All prisons should be therapeutic communities

‘All prisons should be therapeutic communities’

Reasons why most prisons are not run on a therapeutic community model

Debate around whether prisons should be therapeutic communities often raise concerns about the role of these facilities, whether they are meant for punishment or rehabilitation, debates that often lead to most prisons failing to run on a therapeutic community model (Bennett, and Shuker, 2017). In the United States, for instance, Bennett, and Shuker (2017) note that prisons are less seen as places for rehabilitation but more for its basic punitive role. This, therefore, means psychotherapy is usually only welcome in prisons where rehabilitation is the main goal. The main goal of rehabilitation is to minimize or reduce reoffending, a significant problem in many countries globally (Bennett, and Shuker, 2017). The aim of this piece of paper is to critically discuss the factors that are making it difficult to establish the therapeutic community model in prisons. The probation service, offered to release prisoners, is often traditionally seen as playing a role in the rehabilitation process (Wampold and Imel, 2015). Additionally, the criminal justice system or CJS is also seen as important in impacting psychotherapy contexts in prisons because it is responsible for establishing strong structures and environments with robust institutional features (Wampold and Imel, 2015). The CJS influences psychotherapy contexts in prisons (Wampold and Imel, 2015). Wampold and Imel (2015) claim that while therapeutic relationships are vital in achieving effective psychotherapy, in forensic or prison contexts, establishing this therapeutic relationship between a prisoner and a therapist is heavily influenced and hampered by the prison or institutional environment. This challenge exists because the institutions focus mostly on security and punishment, and less on rehabilitation shown by an even lesser interest on psychotherapy (Wampold and Imel, 2015). Psychotherapists working in these institutions are often told not to ignore the issues of their security and the crimes committed by prisoners, two factors which significantly and directly affect the formation of a therapeutic relationship (Wampold and Imel, 2015). It affects confidentiality within the therapy room and increases the therapist’s anxiety levels (Merkt et al., 2020). Additionally, the therapeutic process needs flow of data or information to a psychotherapist, a situation which requires a client to tell the professional the crime or offence committed (Merkt et al., 2020). The process might also require different inputs other than the prisoner or client. These are seen as being problematic issues in establishing trust between a therapist and a client in conducting psychotherapy in prisons (Merkt et al., 2020). From my perspective, I believe that prisoners might find difficulty in sharing information about the crimes they committed, for instance in cases of rape or murder, a situation that make it difficult to help them overcome the mental health problems they experience because a therapist will not be able to know some of the root causes of the mental health problem, something that may also make it difficult to achieve rehabilitation. Research by Lipton, Martinson and Wilks (1975) played a role in hindering the establishment of therapeutic community models in prisons. The meta-analysis concluded that the success or effectiveness of therapy or rehabilitation in lowering reoffending had been heavily overestimated and exaggerated (Robinson and Crow, 2009 cited in the Open University 2020). This led to a slogan that came to be known as ‘Nothing Works’ in the prison context and reduced trust in rehabilitation and probation and affected the budgets directed towards these programs (Lipton, Martinson and Wilks, 1975). Because of this study, many countries shifted their penal systems towards an increasingly punitive position (Bell, 2013 cited in The Open University 2020). Researchers have dedicated resources and time in examining the effectiveness of the techniques used in reducing reoffending. Examples include Bonta and Andrews (2010 cited in The Open University 2020) who came up with the Risk-Need-Responsivity, the (RNR) model. They believed that the level of treatment should be equal to an offender’s risk and satisfy his or her needs or the reason they committed the crime. According to Bonta and Andrews (2010 cited in The Open University 2020), these reasons should not only be targeted but also transformed into strengths. The programs also need to be responsive to the particular setting and to the characteristics of an individual’s offender (Bonta and Andrews, 2010 cited in The Open University 2020). Even though the model holds considerable influence, it significantly lost support since 2010 (Bonta and Andrews, 2010 cited in The Open University 2020). In the UK, what is preferred is not the RNR model but paying private providers of rehabilitation and probation services, paying providers based on their results of reducing reoffending, using social, voluntary and private sectors through what is known as Community Rehabilitation Companies or CRCs and the use of statutory rehabilitation (Cullen, 2013). The other rehabilitation model is the Good Lives framework by Ward and Maruna (2007 cited in The Open University 2020). Unlike RNR, this one focuses on offenders’ strengths and uses it during the interaction with an offender to plan for life after prison time, something that is attractive for an offender and also incompatible with reoffending (Ward and Maruna, 2007 cited in The Open University 2020). Other factors which pose some difficulty in undertaking psychotherapy in prison or forensic settings is because of the emphasis put on diagnostic categories, as well as the impact of the 2005 Mental Capacity Act and the 1983 Mental Health Act which ensure that mental health in these settings are under the NHS with major decisions on treatment made by sanctioned forensic psychiatrists (Owen et al., 2009). In these settings, prisoners also experience different disorders like dissociation, PTSD, personality disorders and substance abuse (Phillips, McKeown and Sandford, 2010). Working with offenders needing psychotherapy who are also under drug treatment, a situation referred to as dual diagnosis, for instance, is a challenge for many psychotherapists (Phillips, McKeown and Sandford, 2010). I believe that while several models have been used in the UK like the RNR which has already been abandoned, it is evident that working with prisoners as a psychotherapist, particularly in high-security or tense prison environments is a daunting or challenging task for these professionals. The lack of a proven effective model and the impact of these environments have no doubt hindered the establishment of therapeutic communities in prisons. My view is that although prisoners can be cooperative with the process of therapy, it is likely that their problematic mental health issues, for instance, those suffering from depression, schizophrenia, PTSD, or hallucinations might show aggression. As indicated by NICE Guidelines for Personality Disorder, NICE (2009), more than 50% of prisoners and offenders in forensic settings are diagnosed with anti-social personality disorder, borderline personality disorder and personality disorders. Similarly, some are diagnosed with dissociation and PTSD (NICE, 2009). This has several implications. First, these individuals can be aggressive (NICE, 2009). They may end up harming the therapist, particularly when certain aspects or notions of their lives are challenged during therapy (NICE, 2009). My view is that as a Psychotherapist, the thought of prisoners being violent individuals and the actual risk of being hurt by them can make a psychotherapy professional reluctant to offer their services in prisons or forensic settings. The other issue is that therapy for these conditions takes significantly longer time, about one to two uninterrupted years, or more in certain serious mental illness (Dowsett and Craissati, 2008 cited in Logan 2020). As noted by NICE (2009), this length of time requires special models like the Dialectical Behaviour Therapy of the Mentalization-Based Treatment which uses a combination of weekly treatment, group therapy, psycho-education sessions and individual psychotherapy. Treatment of these conditions also require teamwork between different therapy providers, making it more challenging to implement in prison settings (Lotfi et al., 2018). From my perspective, the more complicated a prisoner’s mental health, as indicated by these literatures, the more time and sophisticated treatment approaches are needed to help them recover and reduce their risk of reoffending when released into society. Together with the risk, this lengthy period, as well as the risk of being harmed and the rigid nature of prison settings where the movement of prisoners is limited and collaboration from other therapy experts is limited, if any, makes establishing therapeutic communities in prisons about impossible. The main contacts for prisoners, as shown by English prisons, are prison officers and probation officers (Volker and Galbraith, 2018). These individuals also act as points of contact between the prisoners and their psychotherapists. The prison officers is thus aware of all the therapy appointments (Volker and Galbraith, 2018). These appointments are also often visible to the other prisoners on the wing where therapy happens (Volker and Galbraith, 2018). The lack of privacy linked to psychotherapy in prisons hardly motivates them to seek psychotherapy, making it even more difficult to establish therapeutic communities in prisons (Volker and Galbraith, 2018). Instead of being directly completed to seek psychotherapy, evidence by (Bell, 2013 cited in The Open University 2020) shows that they are also often pressured into the process. As noted by Bell (2013 cited in The Open University 2020) the involvement of psychotherapists in the whole process of rehabilitation when they move around together with other prison personally. This shows a power difference between prisoners and the psychotherapist, seen when they can easily move around and lock doors, unlike the confined prisoners. This makes it even harder for prisoners to open up during the psychotherapy sessions (Gaston, 2018). According to Gaston (2018), there are competing agendas in many prison systems. First, Gaston (2018) claims that this is seen when adaptations from normal psychotherapeutic models are imposed by security considerations and by the prison setting/environment. Prison officers, are entitled to look into a prisoner and see if there is a problem. Their assessment might occasionally lead to lock-down a prisoner even before the therapy plan is complete (Gaston, 2018). This issue also brings our attention onto the quality of therapeutic relationship, something that Combalbert et al. (2018) note that is crucial for effective treatment. When prisoners are transferred or locked-down without notice, insecure attachment is experienced by offenders (Combalbert et al., 2018). This interruption interferes with the psychotherapy process, a situation that occasionally leads to separation anxiety (Combalbert et al., 2018). Unfortunately, the decision to stop therapy rests with prison authorities who come up with offender management decisions and ignore psychotherapeutic effectiveness requirements (Combalbert et al., 2018). I believe that such a situation would also impact me as a psychotherapy expert as it would affect my thought process and plan for specific prisoners. It might also waste all our efforts into helping an individual prisoner undergo mental health treatment to equip them with skills that might be useful in avoiding reoffending or relapse into drug dependence. Lastly, Durcan and Zwemstra (2014) note that most prisons lack dedicated spaces for therapy. Available spaces are dedicated for other things like the conference room or waiting room. Unlike the normal therapy settings which are intricately arranged to help free people, prisoners lack personal freedom and quickly get accustomed to receiving psychotherapy in less comfortable or okay settings (Durcan and Zwemstra, 2014).

Creating a therapeutic community prison.

The establishment of the therapeutic community in prisons is one approach that has proven effective in dealing with these problems, a good example being shown in HMP Grendon (Dolan, 2017). Directly therapeutic prison environments or the therapeutic community, also known as the democratic therapeutic community is a model where medium-security prisons or specific wings of the institution is converted into a small community with security and run according to the principles of democracy (Dolan, 2017). In this community, substantial psychotherapy is provided, especially using group therapy (Dolan, 2017). This approach is considered to be an effective form of rehabilitation and a means to prevent or reduce reoffending for released prisoners. According to Dolan (2017), this model has been used in the United Kingdom since the Second World War in hierarchically operated institutions to effectively help individuals with alcohol and drug related issues. An example is the HMP Grendon, one of the oldest surviving institution in the UK (Dolan, 2017). Despite its immense success, promise and the long period of existence, the therapeutic community model has been criticised for not leading to significant reduction in the rates of reoffending and costing more resources compared to standard prisons (Shuker and Newberry, 2017). Shuker and Newberry (2017) also highlight that the model has been associated with compromising security, thanks to some of the highly-publicised prison escaped that have taken place through the years. This author also claims that there are arguments of it being quite costly compared to standard prisons. According to Ruttler and Tyrer (2003), there is lack of sufficient evidence that therapeutic prison communities reduce reoffending. I find this model quite appropriate in establishing prisons where prisoners view therapy as a normal things. With an entire wing where prisoners live in some kind of a community, even with some level of security maintained, I believe that a significant number of those suffering from mental health issues will not shy off from seeking psychotherapeutic help, making this model the best, from my perspective, in establishing therapeutic communities in prisons.

Conclusion

Working in prison settings as a psychotherapist is quite challenging. There is the risk of being harmed by the prisoners, particularly those suffering from serious mental health conditions like PTSD. Prisoners are also less motivated to attend psychotherapy due to lack of privacy and lack of trust on the therapists and prison officers. The power difference between prisoners, prison staff and therapists also discourage these individuals from seeking therapy. Despite the numerous challenges in establishing therapeutic communities in prisons, the therapeutic community model tested in Grendon prison in the UK, despite being linked to several escapes, seems appropriate in establishing therapeutic communities in prisons, democratic environments where prisoners find ease in seeking mental health support.

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