notes 9-14(1).docx

Ethical Issues in the Treatment of Offenders Week 9 Introduction Ethical challenges in the forensic and correctional domains are frequently formulated in terms of specific obligations such as consent to treatment, confidentiality or a duty to warn potential victims This is to identify challenges tha...

Ethical Issues in the Treatment of Offenders Week 9 Introduction Ethical challenges in the forensic and correctional domains are frequently formulated in terms of specific obligations such as consent to treatment, confidentiality or a duty to warn potential victims This is to identify challenges that occur in the front line of practice. Why to burden practitioners with the task of deep engagement? Safety of the community and the safety of the therapist Mandatory consent for treatment as there are consequences for not following the treatment order. Operational level: it is easier to come up with guidelines for ethical combats. How do they implement treatment or assess what they do or want to do for treatment? Do we need to address conceptual ethical challenges when operational challenges exist, like guidelines that prevent certain actions? In jail, there is no autonomy, so people mainly focus on an operational level. Operational conditions should be sustainable. There are two worries with this strategy. First, it can create inflexibility because clinicians look to standards contained in the code to resolve every ethical concern they experience. There may not be enough tools in the ethical toolbox to deal with all the difficulties that occur in clinical contexts. Guidelines - may also lead to ethical blindness If no understanding of human rights level of operation guidelines. We have a capacity of discretion, and sometimes we do not follow the guideline and ethical concerns are not specific or too long to comprehend in different situation when ethical conditions are raised. Legal guidelines are more important than ethical ones. Guidelines create ethical blindness. 4 clusters of ethical problems and dilemmas in offender assessment and treatment: -Conceptual level of ethical concerns Human rights; Punishment; Moral repair; and The dual relationship problem. HUMAN AND MORAL RIGHTS LEGITIMATE ETHICAL CLAIMS (Concerns) AGAINST OTHER PEOPLE Autonomy: the capacity to be self-governing Liberty: freedom from undue interference Welfare: a person’s well-being needs Moral decision-making: moral rights + dignity Specific document, declaration of human right, charter of rights. Specific documents, access to medical care, or expression, etc., the conceptual level LEGITIMATE ETHICAL concerns at the ethical level When you are thinking of human rights in context of the specific document like human rights but being able to understand the conceptual level of specific rights are broken. There is a rule specified in advance and it is impossible to break. Human rights are minimum requirements of person’s well-being. Dignity is heavily involved in forensic settings. When the client has dignity issues , you may search the inmate. If there are concerns of safety of other inmates the dignity no concerns. Human Dignity Due to their inherent dignity, all human beings are presumed to have the same degree of moral standing when it comes to considering the social and political arrangements that directly affect their core interests and subsequent well-being. Dignity will guarantee each person access to services and goods that enable them to function as purposeful agents able to pursue their own conception of a good life without unjustified interference from others. Such rights are human rights The human rights dictates universal rights that are not the privilege. But it is challenging as you want to keep the inmate's dignity, but the process is designed for punishment. How do you justify the ethical level of practices? Autonomy, liberty, and well-being in forensic settings involve human rights but how do we detain them because it is justified. The concept of human rights is a moral (and legal) one that can fulfil this role by virtue of its ability to safeguard the provision of the social, economic, environmental and psychological goods necessary for a dignified human life. Human rights are typically cast in a universal form the social, economic, environmental and psychological goods necessary for a dignified human life Verbal assault- if it relates to breaks the human rights like hate speech. In forensic settings the legal frame works take priority. Minimum standers they are universal. According to Nickel (2007, human rights: are universal and extend to all peoples of the world; are moral norms that provide strong reasons for granting individual significant benefits; have normative force through both national and international institutions; are evident in both specific lists of rights and at the level of abstract values; and set minimum standards of living rather than depicting an ideal. Nickel looked at common features of human rights. Any citizens on the soil not carrying if they are refugees or immigrants. Minimal standarts Offenders are simultaneously rights-holders (with a right to non-interference in personal affairs unless they infringe upon the rights of others), duty-bearers (in that they are able to pursue personal goals as long as they do not infringe upon the rights of others) and rights-violators (when they infringe upon the rights of others through offending behaviour) The major implications are as follows: importance of avoiding unjustified discrimination; dealing with the inevitable pressures toward paternalism and working collaboratively wherever possible; and working with offenders to promote good or better lives, rather than adopting a simple risk reduction and management intervention model. When it comes to offenders, the focus is on the right violators. They are in forensic for a reason and they are obligated to perform certain acts. The risk assessment involves bail hearings or early release. DISCRIMINATION variables such as offenders’ ethnicity, religious beliefs, sexual orientation, occupation and gender are irrelevant, and it would be wrong to exclude such individuals from treatment purely upon the basis of their presence Overlooked factors: type and severity of the offence and level of risk. Practitioners have a responsibility to look carefully at their work with offenders and ask themselves the following two questions: 1) are offenders being subject to unnecessarily restrictive and harsh living conditions, and 2) are they being denied legitimate access to treatment resources because of what they have done and their characteristics? Overlooked factors: type and severity of the offence and level of risk For higher levels of risk like homicides is stricter compared to theft or sex offenders. However, theft is more likely to happen again. How to eliminate the risk of reoffending. Longer detention more problem are leading to recidivism. Recidivism is increasing as the release is too early bit it is also a challenge if it is too long. Treatment is reducing the recidivism rates. Statutory released 2/3 of the offence, and you can be released or graduate transition. There are differences. The recidivism in graduate transition is lower. GOOD LIVES PLANS A strength-based rehabilitation model aims to help offenders acquire the competencies and social opportunities and supports necessary to realize reflectively endorsed personal goals. These goals will be derived from core human needs, personal abilities and interests, and cultural resources, and reflect individuals’ self-conceptions. The aim is to enhance a person’s functioning (i.e. address entitlements and needs) and to reduce individuals’ risk of reoffending (i.e. meet their obligations to others). In actual practice, having a good life plan both directly and indirectly impacts one’s dynamic risk factors When you know the individuals at individual level it takes to ethical dilemmas. The two objectives are not contradictory: address human rights and their needs in comparison to meet their obligations. Static risk factors like criminal record. It is there cannot be change. Dynamic risk factors- modify the change lie internal like cooping, interpersonal, social. Punishment – the moral status of offenders An important set of ethical issues that are indirectly related to assessment and treatment concerns the moral status of offenders. Restricting liberty on the basis of what an individual may do undermines legal principles and core rights such as the presumption of innocence, finality of sentencing, the principle of proportionality, and the principle against double punishment Punishment- like sex offence serve sentence and if they want to work with vulnerable group they cannot get the clearance. Punishment is the nature of forensic settings, but then legitimate and illegitimate. It should be imposed specific legal rule, it is clear so far. A punishment is the suffering of the burden the reoffender and you try to improve them and punish. How do we justify punishment? The primary aim of punishment is to restore the moral balance. Criminal justice is designed to have proportional punishment. A common view among philosophers and theorists of law is that the criminal justice institution of punishment has at least six essential elements to it. In essence, the actions constituting legitimate punishment should: follow an offence against legal rules; be imposed and implemented by authorized individuals; be intentional (directed toward a particular end or outcome); be reprobative (express disapproval or censure); be retributive (follow an actual wrongful act) and be harmful (result in suffering, a burden or deprivation to the offender). There are at least three theories of the jus5fica5on of punishment evident in the literature: (i) retributive, (ii) consequential and (iii) restorative The retributive theory: the primary aim of punishment is to hold offenders accountable for crimes by inflicting burdens that are roughly equal in harm to those inflicted on their victims. It is a question of restoring moral balance. Consequential theorists assert that punishment is more likely than other types of crime reduction practices to produce an overall aggregate effect of crime reduction and that this is what justifies them. Utilitarianism – Human Rights Restorative: the aim of punishment is to repair or restore offenders’ relationships with victims (if possible), and the broader community. For example, Duff (2001) argues that there are three aims integral to the institution of punishment: secular repentance, reform, and reconciliation through the imposition of sanctions. Punishment is to take the crime rates down. To save many, we sacrifice few. The theories see punishment to punish the person for cheating that others will be afraid for cheating. The most advance is the restrictive justice practices the victims have an active saying what happens to offenders. Before a judge runs the verdict, the victim has impact on the verdict. The retributive theory – eye for eye principle. Consequential- Is leased advanced as it doesn't make sense. But all the justice system is focusing on that one as it did not occurred yet. The relationship between punishment theories and risk assessment is complex but significant. Ward and Salmon (2009) state that: the types of interventions logically implied by consequential theories of punishment resembles those promoted by the current treatment paradigm Dominating correctional jurisdictions throughout the western world, the Risk–Need–Responsivity model. (p. 242) The concern is that offenders are treated as a means to the ends of other people (i.e. goals, needs) and are not treated as ends in themselves (i.e. as persons of equal value and dignity). Consequential in order to prevent future offender so it will prevent future people to do this. But the victim is the one who no one cares. Ask the victim what you want money back or imprisonment? But there are no repairing the relationship with victim it is only to prevent the future people to not conduct crime or offence. Dominating correctional jurisdictions throughout the Western world, the Risk–Need–Responsivity model. (p. 242) it is successful but not perfect. The goal is not to end the society needs but crime reduction. One of the background ethical assumptions inherent in risk management approaches to offender treatment is the endorsement of a consequentialist theory of punishment. It is not that punishment is necessarily treatment but, rather, because offenders are typically undergoing or face the possibility of punishment, practitioners should confront the ethical issues that arise from this consequence. There is a danger that risk assessment and treatment can be underpinned by a consequential defense of punishment, and thus makes it easy for practitioners to justify the interests of the community more than those of the offender. Ethical dilemma focuses on consequential level of punishment, as treatment may be a part of risk reduction and ignoring well beings. For example, there may be a failure to consider the possibility of potential harm to the offenders when creating risk management treatment plans (following a risk assessment) through the imposition of unnecessarily severe restrictions, and depriving them of the opportunity to make important life decisions for themselves. In addition, the weakening of core relationships and social connection to other people may cause significant damage to an offender, frustrating, as it does, basic human needs for connectedness and intimacy. Moral repair The key ethical concern from a moral repair viewpoint is to determine to what degree, if any, an offender’s own past experience of victimization ought to be taken into account in the treatment process Interests of offenders, victims, community Rights- as they are like victim Punishment-as they committed the offence Dual relationships Moral repair is ‘restoring or creating trust and hope in a shared sense of value and responsibility’ (Walker, 2006). Ethical dilemma increases when the offender has childhood abuse. The sex offender was abused as a child and has trauma, and they are both victim and offender. Rights- victim Punishment- but obligated to serve the sentences Dual relationships Moral repair Six core tasks encompassed by moral repair (Walker, 2006): Placing responsibility on the offender; Acknowledging and addressing the harm suffered by the victim; Asserting the authority of the norms violated by the offender and the community’s commitment to them; Restoring or creating trust among the victims in the relevant norms and the practices that express them; Creating hope that the norms and the individuals responsible for supporting them are worthy of trust; and Re-establishing or establishing adequate moral relationships between victims, wrongdoers and the community. Focus on trauma they experience, creating hope Moral repair is must be accomplished Moral repair Practitioners who are engaged in a risk informed assessment and subsequent treatment of offenders who have been victims of violence in the past might overlook their entitlements to some type of restoration. Human Rights = offenders entitlements to services + their obligations to others Normative position can achieve the aim of developing an integrated approach Offender as victim and wrongdoer Dual Relationship Problem Two sets of ethical norms Community protection and justice VERSUS individual well-being and autonomy Justification of forensic work may be ethically challenging for treatment providers Value pluralism occurs when a number of distinct ethical codes (or if you prefer, sets of norms) exist within a society or community, none of which can be established as ethically superior by a rational, impartial observer. Conflicts regarding value pluralism is challenging and calls for dialogues that are open and intent on incorporating varying viewpoints. Value pluralism – for example the wellbeing of community vs of individual and you do not know which one is more important. Conflicts- involve open dialogs including viewpoints. Dual Relationship Problem The ethical risks arising from the dual relationship problem for practioners are that they will: (a) fail to acknowledge there is a problem, (i.e., ethical blindness) or (b) dismiss its significance Moral acquaintances have some overlapping norms rela5ng to the problem in ques5on; they are not total strangers and can arrive at similar decisions about how best to act (Hanson, 2009). For example, one forensic practitioner might justify the implementation of a treatment with an offender because of the anticipated beneficial effect on reoffending rates while another forensic practitioner might argue that the offender ought to receive treatment because of pressing psychological needs. For example implement treatments effectively because their concern involve public safety, but other therapist focus on offender's wellbeing. These are different moral values. Conclusion A number of general ethical issues that are directly or indirectly associated with offender assessment and treatment: human rights, punishment, moral repair and the dual rela5onship problem. Is the aim of correctional treatment to reform individuals or to restore the ruptures within community rela5onships (i.e. between vic5ms, offenders and the members of the community)? Again and again, it comes down to looking for a way to balance competing values and their associated norms. Values are different as some values punishment or ethical Conclusion One of the advantages of adopting a human rights framework when working with offenders is that practitioners learn to automatically think about the overall balance of interests at stake in specific situations, and to take note of each person’s obligations and entitlements. Codes of ethics and their constituent principles and standards are valuable resources, but that is all they are. The advantage of human rights is that it is easier to talk on conceptual level and not on individual level. They are human beings and members of society. Conclusion Ethical standards are valuable resources, but that is all they are. Practitioners need to develop ethical sensitivity and responsiveness so that they are able to identify ethical hotspots as they are forming. It is important to work on the development of professional virtues such as flexibility, compassion, humility, respect, empathy, problem-solving and mediation skills, and the ability to tolerate uncertainty and intense emotional climates. Ethical guidelines are important and valuable resources, but how you use them is up to you. Humility is important- as person priority the level of treatment is very elementary. Evidence base treatment- is found more effecting on comparison of placebo and no treatment. Mentalization Based Treatment (MBT) Week 10 Introduction Mentalization based treatment (MBT) is originally developed to treat Borderline Personality Disorder (BPD). MBT has also been applied to other disorders The capacity to mentalise is an essential human ability which can be impaired in a wide range of conditions BPD and ASPD are overrepresented in For. Set. Biological and ecological are both factors. A borderline personality disorder is a very difficult disorder. And it takes months, if not years, to address it. MBT is applied for different areas outside of forensic settings. Mentalization is very important. Mentalization=imagination It can be distorted in early childhood attachment 70% of inmates are BPD or ASPD People are more likely to commit crimes when they have this disorder. Mentalization, according to behaviourists, has an impact on behaviour and subjective reality, the person’s interpretation of events. Mentalization action of ourselves or others' needs or feelings, why they are doing this = mentalization, can be capacity of thinking about yourself and others as well. With capacity, it shapes the perception of relationships. Secure attachment- capacity may increase mentalization, emotional bonds and interactions. BPD biological predisposition and on top interpersonal relationship with caregivers invalidated environment with cognitive questions like Do not be angry; you should not be crying now. What is mentalizing? Cognition influences our behaviour. Mentalisation is ‘the process by which we interpret the actions of ourselves and others in terms of those underlying intentional states such as personal desires, needs, feelings, beliefs and reasons’ mentalisation is the capacity to think about one’s own mental state and the mental states of others Shapes our understanding of others and underpins our interpersonal relationships. The capacity to mentalise develops within early secure attachment relationships Attachement Theory: A body of knowledge concerned with the emotional bonds and affective interactions between human beings and the psychological difficulties and psychopathological consequences which arise when these processes go awry. The emotional availability of the caretaker is also important. If the child is accurately represented as a thinking and feeling individual in the mind of the attachment figure, then the child’s capacity to mentalize will develop smoothly; securely attached children outperform insecure children on mentalizing tasks. However, the development of healthy mentalizing is thought to depend on more than just a secure attachment relationship with caregivers. A secure relationship with the caregiver should be emotionally available and experienced. Mirroring Mirroring must be accurate (contingent) and marked (exaggerated) or slightly distorted as this allows the infant to differentiate the infant’s emotional experience from that of the caregiver. The absence of marked, contingent mirroring has been linked to the development of disorganised attachment The absence of marked, contingent mirroring has been linked to the development of disorganized attachment, the chances that disorganized attachment will be reinforced. Relationship with parent created the BPD and ASPD Developmental threats to mentalization Trauma, maltreatment and exposure to violence, disorganise the attachment system, disrupt the development of mentalisation and compromise affect regulation Emotional regulation is one of the significant areas of research in forensic settings. Inmates have issues with emotional regulation. What happens when mentalisation falters the breakdown or suppression of mentalisation leads to the emergence of prementalistic modes of thinking Mentalisation is prone to fail in the context of high emotional arousal, often in the context of attachment relationships Bateman and Fonagy (2006) describe three modes of subjective experience that predate mentalisation. Psychic equivalence Teleological mode Pretend mode Emotions can be positive or negative in low arousal and high-arousal They created body arousal BPD can be stuck in low or high arousal when they cannot function properly. Research shows 3 subcategories of mentalization Psychic equivalence Teleological mode Pretend mode In psychic equivalence the individual’s inner reality is believed to be the same as outer reality. In other words, what the person thinks is experienced as real or true. Related to a strong and inappropriate conviction of being right For example, ‘if I think you hate me then you do hate me’. Some refer to this state as concrete thinking The person believes that it is a perfect reflection of reality. The person has real and true experiences, no questions and no research. The person believes that gest how other people think and feel. Strong and maladaptive conviction of being right. In teleological mode, the only way the individual can work out the intentions of the other is by their physical behaviour and observable actions as the individual cannot fathom the mind of the other. For example, ‘if you really cared for me you would have held my hand; let me phone you; given me a birthday card.’ For the patient, the professional’s motivation to help has to be demonstrated by increasingly heroic acts. If the therapist accepts these teleological invitations there is a risk of boundary transgressions A person can only understand inner feelings by looking at the physical behaviour or action They cannot think of the mental processes as they do not understand the victim is suffering or experiencing sorrow. The perceiver cannot understand if you are busy or have other tasks or things. Does not see inner states of the person. In pretend mode, ideas form no bridge between inner and outer reality and emotional experience can become dissociated from thoughts. This often leads to feelings of emptiness. In this state of mind, patients can talk about their experiences; however, the narrative is cut off from any meaningful link to his or her internal experience and, at the extreme, may have a dissociative quality; it can often sound inauthentic to the listener – that the patient is ‘talking the talk’. Lack of capacity of mentalization. The 3 subgroups show this. The last one leads to the feelings of emptiness. They do not have link between emotional and mental experience. Mentalising is a multidimensional construct and that patients may have different degrees of mentalising ability on each dimension. Automatic-controlled Internally vs extenally focused Self vs other oriented Cognitive vs affective In good mentalising each dimension is best conceptualised as a balanced seesaw; for example, with affective mentalising being in balance with cognitive mentalising. Dimensions go into 4 categories or dimensions of mentalization The imbalance creates maladaptive functions of mentalization. Automatic (implicit) – controlled (explicit) mentalising; most of the time mentalising is implicit and happens automatically out of conscious awareness. Explicit mentalisation kicks in when we get an unexpected response or cannot fathom another’s behaviour. Explicit mentalisation requires reflection and effort, and needs to connect meaningfully with the patient’s emotional experience. Implicit-automatic Explicit- expected response and you pay attention and try to understand the controlled what is going on. It requires reflection. Self-orientated – other-orientated mentalisation; refers to impairments and imbalances in the capacity to reflect about the self and others. Imbalance in this dimension can lead to excessive rumination and inferences about the mental states of others or the self which far exceed observable behaviour and is described as hypermentalising. Self excessively focus it may dissolve into rumination. Cognitive – affective mentalising; refers to the balance and integration of cognitive aspects of mentalising such as reasoning and perspective taking with other more affectively driven components related to empathy. For example, patients with ASPD can often describe highly emotionally charged interpersonal interactions in a ‘matter of fact’ way that is cut off from the appropriate affect – ‘well I stabbed him because I wanted to try out my new knife’ – real statement form an offender with ASPD whereas individuals with BPD are often overwhelmed with affect indicating that the cognitive dimension of their mentalising has failed. The balance between reason and perspective-taking. It is important for empathy. CBT is used where direct challenge of the content. BPD: Borderline Personality Disorder Bateman and Fonagy see the failure of mentalisation, within an attachment context, as the core pathology of BPD. Childhood abuse and neglect are over-represented in the early lives of these individuals as are levels of insecure attachment. These factors threaten the child’s developing capacity to mentalise and later disrupt mentalisation in adult attachment relationships. People with BPD may be able to mentalise reasonably except in the context of attachment relationships. The model proposes (Luyten & Fonagy, 2014) that the attachment systems of people with BPD are hyper-activated, as a result of interpersonal experiences of childhood trauma. As a consequence, they actively need to be in relationships, but, in this context, minor experiences of loss or small emotional upsets may cause an intense activation of the system CBT is mostly used. BPD has a problem with emotional regulation. Dysfunction in emotional regulation is when you cannot control your anger. Some psychopaths can be in corporate roles and successful in their personal lives. Psychological flexibility is very important. BPD: Borderline Personality Disorder. The rigid views that characterize psychic equivalence make the person with BPD vulnerable to affect dysregulation and impulsive acts. From a forensic perspective, impulsive acts of violence in BPD, particularly interpersonal violence, can occur when psychic equivalence and teleological states of mind predominate and They are often precipitated by the individual feeling humiliated, which induces overwhelming shame. Psychological flexibility is important to establishing cognitive regulation. Psychological rigidity Mentalization-based treatment in forensic settings in BPD, particularly in domestic violence, is highly likely mentalization that people have psychological rigidity. Reactive violence gives high body arousal. Shame or humiliation produces interpersonal violence. Normally people with normal engagement the people slow down When people with emotional dysregulation, they become more overreactive. Shame usually makes you not move. You just do not engage in behaving anymore. But in BPD, it makes you overreactive; the anger moves me. The angrier is increased, and they always get alert. Mentalization matters when it comes in idea about conflict as it makes important for direction of conflict escalation or de-escalation. The third way therapies Focus is to understand the function of the behavior like cutting themselves. It has a function why they cut themselves if it is attention seeking behavioral. ASPD Within MBT, ASPD is conceptualised as arising from an interaction between a genetically determined predisposition and an adverse early environment which results in abnormal personality development; particularly in the areas of affect regulation, impulse control, violent acting out and the ability to mentalise. ASPD Insecure attachment, particularly dismissing attachment, is over-represented in forensic populations many of whom have ASPD and poor mentalisation. People with ASPD can explicitly mentalise but they fail to connect this with emotional experience in the self or other. For example, a patient may be able to work out that his victim would have felt terrified of him but fails to feel any sorrow for the suffering of the other. In individuals with ASPD, prementalistic modes of thinking frequently predominate. Explicitly mentalize but fail to connect with emotional experience in themselves or others. Perspective taking is not compromised but emotional aspect is compromised The origins of MBT and its relevance to forensic settings MBT is a modified psychodynamic treatment originally designed for the treatment of BPD in non-forensic populations RCT showed significant improvements in mood states and interpersonal functioning of the participants The benefits, relevant to treatment as usual, were large with the Number Needed to Treat (NNT) of around 2 the treatment of ASPD remains shrouded by therapeutic pessimism and the evidence base for effective treatments is far less robust RCT is a randomized trials How many patients need to be treated? the number is high, and it is a very effective treatment when it comes to BPD, but ASPD is not successful. MBT is 3-d waves It is not to treat symptoms, but to ensure relationships are modified and teach mentalization skills. Deficits can vary, and interventions are taken accordingly. The aims and focus of treatment MBT is a relational psychotherapy where the primary aim is to create a therapeutic process in which mental states of self and others become the focus of concern. MBT is tailored for patients where specific deficits in mentalisation are core to the disorder. The overarching aims of MBT In generic settings, where MBT was first developed, treatment was aimed at improving psychiatric symptomatology such as mood states and interpersonal functioning, decreasing self-harming and suicidal behaviours and helping individuals’ process trauma. When working with offenders and forensic patients MBT has the additional aim of reducing the risk of aggressive and violent acts within the forensic setting and decreasing the risk of particular offences; those that involve the impulsive, interpersonal violence that emerges when mentalisation fails Each treatment has an initial objective: Reduce aggressive violence and reduce recidivism. with is in forensic settings, and when they are released, too. Challenge: people are mandated to participate in treatment. Validated experiences Group treatment to lean skill training. Why in groups the skill training? Cost is important. BPD, the concern is invalidating investment, and when you have a group but other participants can validate their experiences, that is not only me and other people who have the same problem. Key clinical concepts The therapist needs to be alert to the markers of distruptions in mentalisation, such as: expressions of certainty; sweeping generalisations; a focus on external events; blaming; and denial of involvement in a problem. Key to the inquisitive stance is a focus on the patient’s mind rather than on the individual’s behaviour (self-harm; drinking; violence) and encouraging the patient to do the same. Rigid thinking, or denial, is a signal of pre-mentalization perceptions. Why does having the function of certain behaviours come with intervention? The relationship between the psychotherapist and the content is not important. What is the function of the emotion or behaviour so they can get rid of it? It is a function of their emotions. We try to understand the function of the behaviour. Another crucial clinical concept is that interventions need to relate to current mental reality that the patient can recall; the model de-emphasises unconscious concerns. The model also cautions the therapist against making historical causal interpretations that link past and present as these often close down mentalising. The MBT model describes a clinical pathway aimed at strengthening the patient’s capacity to mentalise. MBT it increase the patient capacity to mentalize MBT in forensic settings Adaptations to the original MBT treatment model, designed for BPD, can be considered to fall into three areas: those adaptations needed to tailor MBT to the treatment of ASPD, the development of mentalisation based art therapy (MBAT) and those adaptations needed to deliver MBT-BPD, MBT-ASPD or MBAT within forensic settings. MBT should be an adaptive method to treat the ASPD as it is not effective as it is effective with BPD but not ASPD MBT art therapy In a forensic setting, ASPD is higher in male BPD is higher with female offenders The development of MBAT MBAT developed in prison settings as this is where BPD women, who have the most impaired capacity to mentalise, can find themselves; these women rely heavily on automatic/implicit mentalising. Art therapy facilitates explicit, reflective mentalising in a way that can be tolerable for highly disturbed minds The art each patient produces allows the group and patient to reflect on aspects of their mind in the presence of other minds. Woman rely on automatic mentalization and where target intervention appear Delivery adaptations MBT-ASPD in forensic community settings combines weekly group therapy with monthly individual sessions, whilst the original MBT programme for BPD had weekly individual sessions. Individuals are often referred because of behaviours such as self-harm or aggression and a good clinical assessment will clarify the underlying psychological problems and whether MBT is likely to be helpful It takes months of treatment when it comes to personality disorders. Even if the weekly session has group sessions and monthly individual as BPD and ASPD are prompted to suicide or self-harm Those individuals whose mentalising is highly rigid with respect to the self and other, such as in highly narcissistic and paranoid personality disorders, tend to fare poorly with MBT. the initial studies of ASPD excluded patients with scores greater than 30 on the Revised Psychopathy Checklist All people who are diagnosed as psychopaths they can also be diagnosed with ASPD but not all ASPD are having psychopathy Key directions for future research MBT is in its developmental infancy in forensic settings; however, its robust theoretical framework and the translation of this into an evidenced-based treatment for some PDs is a source of optimism. RQ: Do different components of MBT have differing therapeutic potencies? What is the optimum treaetment time that is needed? MBT is in infancy, and it appears to be in some subpopulations of some personal disorders.so has some hope that this treatment may be a successful treatment. Longer is not better, but for BPD, it is up to 2 years of treatment. Conclusion Mentalisation is not only at the core of a range of treatment approaches but a mentalisation based approach can provide staff with additional skills to engage offenders, and is already being used in some forensic institutions and services. Embedding a mentalisation based approach offers the possibility of supporting patients, teams, systems and networks and, as such, can help shape the social environment in forensic services and institutions. Week 11 Personal Construct Psychotherapy Introduction Personal construct psychotherapy (PCT) focuses on how people construe PCT intentionally uses abstract language People act based on how they make sense of the world Others actions may be difficult to make sense How people interpret their social interaction (abstract language that is difficult to understand) The point of PCT is to re-behave (how to interpret the world and actions) that determines our behaviour Professionals can bring to bear our own perspective of concepts, theories and procedures, Some clients embrace our efforts On the other hand, the sense-making and views of the world of some forensic clients is notoriously NONCOMPLIENT The clients may be non compliant Many practitioners are skilled in empathy and motivational work. PCT is concerned with exploring personal perspectives and fostering renewed development in the client Construe = interpret Professionals who deliver the treatment are skilled in empathy. The requirement of rapport building, emotional bond. PCT- it is to explore personal perspectives, how the person came to believe what makes sense to him in this world. How do they interpret the intentions of others? Biological predisposition like people who have emotional disregulations. Some central premises Anticipations come from awareness of recurring patterns; Those that lead to anticipated outcomes are likely to be used again While they often need to be revised Behaviour tests a hypothesis with discrepant results leading to the modification of underlying theories. We test theories on an individual level. if the person's private emotions are invalidated, their anticipation comes from awareness of internal patterns. When we experience a desired outcome or avoid an in-desire outcome, we start to use the same behaviour over and over. You engage in behaviour, you test it, and you start to modify the underlying therapies. In some behaviors, like aggressive verbal aggression, you can create a pattern to escape some situations. When the dog is aggressive with, are you afraid of all dogs or specific dogs? Some people have very many details to make sense of certain things and patterns. Constantly checking hypothesis. PCT does not care if it is conscious or unconscious testing of a hypothesis, but it tells you if it is correct. Interpretation is based on biological predisposition to learning history and at the time of the present mood. We notice the outcomes of our desirable or undesirable (implicit bias) Organization is achieved efficiently by subsystems of connected discriminations at different levels of generality Some people have developed very detailed and organized ways of making sense in some areas of their lives but not in others. Such systems are individual affairs. Learning history, past experiences, and biological, so the interpretation comes for social interaction. The wrong mentality ( she said no, but it means yes) PCT( not third-wave therapy but has a connection to it), just like DBT, the elements of interpretation of how the person creates the meaning for interactions. Problems in living: Setting or time period variation Variations on these processes can contribute to problems This is like bilogical evolution may have many advantages but can also result in vulnerability Pscyhoglogical systems: What is adaptive in one setting or time period may not be in another. One biological change can make adaptability in one setting but disadvantages in another. Parenting style ( democratic, authoritative, flexible) all depends on the setting of the social environment to survive. It makes you adaptive in one setting but not in another. Context variation: Military service vs civilian life Some events evoke anxiety while others psychologically threatening Change involves living with unpredictability and the setting aside of what has been invested in. Change is most difficult for those who have evolved narrow and inflexible systems for anticipating Context is the interpretation of certain social interactions. In this framework, when you live in unpredictable environment settings. Specifically, it is difficult for people with narrow and inflexible systems to anticipate, similar to people with psychological inflexibility. With the change of different environments when they are forced to comply with their anticipation. In modern life, changes in unpredictable life changes are inevitable. EMDR: HYPOTHESİZED MECHANISM People how try to force others to comply with their anticipations are particularly troublesome If such dissent is inferred as intentional and malicious Some people maintain predictability and control in life by associating only with like-minded people or by intoxication or fantasy A PCT perspective on helping people with problems in living To help clients find new ways of navigating their lives, PCT has techniques for helping clients explore their present ways. Self-characterization Repertory grid There is no clear line between assessment and intervention The therapist’s role edges into something akin to a research supervisor PCT first assists the clients in identifying the problem in forensic settings. How the world doesn’t make sense to them. One technique is self-characterization, and another is structure. The clients must identify the elements in their lives and interpretation of the elements. There is no clear line between intervention and assessment. Adaptations for forensic settings Constructive alternativism: all of our present interpretations of the universe are subject to revision or replacement’ It is different than mentalistic view of human functioning PCT locates mind in a wider system that incorporate both person and environment, including other people The therapist's role is the research supervisor. Ti finds that the behaviour and consequences facilitate making sense in different settings. Constructive alternativism: the way we interpret the world is it fixable or can change? All our interpretations can be modified or changed, but it is different from the mentalistic view of human functioning. Mentalistic view you change the cognitive absolute interpretation and changes your behaviour. The focus is not on a mentalistic perspective because the behaviour does not function well in society based on learning history and experience, and let’s identify how you build it and how to change it. PCT argues to locate the mind in a wider system. Limited construing at the organizational level may contribute to outcomes such as the ‘lowered self-respect and lowered aspirations’ found in a PCT-based study of a detention center for young offenders. In both penal environments and community services the dominant official agenda has come to focus on assessment and reduction of ‘risk’. PCT has clients adapt their interpretation of social interaction in a way that is functional for the general public. You are trying to create higher self-esteem and high levels of aspirations. Young offenders have low self-esteem and high levels of aspiration. Interaction with sex offenders and the sexual assault of their experience of their life experience. The early sex abuse it may be a high risk to become sex offender. PCT Technique: Laddering A noteworthy way in which case formulation regarding offences can be enhanced is by employing a version of the PCT technique of ‘laddering’ This form of inquiry enables formulation of hypotheses concerning meanings that were invoked or challenged Laddering starts from concrete to abstract emotions of their life. Assisting the client to formulate the hypothesis relating to the meanings. If the child is a victim or offender. Other adaptations of PCT techniques for forensic clients include the incorporation of elements in repertory grids Grids (and/or laddering) can also be used to explore what is at stake for a person in situations relevant to, for example, anger or difficulties in social interaction. An individual’s sense of connectedness to others Software that creates factor analyses exploring important elements like father, caregiver, victim, or perpetrator and different elements, you let the client identify the elements and have them run the important elements to create factor analysis. How some offenders can stop offending and some not. Need for desistance One technique that embodies some of these aspects is the WOMBAT This stands for ‘Way Of Me Behaving And Thinking’ PCT is used to understand how the context or interpretation facilitates their thinking and behaving. Client characteristics (indicators/contra-indicators) PCT has a wide ‘range of convenience’. PCT does entail a degree of ability in verbalizing and reflection Where grid methods are used, cognitive load should be reduced Caution is needed with clients who have very ‘tight’ construing related to themselves and other people In every treatment, some clients’ feet are very good, and some do not. PCT offers a wide range of conveniences. It is similar to third-wave therapy. Therapists must be careful with clients who have black-white social interactions. Studies of the evidence in forensic settings Studies of offenders have elaborated our awareness of possible processes and issues, Behavioral change is likely to endure only when new ways of sense-making become integrated within the sense of self Research into outcomes of PCT-based psychotherapy comes largely from single case studies or small groups Watson and Winter (2005) indicated that experiences in cognitive therapy and a PCT-based approach could be differentiated and that the latter was at least as effective as the former. Avoidance is not enduring. Only when they change a certain person but not violently, will it help to change. CBT and PCT difference: you provide general tools for CBT, whereas in PCT, you have an individual interpretation of understanding of self, and it is an individual and single case design. CBT is mostly used, but the findings suggest that PCT is not CBT, but it is also the least effective compared to CBT. Case study James was a 30-year-old man serving an eight-year sentence for a violent assault and rape of a woman. Repeated trauma in his childhood Feared to be killed as a child History of substance abuse His parents did not believe- in the future of an invalidated environment. It can be a traumatic experience. Intoxicated women were the victims. No is a yes for him Repertory grid assessment Tailored to focus on his construal of his offending. The therapist facilitated the identification of elements. Mom did not believe as he was a victim of a babysitter. He wanted to be like Dad, but he was an abuser. Constructs were elicited by comparing elements Comparing the elements to understand the self. He perceived himself as lazy, but by making sense e of the world, he wanted to be the provider. He interpreted sexual offence as very functional in sexual relationships, but the victim was inhibited and making sense of the world as how he was a victim because he was open-minded and liberal. Reconstruction of his identity. Self of self and others. Once the elements are identified and obtained 1-7 scale Analysis The next step was to obtain ratings for each of the elements on a scale of 1 to 7 Using each bipolar construct to anchor the scale. This matrix was then analyzed using principal component analysis (PCA) It created different components where 4 different dimensions. He wants to be like Dad. But he is victimized and not believed. Exploration included the following areas How he construed sexual ‘openness’ Links between his own victim experiences and his offending Identifying where he wanted to be in the future He believes he is sexually open-minded, but the victim is inhibited. The second is the link, and he made the connection between him being a victim and his victims. He could empathize with his victims, and the third is where he wants to be in future. Final Remarks At its inception PCT was ahead of its time Clinical applications center upon understanding Where clients are coming from What they face How they can be helped in finding new ways of navigating and engaging the word. Final remark: The perspective of where the clients come from and how they face the interpretation of the world. Based on single case studies, it is effective in forensic settings. What is the difference between mentalization and PCT? The efficiency CBT is the best. But the PCT is individual and it take other resources. CBT is done by correctional. But in PCT, you need to use software for dimension and needs education to be provided. Week12 Schema Therapy Introduction Schema Therapy is a medium- to long-term form of psychotherapy primarily for patients with personality disorders Often delivered in an individual format but can also be administered in groups or mixed format. Schema Therapy (ST; Young, Klosko, & Weishaar, 2003) combines different elements from various therapeutic approaches. Certain techniques are derived from cognitive-behavioural traditions, Other techniques and concepts originate from Gestalt and experiential therapies. Specifically, cluster B personality disorders 3 years- first years assessment, second …. Borrowed from CBT and other Main Concepts: Early maladaptive schemas: Cognitive structures that contain self-defeating themes about oneself, others and the environment. Similar to the concept of Beck’s cognitive model but ST places more emphasis on the origins of schemas According to ST, schemas originate from universal emotional needs, identification with significant others, experiences during childhood and adolescence, and early temperament. The main concept of early maladaptive schemas Childhood trauma leads to maladaptive Assumption biological predisposition Moreover, children imitate and internalise significant others; Schema Therapy distinguishes five universal emotional needs: the need for secure attachment; autonomy and independence; limits and boundaries; validation of needs and feelings; and spontaneity and play The children construct social identity by imitating loved ones. ST universal emotional need for every child DBT exposure to the environment creates emotional vulnerability. When these needs are profoundly unmet for example in situations of trauma, abuse or neglect – or when there is a lack of balance between needs (i.e. too much/little of a good thing), a distorted blueprint about oneself and the world is likely to develop. These patterns begin early in life and develop throughout the course of a lifetime. Earlier emotional needs the attachment- too much or too little can be a bad thing Young and colleagues (2003) defined 18 schemas that cover five domains that are consistent with the emotional needs Early maladaptive schemas Abandonment/ irritability/mistrust/ abuse/ emotional deprivation/ defectiveness/ shame/ social isolation/ alienation Domains Disconnection and rejection Universal Needs Attachment and security Early maladaptive schemas Dependence/incompetence/ vulnerability to harm or illness/ enmeshment/undeveloped self/ failure Domains Impaired autonomy and performance Universal Needs Autonomy and dependence Early maladaptive schemas Entitlement/grandiosity/insufficient self-control Domains Impaired limits Universal Needs Limits and boundaries Early maladaptive schemas Subjugation/ self-sacrifice/approval or recognition seeking Domains Other directedness Universal Needs Validation of needs and feelings Early maladaptive schemas Negativity/pessimism/emotional inhibition/unrelating standards/hypercriticalness/punitiveness Domains Other vigilance and inhibition Universal Needs Spontaneity and play 5 domains that are consistent with emotional needs Connections and rejection related to maladaptive schemas. If we accept the assumption as true, how can we fix this? The therapist should try to identify the unmet needs and have the client identify them so that the maladaptive schemas can be replaced with adaptive schemas. Second: coping strategies when a person is in forensic settings activating maladaptive schemas the coping styles of 3 general dysfunctional coping strategies for adaptation problems Main Concepts: Cooping Styles: Typically, the activation of maladaptive schemas elicits strong and painful emotions, such as fear, anger or shame. ST defines three broad, usually dysfunctional, coping styles that are often used to deal with these emotions: passively giving in to a schema (i.e. schema surrender); avoiding situations that trigger a certain schema (i.e. schema avoidance); and doing the opposite of a schema (i.e. schema overcompensation). ST handles 3 concepts of schemas Main Concepts: Schema modes The combination of particular maladaptive schemas and dysfunctional coping styles manifest themselves in certain emotional states which are labelled as schema modes A schema mode is a state-like concept that represents someone’s emotions as well as cognitions and behaviour at a particular time. Young and colleagues (2003) originally distinguished 11 schema modes; over time, others have proposed and reported evidence for additional modes In forensic ST modifies crimogenitic needs.ST, It is only for people with personality disorder. What triggers the crimonogenetic act. The healthy domain refers to expression of healthy, balanced self-reflection, and feelings of pleasure and joy. Typically, four dysfunctional schema mode domains are distinguished: child modes: feeling, thinking & acting in a child-like manner; avoidant coping modes: attempt to protect oneself from pain by means of avoiding; parent modes: relate to self-directed criticism or demands that reflect internalised parent behaviour and emotional stance; overcompensatory modes: refer to extreme attempts to overcompensate painful feelings (i.e. child modes). In forensic settings, there are 11 schemas modes but 4 dysfunctional. Modes fluctuate from time to time; the extent to which someone has natural control over these fluctuations may also change. Healthy individuals are considered able to understand and regulate their emotional swings and are less prone to strong fluctuations, while individuals who suffer from psychopathology are less cognisant of when one mode changes into another. Moreover, not all schema modes are relevant for each individual. Challenges Often, people with personality disorders cannot identify their feelings. Schema Therapy is particularly developed for individuals with personality disorder (PD). According to ST theory, each personality disorder is characterised by a different combination of schema modes. Borderline Personality Disorder (BPD), for example, is characterised by the vulnerable child mode (feelings of abandonment), angry child mode (uncontrolled anger), punitive parent mode (self-mutilation) and detached protector mode (emotional detachment) ST- specifically only for Personal disorders. According to conceptualization it is characterized with schema mode. Assessment phase Schema Therapy assumes that changes in dysfunctional modes will lead to change in personality disorder symptoms. (takes a year) The goal is to reduce early maladaptive schemas, process painful emotions and moderate or eliminate dysfunctional schema modes in order to help the patient meet their basic emotional needs in a more healthy and successful manner. First phase is assessment- identification of dysfunctional modes not early maladaptive schemas. This stage last for a year. Every individual is unique. In the initial assessment phase, the therapist works together with the patient to assess the patient’s early maladaptive schemas and dysfunctional coping responses (or in more severe PD patients, their schema modes), exploring the origins and links to the patient’s presenting problems, such as addiction and criminal/aggressive behaviour. First phase: medical records and assess the patient schema modes are related to criminogenic needs. You try to change who the person is. Risk analysis of the risk of recidivism shows that 5 years and it is the recidivism is low In forensic ST, the focus is on the patient’s schema modes, because the mode concept facilitates working with extreme and fluctuating modes such as those seen in these patients Various assessment sources are used: questionnaires Obervations of emotiaonal states (in and outside of session) Patient’s clinical notes The questionnaires are used for assessment and clinical and medical notes. The therapist explains the mode concept to the patient, and teaches them to use the ‘language’ of schema modes to describe their own emotional states. For example, the therapist might explore the origins and functions of the patient’s Detached Protector mode, asking the patient to come up with a name that they can use to label this ‘side’ of them (e.g. ‘the Wall’), thus facilitating communication. The mode concept and language is emotionally neutral and non-judgmental, making it possible for therapist and patient to discuss the patient’s problematic behaviours constructively. The language should come from the patient and not be judgmental. No medical treatment and communication is the main treatment. In less complex patients, the assessment process takes five to ten sessions. In more severe patients, the therapist may need to immediately address motivational issues and other challenging patient behaviours, which means that the assessment process may require more time to complete. In the general population, there are 5- 10 sessions, but forensic therapy requires more time to complete. The entire therapy takes about 3 years. This is an approximate duration, and in some cases, it takes 5 years. The entire therapy in closed forensic settings usually requires three years, encompassing an attachment phase (roughly first year), a mode reprocessing phase (roughly second year) and a reintegration phase (roughly third year). Therapy is usually delivered twice per week in the first two years, with diminishing frequency in the third year until termination. The therapist often met twice a week or sometimes once a week, and usually, in the third year, it reached the termination. Limited reparenting and empathic confrontation The cornerstone of Schema Therapy practice is the therapeutic relationship that is defined as limited reparenting. It parallels a healthy parenting style. Limited reparenting needs to be balanced by empathic confrontation This involves providing warmth, nurturance, playfulness, but Also discipline and confrontation or setting appropriate limits in a firm and consequential but not overly punitive manner. The therapist is trying to replace early childhood experiences and confrontations with the client to repair all schemas. Healthy parenting involves a warm and nurturing style but also discipline. Cognitive, behavioural and experiential interventions Schema Therapy has a large ‘tool kit’, combining techniques from cognitive, behavioural, psychodynamic, object relations and humanistic/experiential schools of therapy. Experiential techniques are supplemented with cognitive and behavioural techniques. ST uses techniques from many therapies. They keep cognitive diaries of how they feel and what is going on in their minds, feelings, and thoughts. Role techniques and chair switch Reinforcement and reward so the client will connect the dots. ST uses the same techniques, but it does not modify future behaviour. The objective is only to modify the modes=early schemas. Schema mode work In schema mode work, the therapist helps the patient to recognise, and change, their maladaptive schema modes, And to build up a strong healthy adult mode that can view situations in a balanced way and make healthy choices Schema mode work is most suitable for patients with severe PDs, such as the forensic patients exhibit emotional states which are extreme, and often fluctuate from moment to moment, making it very difficult to make progress with more standard therapeutic approaches. schema mode starts first Adaptations for forensic settings Forensic treatment focuses on psychopathology and the causes of crime; its primary target is to reduce recidivism risk to an acceptable level so that offenders can be rehabilitated. The aim of ST in forensic settings is to reduce recidivism risk by means of targeting schema modes that represent psychological risk and protective factors for violent behaviour. In effect, Schema Therapy promotes psychological change as a means to reduce the risk of reoffending. To reduce recidivism and rehabilitation of offenders to back in society. ST- objective of the institution or state- psychological change to reduce recidivism In forensic patients, reactive aggression is a more immediate, prominent issue compared to those in general psychiatric settings. Second, offenders may display more marked affective and interpersonal deficits, such as emotional coldness and deception. The clients are the result of court orders to ensure the safety of clients, too. Third, offender treatment is usually compulsory, whereas general psychiatric patients are generally treated on a voluntary basis. In forensic hospitals, staff are not only responsible for treatment and a patient’s well-being, but also for the safety of the patient and their environment According to Schema Therapy, criminal and violent behaviour can be explained in terms of sequences of schema modes. St the criminal environment behaviour is explained by schema mode The person have poor coping skills The events preceding the criminal/violent act are often initiated by painful emotional triggers (i.e. situation in which someone feels abandoned, lonely, hurt, etc.). Child modes are triggered and subsequently covered up, avoided or overcompensated. For example, a girlfriend breaks up with a person; he feels abandoned (vulnerable child) and angry (angry child). To numb the pain, he takes a lot of drugs which results in a lack of impulse control. This progress towards stalking his X (bully and attack) Antisocial behaviour is the result of a reciprocal relationship between Positive childhood experiences Predispocing factors Activated schemas External risk and protective factors Healthy functions Protective childhood factors Predispositions External protective factors Unhealthy functions Actively early maladaptive schemas Antisocial behaviour External risk factors five schema modes to Young’s original schema mode model schema modes Vulnerable child Angry child Impulsive child Lonely child Mode domains Child modes schema modes Detached protector Detached self-soother Compliant surrender Angry protector Complaining protector Mode domains Avoidant coping modes schema modes Punitive parent Demanding parent Mode domains Parent modes schema modes Self-aggrandiser Bully and attack Conning and manipulating Predator Obsessive- compulsive overcontrolled paranoid overcontrolled Mode domains over compensatory modes schema modes healthy adult playful child Mode domains healthy modes Forensic PD patients pose specific challenges for their therapists. For example, these patients may be devaluing and hostile which makes it difficult for the therapists to stand their ground. Also, the restrictive nature of a forensic hospital may discourage a therapist’s inclination to serve as a parent-like role model. As a result, therapists may be too distant towards the patient, or overly critical. Furthermore, their tendency to self-disclose (within appropriate limits) may be hindered. Ethical debate to the level of self disclosure and some people say that should be structured and some think it should be casual. The therapist to tell personal info self disclusore. General self disclosure is recommended but in forensic due to ethical and security concern may make therapist vulnerable. Rapport building is an art The adolescent love structure therapist Low resilience they prefer casiual. Client characteristics (indicators/contra-indicators) Primary inclusion criteria for forensic Schema Therapy: Cluster B PD, PD Not-Otherwise-Specified with predominantly Cluster B traits, a high risk of reoffending and a history of aggressive behaviour. Exclusion criteria for the forensic adaptation of ST: serious neurological impairments, an autistic spectrum disorder, the presence of current psychotic symptoms or disorders, current drug or alcohol dependency (but not abuse) and current serious mood disorders. ST may be used with other clients but it is used for cluster B personality disorders. Forensic setings is used only with cluster b and aggressive behaviour Exclusion criteria: serious autism but there is modified ST for them It is like exposure therapy and psychotic disorders may trigger psychotic episode Status of the evidence in forensic settings A number of studies have supported the schema mode concept in PD patients. Studies also show that switching between modes can be induced experimentally, for example, by showing patients short film segments depicting child abuse Several attempts have been made to validate early maladaptive schemas and the schema mode concept in offenders Evidence for the ST theoretical model in forensic patients Results showed that criminal behaviour is often preceded by vulnerable feelings such as sadness, loss or shame (vulnerable child), loneliness (lonely child) and states of intoxication (detached self-soother). Criminal behaviour was characterised by impulsivity (impulsive child), anger (angry child), callous aggression (predator) and intimidation (bully and attack) Case study Max is a 35-year-old man of Eastern European origin with a PCL-R score of 33 (i.e. psychopathic range) who was sentenced for treatment with an indefinite sentence in a high security forensic hospital.(UK but similar sentences in Canada) As a young boy, he was seriously neglected by his mother. After moving to the Netherlands, he was physically abused by his father and stepmother, and sexually abused by an older cousin. He had exhibited serious behaviour problems from a young age. By the time he entered secondary school, he was involved in drugs and criminality, eventually becoming a powerful figure in the criminal underworld. One evening, after taking drugs and feeling that his life was ‘out of control’, he decided that someone ‘had to die’. He met a woman in a bar, lured her outside and brutally murdered her. He was sentenced to forensic treatment, part of which included five years of twice per week Schema Therapy from a senior therapist along with once per week Art Therapy and later Drama Therapy as ancillary treatments. Initial phase of ST 1 year: Max showed pronounced need for control and suspiciousness (Paranoid Overcontroller mode), as well as anger (Angry Child mode) and self-aggrandisement (Self-Aggrandiser mode). He filled the sessions with monologues detailing his complaints against the clinic (Complaining Protector mode). The therapist used empathic confrontation to interrupt these diatribes, creating moments when the patient could reflect on his emotional states and how they were triggered in specific situations: Which side of you is this that won’t let me get a word in edgewise?’ Schema mode model for ‘Max’ Case study The second phase of therapy (approximately the second year) was characterised by ‘two steps forward and one step back’. Max had frequent conflicts with ward personnel, where he questioned their motives and devalued their competence His therapist helped him to analyse these situations in terms of modes in himself and in the staff, which triggered each other, producing escalations. Sometimes his anger would increase in the therapy sessions to the point where his therapist had to set limits. Limit setting in Schema Therapy is done in a firm and consequential, but personal way, emphasising rights such as safety and respect Your anger is leaving me feeling uncomfortable right now. You and I both have the right to feel safe. If you’re having trouble controlling your anger now, then we need to take a break in the session. In this same phase, the therapist introduced experiential techniques, using guided imagery to link present situations to painful childhood events involving abuse or neglect. In the third and final phase of therapy (approximately years three to five), Max showed fewer maladaptive modes and an increase in his capacity to self-reflect and handle problematic situations adaptively (Healthy Adult mode). His conflicts with ward staff decreased significantly and he developed greater patience and frustration tolerance. He applied for supervised leave, the beginning of the ‘resocialisation’ process of gradually reintegrating into the community. His risk assessment scores on the HCR-20 indicated a reduction from high to moderate risk levels, with his moderate risk due mostly to past risk items and not current, dynamic ones. Not to increase compliance but only to mode modification The treatment lasted 3 years, and he was able to create an adaptive mode. HCR- 20 is a historical and dynamic risk factor. Week 13 A service evaluation of the Behavioral Treatment for Substance Abuse (BTSA) programme for forensic dual diagnosis populations INTRO MH problems + substance abuse = longer recovery time This study aimed to evaluate the effectiveness of the BTSA group with this population. Motivation, locus of control, confidence to abstain and self-efficacy questionnaires were administered to six different cohorts of BTSA participants (N = 38) at baseline, post, and follow-up stages. Not only mental problems plus substance abuse It makes it harder to address both issues. So, scientists were looking for effectiveness. And most of the time, substance abuse comes first and after mental health treatment. The effectiveness test: the impact of the treatment of BTSA and the cognitive process of the events of social environment where are you in control of your life and social environment. Semi-structured interviews looked in 6 different groups. The baseline data and follow-up stage. To see if the treatment lasts, the motivation of clients and how long it lasts. BACKGROUND Dual diagnosis is a broad definition for mental health and substance misuse problems that occur concurrently and data show high comorbidity between substance abuse and mental health disorders Substance abuse problems also comorbid with physical health problems that adversely impact mental health. Substance abuse can have a negative impact on adherence to treatment plans, including medication compliance. Diminish the effectiveness of medication for physical conditions Operational definition Dual diagnosis may include many things, but in the current cases, only mental illness and substance abuse are any type of. Substance abuse takes priority even including medication and those may affect mental health or impact the treatment for mental health. The Behavioral Treatment for Substance Abuse Addresses substance misuse for the psychoses. BTSA is based on harm reduction principles rather than abstinence and It is highly repetitive to account for the cognitive deficits associated with individuals with a psychotic disorder, particularly schizophrenia Treatment programs for offenders should include motivational interviewing and a contingency management component Contingency management has been found to reduce substance misuse, increase length of time abstinent, and decrease time spent in treatment Alcohol consumption may not interfere day life, but excess may impact it. Decrease the excessive level of substance use. BTSA will modify the consequences that impact the behaviour. Modifying the level of substance misuse may not be the target, but people may stop using or abusing and may help to stop the treatment. Motivation interview and contingency management. Motivational interviewing has been proven to increase the motivation of individuals who need to change substance abuse and other health behaviors and have a positive effect on retention in treatment in community-based programs Contingency management has been found to reduce substance misuse, increase length of time abstinent, and decrease time spent in treatment It has the opposite effect. Motivation interview- Contingency- number of different techniques. The relationship between them is totally temporary relationship. After it is the consequence Anticivent or consequential. Contingency management in BTSA is used both as a treatment approach and as a motivational buffer. Reinforcement is contingent primarily on attendance at sessions and, for every session attended, a participant is reinforced by a payment £í1.50. This increases incrementally by £0.50 up to £3.50 when a participant continuously attends and provides negative drug and alcohol testing. If, however, a session is missed with no valid reason or a participant provides a positive test, they would return to the baseline of £1.50. Contingency may have an impact on motivation and vice versa. Participant One, when they attend the session, is reworded, and it is like reinforcement. But if the reward makes people not attend, it is not working, called a functional reward. BTSA runs for 35 sessions, twice weekly for a period of five to 6 months; Covers various topics aimed at improving goal setting skills, emotional management and drug refusal/ social skills in program participants. BTSA incorporates a psychoeducation component about the impact of substance misuse on physical and mental health and behavior for the self and others 35 is long for a typical behavioural intervention. In frame of treatment is long, but compared to CBT, it is not enough. If time out is not working for 10 sessions, it means it is not working. Skills mean role-playing and goals. RCT in non-forensic settings found that participants who attended BTSA were significantly more likely to return negative drug tests, had less subsequent inpatient admissions and reported greater life satisfaction Compared to a comparison group with an emphasis on psychoeducation. Other research yielded mixed results. Some argues that BTSA is not suitable for forensic settings due to its intensive, rigorous, repetitive and lengthy content It is important to know that RCT can bring confidence to treatment, but research from the field shows mixed results. It needs to be looked at in both lab and field research. Objectives of the Study The aims of this study were: To evaluate whether the BTSA program increased participants’ motivation and readiness to change, locus of control, confidence to manage substance misuse and self-efficacy; To use a focus group to evaluate participants’ overall experience of the program. It was hypothesized that There would be increases in participants’ motivation, locus of control, confidence, and self-efficacy post intervention. Methodology: Participants Participants (N = 38) were adult males, Living in male only low secure and rehabilitation inpatient wards or living in the community and accessing community forensic services All participants had a history of offending and aggressive behavior. Participants had coexisting serious mental disorder and problematic substance use. Participants’ ages ranged between 21 and 59. BTSA is hard to implement in high-security settings. Methodology: Materials The evaluation used a mixed design. Psychometric data were collected as a routine clinical practice at pre-group, post-group and two-month follow-up, over six different cohorts of BTSA participants, over a period of 4 years. After the end of the latest BTSA program, qualitative data were collected using a semi-structured focus group interview Psychometrics used included: Stages of Change, Readiness, and Treatment Eagerness Scale (SOCRATES) Drug and Alcohol Internality, Powerful Others and Chance Locus of Control Drug Taking Confidence Questionnaire for Drugs and Alcohol – Shortened General Self-Efficacy Scale The questioners were used to report the impact of the intervention. The questions were pre-session and after 35 treatments and followed up every two months. Intervention The BTSA program was developed by Bellack et al. (2006) and incorporates six core components: motivational interviewing, contingency management, goal setting, social skills training, psychoeducation, and relapse prevention training. The program took place at a community-based drug and alcohol recovery charity. The group ran twice weekly for 35 sessions, lasting 75 minutes. Results Participants’ confidence was significantly higher, but Their self-efficacy, motivation, and locus of control following completion of the program were not significantly higher. Thematic analysis identified three key themes relevant to participants, Empirical research works outside of forensics but not in forensic settings. Themes Theme 1: validation ( acceptance by therapist) A consistent theme within the focus group was validation. Those who attended the focus group spoke about the importance of recognizing and accepting (their own and others) thoughts, feelings, sensations and behaviors. Theme 2: Psychoeducation highlighted that service users found it helpful (enjoyed this component of self confidence and maintaining absence were increase) learning up-to-date information about various substances, their impact on physical and mental health in the long term, and the legal consequences of carrying drugs, Theme 3: Identifying progress summarized participants’ experiences of their recovery journey. All focus group members expressed being more aware of things that cause relapse like triggers and stressful situations Why did it not work? CBT is similar to yes and no; it has cognitive parts, but BTSA is the target of behaviour but is less cognitive. Self-report can be the cause too. Risk-Need-Responsivity Model for Offender Assessment and Rehabilitation  Introduction The Risk-Need-Responsivity (RNR) model is the most influential model for the assessment and treatment of offenders. First formalized in 1990, the RNR contextualized within a general personality and cognitive social learning theory of criminal conduct. Since 1990, a number of principles have been added to the core theoretical principles to enhance and strengthen the design and implementation of effective interventions. ( we focus only on 3) Three Core Principles Risk principle: Match the level of service to the offender’s risk to re-offend.  Need principle: Assess criminogenic needs and target them in treatment.  Responsivity principle: Maximize the offender’s ability to learn from a rehabilitative intervention by providing cognitive behavioral treatment and tailoring the intervention to the learning style, motivation, abilities and strengths of the offender.  Risk principle- who does need to receive the intervention? Mostly high-risk offenders. High risk is more likely to reference. Sometimes, treatment may increase the risk of reoffending for people with low risk. So it should not be that intense for low risk. Need principle- offender misuse the substance, but it does not appear in criminogenic need, so no targeting this person. Only criminogenic needs are targeted. Responsivity principle –the treatment should have a strong conceptual foundation and be tailored to specific offender needs. It is like principles of CBT. Responsivity Principle There are two parts to the responsivity principle: general and specific responsivity. General responsivity calls for the use of cognitive social learning methods to influence behaviour. Cognitive social learning strategies are the most effective regardless of the type of offender  Core correctional practices such as prosocial modeling, the appropriate use of reinforcement and disapproval, and problem solving are the specific skills in a cognitive social learning approach.  Specific responsivity is a “fine tuning” of the cognitive behavioral intervention. It takes into account strengths, learning style, personality, motivation, and bio-social (e.g., gender, race) characteristics of the individual.  This paper summarizes how the RNR model has influenced development of offender risk assessment instruments and offender rehabilitation programs  A brief history of risk assessment  First generation: Professional judgement  For much of the first half of the twentieth century, the assessment of offender risk was left in the hands of correctional staff and clinical professionals. Guided by their own professional training and experience, staff would make judgements as to who required enhanced security and supervision. The assessment of risk was a matter of professional judgement.  First generation Risk assessment it was professional judgement. Second generation: Evidence-based tools  Beginning in the 1970s, the assessment of risk included more upon actuarial, evidence-based science and less on professional judgement. Actuarial risk assessment instruments consider individual items (e.g., history of substance abuse) that have been demonstrated to increase the risk of reoffending and assign these items quantitative scores. For example, the presence of a risk factor may receive a score of one and its absence a score of zero. The scores on the items can then be summed – the higher the score, the higher the risk that the offender will reoffend.  They did not include dynamic risk factors, only static Third generation: Evidence-based and dynamic  Recognizing the limitations of second generation risk assessment, research began to develop on assessment instruments that included dynamic risk factors. In addition to items on criminal history and other static items such as past substance abuse there were dynamic items investigating the offender’s current and ever changing situation. Questions were asked about present employment (after all, one can lose a job or find a job), criminal friends (one can make new friends and lose old friends), family relationships (supportive or unsupportive), etc. The third generation risk instruments were referred to as “risk-need” instruments  The third includes static and dynamic, and you need to include professional expertise. This generation start to take risk factors in consideration static and dynamic. Fourth generation: Systematic and comprehensive  These new risk assessment instruments integrate systematic intervention; monitoring with the assessment of a range of offender risk factors; other personal factors important to treatment  Third and fourth generation risk assessment instruments would not have been possible without the risk-need-responsivity model.  Now not only you have a clear instrument Assessment was a part of process for intervention. You make risk assessment and then intervention but here it is implemented at same time. RNR & Offender Risk Assessment  Offender recidivism can be reduced if the level of treatment services provided to the offender is proportional to the offender’s risk to re-offend. The principle has two parts to it: level of treatment and, offender’s risk to re-offend  Criminal behaviour can be predicted in a reliable manner beyond specialized training and experience The focus of correctional treatment to be on criminogenic needs.  Criminogenic needs are dynamic risk factors that are directly linked to criminal behaviour.  Intense treatment is not always necessary for the offenders. It should match the level of risk the person is pausing. The focus is only on criminogenic (dynamic risk factors) and nothing else. Static risk factors hard to change and the criminogenic needs are directed to criminal behaviour. The need principle assess the criminogenic needs/dynamic risk factors. third and fourth generation risk instruments do just that.  General responsivity refers to the cognitive social learning interventions to teach people new behaviors regardless of the type of behaviour.  Effective cognitive social learning strategies operate according to the following two principles:  The relationship principle (i.e., rapport building)and,  The structuring principle (prosocial change: modeling, reinforcement...) Protective factors is not the absence of risk factors Protective factors include family support, strong family ties and role models. Report building is not a strategy or method as long as it is based on relationship principles and intervention is a structured process. The essence of this principle is that treatment can be enhanced if the treatment intervention pays attention to personal factors that can facilitate learning.  Offender treatment programs involve teaching offenders new behaviors and cognitions Requires focus to a range of personal-cognitive-social factors.  Rapport building is important and in a structured manner. Treatment providers may need to first deal with an individual’s debilitating anxiety or mental disorder in order to free the individual to attend and participate fully in a program targeting criminogenic needs. If the offender has limited verbal skills and a concrete thinking style then the program must ensure that abstract concepts are kept to a minimum and there is more behavioral practice than talking.  Increasing motivation & reducing barriers to attending treatment must be well thought-out.  Before intervention, if it is needed to address anxiety or other disorders. Mental health and substance abuse first and later criminogenic needs. Offender rehabilitation  Brief history of offender rehabilitation  For a long time there has been evidence that some interventions can reduce recidivism. In 1954, Kirby found four studies evaluating correctional counseling. The studies compared offenders receiving treatment to offenders who had no treatment. He found that three of the studies demonstrated lower recidivism rates for the group who received treatment.  Brief history of offender rehabilitation  Throughout the 1950s and 1960s, rehabilitation was seen as a promising approach to reducing recidivism. Although earlier reviews found that treatment does not “work” in half of the studies, the bottle was seen as half full.  Then in the 1970s the bottle was placed upside down by intervention reviews The conclusion was “nothing works” Half of interventions did not work and why to bother and this perspective start to give harsher sentences and to lock them for longer. We should get tough on crime, but experience shows it did not reduce recidivism. The “nothing works” movement seized criminal justice. If offenders could not be rehabilitated then what to do with crime? Many answered that punishment or deterrence could reduce criminal behaviour. Thus began the “get tough” movement. However, getting tough not only have prison and probation populations skyrocketed but the deterrence has had hardly any impact on offender recidivism and in some situations, actually increased recidivism The first part emphasizes the importance of reliably predicting criminal behaviour and thus, the need for evidence-based risk instruments. The second component highlights the need to properly match the level of service to the offender’s risk level. That is, as risk level increases then the amount of treatment needed to reduce recidivism also increases.  Inappropriate matching of treatment intensity with offender risk level can lead to wasted treatment resources and in some situations actually make matters worse.  The third the treatment to be focused on cognitive 3 principle risk., need and responsibility In the secure forensic facility of the RNR model The treatment did not comply, and it increased the risk of recidivism for the clients. Recidivism increases if the treatment does not include the principle of RNR. RNR model is effective in comparison to chemo or aspirin treatment. Systematic is more effective. Generality of the RNR model  The General Personality and Cognitive Social Learning perspective Reflects a personality predisposition and the learning of criminal behaviour Governed by the expectations an individual holds and the actual consequences to his or her behaviour. Behaviour that is rewarded or that the individual expects will be rewarded is likely to occur Behaviour that is punished or is expected to be punished is unlikely to occur.  You need to have client’s active participation. Punishment and reward it can be related to behaviour. The consequences of behavior the punishment is incarceration and risk increases. Then incarceration functions as reinforcement and not as a punishment. The GPCSL perspective underlies the RNR model of offender assessment and rehabilitation. When we conduct risk assessments we are essentially sampling the rewards and costs associated with criminal conduct. Does the individual have criminal friends? If so, then we know that the individual likely receives rewards and encouragement for criminal behaviour. Does the individual like his/her job and the people with whom he or she works? If so, then we know that rewards are available for prosocial behaviour.  We can go further and dissect GPSCL in order to construct the links to RNR.  Dissection of GPSCL to construct the links to RNR 1. General personality: Antisocial personality pattern is more comprehensive and captures the history of generalized rule violation, some of the personality factors that function as criminogenic needs (e.g., impulsivity, self-centeredness) and responsivity factors (e.g., need for excitement, shallow affect).  2. Cognitive: The cognitive aspect of the theory includes deliberate self-conscious self-regulation and automatic self-regulation and points to the importance of pro-criminal attitudes, values and beliefs as causes to criminal behaviour.  3. Social learning: This highlights the importance of social learning. Assessments of social and automatic the rewards and costs for criminal and prosocial behaviour result in a comprehensive survey of criminogenic needs and strengths. An assessment of what is referred to as the “central eight” then lays the foundation for effective intervention by addressing criminogenic risk factors Summary and conclusions  During the past 20 years there has been significant progress in our ability to reliably differentiate offenders in terms of risk and to assist offenders with becoming more prosocial.  This is not to say that other approaches to risk assessment and treatment have not made important contributions. There are, for example, many valid offender risk instruments that have been developed from a non-theoretical perspective using highly sophisticated psychometric methods. The VRAG and STATIC-99 are stellar examples.  The RNR model has not only contributed to the development of offender risk instruments that predict as well  2 examples That takes care of sttic risk factors The 3 principle RNR it is not in intervention by itself it is framework that features with other interventions.