cognition • Violence Reduction Programme: looking at beliefs and attitudes that support violence • Sex Offender Treatment Programme • Substance misuse work • Interventions for Intimate Partner Violence

10. Do they work? • Research going back 20 years • Alternating pessimism and optimism • Mixed evidence: Risks can be reduced by 10-15% for VRP and SOTP • Changing other factors makes a bigger difference: reducing substance abuse, Improving literacy and employment options • Problems with access: ethical issues

11. The figure shows effect sizes for selected types of interventions from meta-analytic reviews, to illustrate the range of findings obtained. In the graph, the vertical line represents zero change (no difference between experimental and control samples). Bars extending to the right represent increases in recidivism amongst experimental samples relative to controls. Bars to the left represent reductions in recidivism. Variations in effect sizes (McGuire, 2005)

12. The Delaware Crest Project

13. The Good Lives Model • Professor Tony Ward & Professor Shad Maruna • Offenders are people like us • Helping people understand why they offend; why they made bad choices in the past • Helping people to make good choices • Ones that promote their well being and help them achieve pro-social goods • Dynamic approach: minds can change

14. This thing of darkness, I acknowledge mine

15. Giving up the violent mind • Changing distorted thinking • Changing identity • Changing the ways people manage fear, rage, anger and panic • Changing attitudes towards the vulnerable • Changing attitudes towards the self: agency, not passivity: new forms of self-respect

20. Treatment for violence in secure psychiatric care • Treatment for violence risk and mental illness and recovery from both • Medication and recovery focussed occupational therapy • Therapy programmes that address the same risk factors as above • Individual and group therapy

21. Index offence work • MoJ emphasise on-going risk and/or remorse • Understanding the meaning of the offence • Its purposes and intended consequences: did it work? • What do they feel about it now? • How does their ‘story’ fit with other evidence? • Impact on families and communities

22. What might indicate desistance? • We want to know what they really think about themselves as offenders • We want to know the ‘real’ story of what happened • We want to know what the risks of recurrence might be: and who might be a target • Have they worked out the combination of risks?

24. The index offence • First task: Helping people to name what they have done: articulating it • ‘M’index’ or ‘My crime’ • ‘When [she] died’ or ‘passed away’ • The move to the active voice: ‘When I killed…’ • Agency in language reflects ownership of responsibility

25. “I am afraid to think what I have done…” • How to help people who are afraid to think • Slow, steady, secure • Cox (1976) changes of agency • It wasn’t me, ‘It was me, but I was mentally ill’ • ‘I did it when I was mentally ill’ • ‘I did it’.

26. A homicide group • Index offence work for people who have killed someone they knew well • Risk issues: are future attachment figures at risk? • Risk to self: pathological grief, PTSD, suicide • Identity as a ‘killer’: how they experience this in relationships with friends and family • Survivors of a disaster where they were the disaster

27. From a group therapy session • [Jim has a severe mental illness. He often mutters audibly in the group] • (T1: “Jim, I can’t hear what you are saying very well when it’s a mutter”) • Jim: “I was thinking about the person I killed and how I would like to say sorry… when I killed my [relative] I was mentally ill, but… there was no reason for me to kill the second person”

28. Another quote I feel I’m stuck in my previous age… the age I was when I did my offence.. Time’s passing here and there are things I’m not doing.. I want to capture time with magazines and pictures to show what I was doing when I was here… What will it be like in 10 years time? Where will we be? What will I think on my deathbed about this time?

30. This thing of darkness I acknowledge mine “you have to be honest in order to go further……. you’ve got to be honest with yourself before you can go to the doctor, this is how it is….being honest to yourself, giving yourself a chance to breathe and grow again…… short term setback for a long term step forward” “I would like to have more insight, by which I mean taking responsibility for my state of mind, its easy to blame others for your problems, you do feel better if you take responsibility, other things you want fall in to place if you take responsibility for your situation”

31. A wish to repair (Tom is about to leave the group) ‘ If I can make something of myself after leaving here, then two lives will not have been lost.. And she will not have died in vain’.

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33. Does it work? • Better than prison! • Low recidivism rates for mentally ill offenders, especially for severe violence • At least in part because they get supervision longer, which means more support • Caveat: Risk level persists over years, unlike prisoners. High risk of suicide • Risk increases when people discharged from one service to another

34. Aos et al 2001 Economics & Crime reduction

35. Ethical questions • Therapy for offenders and victims is not cheap and not quick • How and who pays? • Is it better to give more people a B grade therapy that has less effect? • Or less people an A grade therapy with a good effect? • Who makes these choices? • What would you choose? For your son?

36. Prevention of childhood adversity is (probably) cheaper