Mental Health & Treatment for Young Offenders PDF

Mental health and treatment for young offenders **Evidence based approach?** Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (centre for evidence based mental health) Evidence based practise = integrating individual clin...

Mental health and treatment for young offenders **Evidence based approach?** Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (centre for evidence based mental health) Evidence based practise = integrating individual clinical expertise with the best available external clinical evidence from systematic research - Evidence based approaches use randomised control trials etc \+ important that we consciously look to the best available research which is grounded in tested evidence: mental health is an apparent issue in offending populations \_ much of this research is focused on male samples: raises concerns about beta bias and generalisability to female offenders **Assessed needs of sentenced children** Table Description automatically generated Various risk factors that those in conflict with the CJS are facing If we know these are risk factors- how can we help? **Offending and mental health** - High prevalence psychiatric disorders in young offenders: - 15% in general population vs 40-90% in YO (Robertson et al 2020) - This range depends upon the sample (variance is to do with setting, ways mental health are assessed...) \_ precision is undermined: if these were true, underlying principles would the prevalence not be the same? (other factors: geographical areas can vary based on socio economic backgrounds: deprivation factors will impact mental health) - Indicates a relationship between offending and mental health - Psychiatric disorders are related to higher rates of recidivism (vermeiren 2003) - Significant predictor of offender status (Dixon et al 2004) - Psychosocial treatments that tackle recidivism (Multi systematic therapy) tested in RCTs (randomised control trials) - Multi systemic therapy: family therapy program aimed at children aged 10-17 at risk of being placed into care: children is placed into 'therapist' families for 3-6 months: aims to promote positive family relationship, encourage engagement in education/ training and tackle problems such as substance abuse - MSTs can be problematic: may report information about offending but not mental health; we do not have all the information about the person - Prevention of further criminal behaviour isn't the only goal of psychosocial treatments for YO - \[ Extremely expensive treatment (youth endowment fund) : large amount of resources used to only indicate about recidivism: also important that the person and their quality of life is considered \] - \[ 2018: whilst it did reduce offending by 17% it was reported that it was no more effective than usual practise (ie case worker and counselling) \] **Types of mental health disorders** Mood and anxiety disorders: - Depression - PTSD Self harm: - Co morbidity (self harm isn't a disorder in itself- symptom of different disorders) - Association with psychological distress, emotion regulation NEUROPSYCHOLOGICAL DISORDERS: Psychoticism is most commonly assumed to cause criminal behaviour: callous, unemotional traits means individuals lack remorse and guilt - Associated with frontal lobe dysfunctions PSYCHOTIC DISORDERS: such as schizophrenia are stereotypically interrelated with offending behaviours Wallace et al 2004: those with schizophrenia acquired a greater number of criminal convictions, especially in cases of violence, than those without. - Associated issues such as hallucination/ perceived threats of violence makes deviancy more likely \+ longitudinal (25 year) study: reliable that these convictions were not mediated by other confounding individual risk factors Associated risks with these disorders can be treated with medication : what is more complex is mood disorders MOOD DISORDERS **Depression** [Criteria DSM] (Major depressive disorder.) 5 or more (in past 2 weeks) of: - Depressed mood -- most of day. - Diminished interest. - Significant weight loss or gain -- unintentional. - Insomnia or hypersomnia (sleeping too much!). - Psychomotor agitation or retardation. - Fatigue or loss of energy. - Feelings of: Worthlessness; guilt. - Thinking/concentration diminished, or indecisiveness. - Recurrent thoughts of death, suicidal thoughts, suicide attempt. Symptoms MUST cause significant impairment in social, occupational or other important areas of functioning - People may function in one area but fail to in other areas (still classed as depression): only needs to affect one - E.g. may be fine functioning academically but cannot fit in social elements Exclude other types of depression: - Bipolar (mania and dep cycle) (feel more negative thoughts) - Dysthymia (persistent, chronic depressive disorder). Check symptoms aren't caused by substance abuse (is it a way of coping or the cause of the problem) Types of psychological interventions: - CBT, Family therapy, Group therapy, etc. Department of psychiatry (2024): 11.4% of offending population showed symptoms of depression (6-8% of general population) Durcan 2021: 45% of adults in prison have anxiety or depression Tran 2015: those with depression are x3 more likely to commit violent crimes Cyclical process: depression is associated with anti social behaviours but anti social behaviours lead to aggression? What are the causal factors? Causal link is uncertain but: General strain theory: depression causes criminality due to its associated negative emotions, delinquency is used to alleviate this (Agnew 1992) : e.g. low mood and seek to rectify this through material means (theft) OR: acting out model: depression causes criminality through the manifestation of its symptoms (Carlson and Cantwell 1980) - e.g. feel a sense of hopelessness and act out aggressively Question still remains: these processes can simply be reversed Failure model: early involvement in criminal behaviour can cause poor academic achievement which is what causes this hopelessness (Patterson and Stoomiller 1991) Most likely explanation is that these are interrelated factors May be that they have the same underlying neuropsychological triggers & act simultaneously: - Apter et al 1990: could be due to dysregulations within [serotonin systems] : associated with anxiety, depressed mood, impulsivity and aggression dysregulation OR: 3^rd^ factor involved: Shared risk model (wolff and ollendick 2006)- could include socio economic status, gender... ANXIETY DISORDERS **PTSD** Some of the Clinical Features (ICD-10): - Delayed or protracted response stressful event (e.g., assault, health problems). - Flashbacks. - Dreams or Nightmares. - Insomnia. - Feeling rather numb. - Avoiding anything that could reminds the person of the traumatic event. Severe/persistent impact everyday life. Department of psychiatry (2024): 9.8% of offending population showed symptoms of PTSD Influences the individual personally: e.g. group could experience the same event but only one individual has PTSD symptoms May have an eventual personality change Types of interventions: CBT? - Important to treat due to the long term impact of the trauma - Not to say that it will work on everyone: need to find other treatments **Trauma and offending** - Prospective cohort: Traumatic experiences = higher rates of criminality, arrests and violent offences (ardino 2012) ; higher rates of PTSD in prison populations - Widom 1989: those who experienced abuse before the age of 11 were more likely to be arrested \+ cohort study: longitudinal -- erroneous factors are limited and we can be sure in this link between trauma and criminal behaviour - Often undiagnosed at a crucial age; left to deal with it alone (could turn to substance abuse) Without coping mechanisms: individuals have no other options : often turn to substances \[ \_ deterministic: does it suggest that all traumatic events will lead to offending - Individuals are often resilient in nature - Bonnano (2002): following a traumatic incident of spousal loss : significant minority (46%) showed resilience: stable trajectory of healthy functioning after adversity \] Growing body of literature on the diagnosis of PTSD after committing homicide - Examined the prevalence among convicted individuals - Variation: Homicide perpetrators can develop PTSD following their offense (e.g., Harry & Resnick, 1986) suggesting that killing another person might precipitate PTSD in some individuals (e.g., Di et al., 2018; Pollock et al., 1999). Is the killing the traumatic event? Or is this triggered by a different event? -- simply a pattern -- not an explanation why SELF HARM Self-poisoning or self-injury irrespective of motivation or suicidal intent. - BUT: Definition varies: attempted suicide, parasuicide, deliberate self-harm, non-suicidal self-injury (NSSI). -- not everyone has suicidal thoughts - Co-morbid with depression and anxiety. (NOT A CONDITION ON ITS OWN!) - Associated with death by suicide: 50-60% who die by suicide have previously self-harmed = suicide prevention opportunity. - Identifying and treating those who self harm is an important part of suicide prevention - Not everyone who self harms does this in an identifiable areas -- often hard to identify -- challenging to see this - Motivations are most often internal (e.g. 'to get relief from a terrible state of mind; Knowles et al., 2011). - Psychological predictors in self-harm status in young offenders (depression, anxiety, low self-esteem) important (Knowles et al., 2011). - Typical interventions: group therapy, family therapy, etc. Important to treat these disorders: consequences are serious - Long lasting - Could lead to depression - Associated with suicide (self harm regardless of intent) & this is the strongest predictor **Why is there an increased vulnerability for mental health disorders in young offenders?** 1. Family history of mental health problems 2. Adverse life events (abandonment, abuse, neglect) 3. Social issues 4. Environmental issues 5. Peer groups 6. Unemployment 7. Education 8. Poor housing 9. Deprivation Cyclical events: mental health problems have the same risk factors as offending - Overlap Added risk for multiple psychiatric disorders, comorbid substance abuse or multiple mental health disorders (Moore et al 2021) e.g. extremely likely an individual could acquire depression following PTSD; accumulates their risk of offending Court diversion for offenders with MH problems/ learning difficulties: - Over represented in CJS - Identity, assess and refer to appropriate treatment/ support service and care/ support instigated - Divert away from custody or community sentences where appropriate (all ages) - Not a softer option but an alternate route when offending is linked to health/ disability - Individuals who go through this liaison and diversion route are less likely to re offend: it does work Impact of COVID 19 Hewson et al 2020: many jury trials and court hearings were suspended, increasing time spent on remand for many prisoners (vulnerable, left distressed thinking about their legal outcome); has led to particularly high suicide and self harm rates - Prison visits suspended : social support that mitigated against mental distress were lost & can make adjustment to prison life more difficult = maladaptive coping strategies - Many recreational activities were halted: individuals could spend up to 23 hours a day in their cells -- severe psychological consequences both within incarceration and upon release Substance abuse: Key risk factor for crime: drug related disorders were associated with the highest risk of lifetime crime and incarceration (Moore 2021) Alcohol can impede neural connections: making it hard to decide fully rational thoughts and make comprehensible decisions ISSUES TO CONSIDER Individual vs group (pros and cons): - Cost; (groups are cheaper- can target more people with one intervener) - Iatrogenic effects; (people in the group can learn bad ideas/ habits from each other) - Disclosure. (may not want to disclose emotional experience with a larger group) - Depends on what we want to focus on -- depends on if individual/ group is more beneficial - Something else to consider: Comorbidity. Evidence-based? Examples of trials/RCTs to follow. Then systematic reviews. Morgan et al 2012: results of meta analysis indicate that interventions of offenders with mental illness effectively reduced their symptoms of distress, helping offenders ability to cope with problems, with this having a positive impact on recidivism. The Correctional services advice and accreditation panel help accredit programs and maintain quality assurance Psychologists role to identify with treatment is the most beneficial to the individual and their mental health needs: **CBT for conduct disorder and depression:** Rohde et al 2004: Balanced in gender (recruited 93 participants) (not always representative: more males within the CJS) Mean age -- 15.1 years 72% had substance abuse disorder at intake Randomly assigned to: 1. Adolescent coping with depression (CBT) - Simplified homework, role plays enhanced, problem solving skills added - Monitored mood and practice skills - Increase pleasant activities, relaxation, reduce negative thoughts, target irrational beliefs, communication skills, relapse prevention and plan for if relapse occurs - Parallel group for parents: reinforce cognitive skills, communication skills, parenting and problem solving 2. A life skills/ tutoring (e.g. paying bills) (control) - Control condition is beneficial -- ethical: means that even control groups have an intervention (not fair to not give these individuals any treatment at all) Higher recovery for experiment group (39%) compared to control (19%) Also reported lower depression levels\ BUT there is no difference in conduct disorder symptoms - Perhaps important to consider the development of co-morbidity focused treatments BUT no significant differences at follow up (6m and 12m) - Is it really effective? Only a short term solution? Further developments are still necessary Conclusion: - First RCT of a psychosocial intervention with depressed-CD adolescents. - CWD-A appears to be an effective **acute** treatment for depression in multi-disordered adolescents. - BUT: Need to improve **long-term** outcomes for depressed adolescents with co-morbidity. - Interventions for co-morbid populations should focus directly **on each specific disorder**. (CD insufficient focus here.) Despite this: cognitive behavioural therapies are extremely useful for treating offender populations as they can be adapted to meet individual needs e.g. "Building better relationships" utilizes the same CBT practices but provides more focus onto reforming violent behaviors **Cognitive processing therapy for PTSD** Ahrens and Rexford (2002) Sample were incarcerated (US) -- 100% male -- mean age = 16.4 years Experimental group: Group cognitive processing therapy (more specific to PTSD) (related to CBT) for 12 sessions in total Control: waiting list (no treatment) - Is this ethical? Can argue that it is because they would give the CG the treatment if it is successful CPT for symptoms of trauma, anxiety, depression, intrusion, avoidance and numbing (self report) CPT group show a significant decrease in symptoms \_ all male sample: beta bias Biggam and Power (2002): Problem solving group therapy for self harming and other at risk YO 100% male sample; mean age = 19.3 years - Vulnerable offenders at risk of suicidal behaviour, under protection or bullied \_ all male sample: beta bias Experimental**:** Brief Group Social Problem Solving. Control: No treatment. (big ethical concerns) Effectiveness: Significant reduction in levels of anxiety, depression, and hopelessness (and social PS abilities)- still at 3-month follow up (not acute: works at follow up) **Coping skills for general psychopathology** Rohde et al. (2004) - Pilot study - Male adolescents incarcerated in YCF. - General coping skills, the "Coping Course". - CBT group intervention. - Coping course (*n*=46) vs usual care (*n*=30). A second correctional facility served as an additional control condition (*n* = 62). Effectiveness: Positive effects remained over time for: life attitudes, self-esteem, social adjustment and cognitive therapy knowledge. - change was associated with participation in coping course - only a pilot study: needs further research: effects may not be seen across a larger populational sample All address underlying emotional aspects: no guarantee that once emotional problems are resolved delinquency will desist - Moffit's dual taxonomy theory: Life course offending: this offending may be so engrained into the individuals daily life it becomes routine - Interventions should also focus on reframing offending e.g. Behaviour modification programs: reinforce desirable behaviours and punish undesirable ones through token economy schemes - May be useful alongside cognitive therapies SYSTEMATIC REVIEWS - Gold standard of evidence based practice : important to look at the quality of the studies (will indicate if there's a limitation) - Cochrane collaboration methods - Robust, scientific methodology -- data synthesis as free from bias as possible - Avoid wasting money on interventions with inflated effect sizes, therapies that do harm \_ most studies use an all male sample: research is biased , meaning the review will be biased -- skewed generalisability of findings **Effectiveness of interventions for mood & anxiety disorders, & self-harm (Townsend et al., 2010).** \(i) interventions relevant to the treatment of mood or anxiety disorders, or self-harm, in young offenders- are they effective? \(ii) mean age of ≤19 years \(iii) specific mental health assessment for suicidality, anxiety symptoms or depressive symptoms \(iv) RCTs or systematic reviews - Exhaustive search strategy - 10 studies suitable for inclusion - Despite - many prevalence studies - association with recidivism  Included studies: - 10 studies met inclusion criteria (from 708): - 7 'no diagnosis specified'; - 1 PTSD; - 1 self-harm; - 1 CD and MDD. - Range of interventions: drugs to CBT. - Mostly male identifying. - Mostly incarcerated (80%). Meta analysis: - Comorbidity - Data from all 3 trials all had: measured depression, done group based CBT with offenders who: (had MDD and CD), (were vulnerable offenders (self harm, at risk of harm) (had PTSD) Townsend et al (2010) conclusions Individual trials/ meta analysis - CBT may be useful 80% were incarcerated: is this representative? Trial quality issues -\> need higher quality RCTs! **Systematic review: adult offenders** Hunt and Perry (2015): Anxiety and depression (participants HAD to be diagnosed with anxiety/ depression -- if not they weren't included) - RCTs custodial/ community trials considering interventions aimed at treating depression or anxiety - Adult prisoners or offenders of any ethnicity, aged over 18 years of age of any sex - Studies were included if participants were diagnosed with anxiety/ depression OR if a validated questionnaire used to assess outcomes Used Cochrane collaboration methods BUT also: - Narrative analysis plus hedges G effect sizes to compare between studies: - Hedges *g* effect sizes: positive effect size = favourable outcome, a negative effect size an unfavourable outcome. - a value of zero identifies a lack of any effect. - 14 studies included: 11 psychological, 2 drug trials, 1 exercise intervention. - Psychological interventions helpful in short term. - Issues with bias (blinding, allocation etc). - Many small studies -- power? - A lot of studies have small sample sizes as there is a small amount of studies: power is important here as it allows us to assess if these have an effect or not Yoon et al 2017: Psychological therapies for prisoners - **Systematic review aim**: to review psychological therapies with mental health outcomes in prisoners and qualitatively summarize difficulties in conducting RCTs. - 37 studies identified. - Most evidence for CBT and mindfulness-based trials; - No differences were found between group and individual therapy; **❌** Effects were not sustained on follow up at 3 and 6 months. **Conclusions:** CBT and mindfulness-based therapies are modestly effective in prisoners for depression and anxiety outcomes. Most importantly a reform within the CJS is needed to better identify and acknowledge these mental health problems: University of Glasgow (2024): of the 85% of young male prisoners that had a current mental health condition, less than 3% had received a clinical assessment whilst incarcerated