Balancing Risk and the Therapeutic Alliance in Offender Rehabilitation: A Day of Presentations and Discussions Notes of discussions by Dr Zarah Vernham Overall, we would like to thank all the speakers for their presentations. They were all very interesting and thought-provoking. Mental Health and Stigma The first couple of presentations discussed the stigma associated with mental health disorders. The findings of these studies were positive highlighting a clear shift in the ways that the general public perceive people with mental health issues in terms of their dangerousness, responsibility and deservingness of treatment. What was clear from both these talks was the effect of a disadvantaged background on the public s perceptions of dangerousness and risk of offending. It was shown that the public were accepting of those with mental illnesses from relapsing, but that relapse was not accepted within offenders. Further research was suggested in terms of deconstructing the term dangerousness and exploring the public s perception on offenders with disadvantaged backgrounds as well as mental health issues. The discussion that arose following these presentations was in terms of collecting qualitative data in order to explore whether we are dealing with the right issues within these studies. A qualitative aspect is needed if we are to gain an understanding of the experiences from the view point of the offender and/or those suffering with mental illnesses. How do they feel they are perceived and/or stigmatised within society? And how does this impact on how they behave? The two studies presented involved petite crimes and therefore it was mentioned that if the crime type changed then the results of the study may also change. However, others argued that this would not be the case because, regardless of crime type, people recognise the effect of family background on development and the need for the individual in question to be supported. Finally, future research was suggested in terms of comparing different cultures: How do the findings differ depending on whether the country is punitive or non-punitive? Young People who Sexually Offend: The Practitioner s Experiences The third presentation was of a qualitative study that examined the lived experiences of youth justice practitioners who supervise young people displaying sexually harmful behaviours. What became apparent from this presentation was the lack of knowledge in this specialist area and the sense of unease that was evident amongst practitioners who had to work with this client
group. Worryingly, it was found that there was a lack of supervision available to practitioners involved in dealing with young people who sexually offend due to the underlying assumption that practitioners should be able to cope with these young people and the type of information that they hear. As a result of practitioners not knowing how to help this client group, it was found that they would often apply their work with non-sexual offenders to their work with sexual offenders. Further research needs to examine whether practitioners perceptions of sexually harmful behaviours impact upon their relationship with young people and therefore whether the practitioners are doing more harm than good (e.g. does the young person pick up on the fact that the practitioner is detaching and struggling with what they are saying if so how does this affect the therapeutic relationship?). The first point made following this presentation was about the differences between public and private practice, because those working in private practice have extensive and beneficial supervision. Supervision was highlighted by the audience as being important for all those working in the field of forensic psychology; therefore, the findings of this study seemed to shock the majority of the audience. Next, a question was asked about how practitioners have responded to the findings of this study. It became clear that the answer here was negatively. Instead, the youth offending practitioners did not want to address or discuss the issues ( bury head in sand came to mind). Finally, the discussion led to whether we should take more risks and if we do how this would affect our sense of responsibility (in practice). It was noted that this was difficult to answer as practitioners want to feel safe and be in control whilst providing a therapeutic environment. It was clear that we needed more supportive risk management, to work more constructively on Good Lives models within the population, and to have a multi-agency approach (e.g. work in conjunction with the police). Biological Approaches to Treatment The fourth presentation discussed innovative approaches to the treatment of offenders. It discussed embodiment and the idea that talking approaches are not enough. This presentation gave an excellent explanation of the brain and the risk factors for offending. It highlighted the differences in brain structure and functioning between those with adverse childhood experiences and those without. Four key treatment approaches were discussed: Eye Movement Desensitisation and Reprocessing (EMDR), Mindfulness, Biofeedback/Breathing, and Animal Assisted Therapy (AAT). Following the presentation it was asked how many sessions it would take for these innovative approaches to have an effect. It was suggested that it varies depending on the
individual and the treatment in question, for example, some people notice a significant difference after only three EMDR sessions or 12 Mindfulness sessions, whereas others may need more. Next, the issue of Psychopaths was discussed and whether such biological treatments would work for these types of offenders. To answer this question, the two types of psychopaths were debated. Primary psychopaths are those who everyone wants to study; however, these psychopaths are not likely to be in prison (unless very unsuccessful). Primary psychopathic tendencies are likely to be a result of genetics and therefore such biological treatments will not be effective. Secondary psychopaths, however, are likely to have suffered significant traumas growing up; therefore, the biological therapies are likely to have an effect (because the offending is linked to developmental deficits). There are plenty of secondary psychopaths in prisons to be studied. Finally, the challenges of applying the biological treatments into practice were debated. It was made clear that it can be and should be applied in practice. It was emphasised that early trauma can lead to lower IQ and visual and verbal deficiencies. As a result, talking therapies such as Cognitive Behavioural Therapy (CBT), will not work because they require offenders to verbalise information, remember information, structure sentences, and actively listen (all skills that those who have experienced trauma struggle with). Breathing therapies and biofeedback have been conducted in prisons and prisoners seem to enjoy it and find it beneficial. Such therapies help prisoners with self-regulation (i.e. these biological therapies have been found to be effective at reducing anxieties amongst prisoners). Members of the audience also highlighted that these innovative approaches have been successful in female prisoners and in those suffering extreme pain. It was suggested that we should deal with trauma (e.g. through EMDR) before moving on to talking therapies (e.g. CBT). Ethical Practice, Therapeutic Alliance and Criminal Justice Legitimacy The fifth presentation took a legal stance, emphasising five key principles: Voice, Neutrality, Fact-Finding, Respect, and Care. It emphasised that offenders do not have any rights across the whole of the legal process and so if we do not give the offenders any choice, the Criminal Justice System should not expect things to work (e.g. a fair trial or a reduction in recidivism rates). The main discussion following this talk was about giving offenders choice. For example, currently, offenders have no choice over the treatment they complete, but instead get told that they must complete certain treatment programmes before they can be released. This was viewed as being abusive. Additionally, the issue of transferring prisoners in the middle of treatment (and away from family members) was discussed (also as being abusive). However, it was made clear
that choices needed to be balanced. For example, whilst treatment was highlighted as an area where choice could be given to offenders, sentencing was an area where choice could not be given to offenders. Overall, there needs to be less discretion and more sharing of information. Where has all the Psychology gone? The sixth presentation emphasised the crisis of psychology within correctional settings. It highlighted the tension between punishment and rehabilitation. An overview was provided to explain how psychology has got to where it is now and the reasons why psychology is being lost in practice. The Risk-Need-Responsivity (RNR) model was developed to guide policy, yet (as a result of correctional pressures) it has become an overarching guide for rehabilitation, which is far removed from best practice in psychology. Whilst the presentation emphasised that we should not completely exclude the RNR principles, it was made clear that we as Psychologists should incorporate the RNR principles within the model of evidence-based practice (EBP). EBP is essential if we are to consider the individual, ensure a high quality therapeutic alliance, and ensure a high level of psychological expertise and competency. The majority of the discussion following this presentation was to do with whether there have been any institutional changes that have contributed to this issue of losing psychology. The no touching policies were debated. For example, shaking hands can be interpreted by others as taking sides and therefore there was a debate amongst the audience about whether this was a good idea. Additionally, there are less staff in correctional settings now and staff are under a lot more pressure than they previously were. Thus, it is hard for psychologists to say no when they are asked to do something that is outside their job role (e.g. head counts or locking cells many members of the audience gave examples of when they have had to take on the role of the prison officer immediately after giving treatment). This is particularly difficult if the prison officer making the request is a friend or someone who has previously helped you out. However, it was emphasised that we as psychologists need to be assertive if we are to build a strong therapeutic relationship with the offender. After all, it is about upholding our identity as a psychologist. The issues highlighted within this discussion were; (i) the reduction in registered psychologists; (ii) the over-reliance on psychologists to assess risk (and not do treatment); and (iii) the fact that forensic psychology is an outlier in the field of psychology because there is no set route to Chartership (people can make their own way to Chartership doing bits here and there). The role of the psychologist has been narrowed down to risk assessment so that paraprofessionals then do treatment. This influences the psychologists identity and affects the perceptions held by others (including prisoners and prison guards) of the role of the psychologist. It is clear that we need to
go back to training psychologists and ensuring a breadth of experience and knowledge if we are to make sure that psychology is not lost. We cannot keep fast-tracking people to be forensic psychologists if we are to ensure competency and proficiency within the field. Dynamic Risk Factors: Explanations or Predictions? The final presentation of the day discussed the constructs of dynamic risk factors, emphasising the issue of using them to inform treatment within clinical practice. The presentation highlighted that dynamic risk factors are in fact predictive constructs (rather than explanatory concepts) that are merely a summary of many different elements. The issues with dynamic risks factors mentioned were; (1) they are composite constructs consisting of multiple elements; (2) they are a mixture of causes, mental states and psychological processes; and (3) they are partly normative. The issue of DSM-V was discussed highlighting that mental disorders cannot be classified in the way that they are in the DSM because many of them have the same underlying mechanisms. It was concluded that theory is critical to good practice and understanding and that theory should be incorporated from other disciplines. The beginning of the discussion was about how one could provide evidence that dynamic risk factors do not exist. It was highlighted that the first step would be to make a clear distinction between predictions and explanations and to draw upon other relevant literature (e.g. mechanisms of change). Dynamic risk factors can be predictors/correlates, but they cannot be explanatory because they are too general and mixed. Dynamic risk factors do not help treatment because this is not what they originated to do. We need to learn from other disciplines and apply it to our own. The next part of the discussion was about protective factors and the belief that they are unclear. It was stated that, just like dynamic risk factors, there are problems with protective factors too: (1) they are too general (meaning we have no idea about their value), (2) there is no clear definition (and definitions vary across disciplines), (3) they have no explanatory value and are only predictors, and (4) the term is too vague. The notion of protective factors was a novel area highlighted to require further investigation. The final part of this discussion were the issues with RNR in terms of the contradictions within the model itself and the fact that it is too generalised (it assumes all offenders are the same). Concluding Remarks We do well to step outside our own discipline to obtain a clearer understanding of ourselves as psychologists. We need to; (i) consider legal and ethical issues; (ii) have a clearer role identity, (iii) have clearer expectations of offenders; (iv) create an opportunity for client
choice and agency; (v) create an opportunity for treatment choice; (vi) have a multi-model approach with treatment adjuncts; and (vii) have better theory and research literature. Overall, we want to ensure best practice that is supported by evidence.