Why prisons should be run on therapeutic lines

1. Why prisons should be run on therapeutic lines

2. 1. Rates of childhood trauma and personality pathology in prisoners are equivalent to those of psychiatric in-patient populations

3. 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

4. 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%

5. 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%

6. - 2. Therapy works

7. 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

8. this is no longer something we can do nothing about!

9. 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”

10. 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

11. 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

12. 3. Workable therapeutic models are possible in secure settings

13. 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

14. 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)

15. 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

16. 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