Abstract
Objectives:
This paper describes the role forensic psychotherapy has in the assessment and treatment of mentally disordered offender patients, and its role in the supervision of individual therapists, staff groups or whole organisations which contain and manage this patient population.
Conclusions:
Forensic psychotherapy has a valuable role to play in the management of mentally disordered forensic patients. As forensic services continue to develop in Australia and New Zealand and interest in this field continues to grow, then the future of forensic psychotherapy looks bright.
Forensic psychotherapy could be used to describe the application of cognitive, behavioural or systems/family therapy interventions; however, within the field and here it will be used to describe interventions which rest on psychodynamic/psychoanalytic principles, and applied to mentally disordered offender patients and to the institutions which house them (e.g. prisons or hospitals). Services in Australia are evolving, drawing on well-established models such as those in the UK and Germany.
Violence is a complex social phenomenon; hence, a complex, multi-modal understanding is needed. There is a long history of using psychodynamic/analytic theory to help understand people who commit violent acts. It is important to continue to include this approach alongside other interventions, particularly in light of an ever-evolving evidence-base of its value and effectiveness in complex severe cases. 1
Prisoners and forensic patients have complex physical and mental health needs, 2 and may have a co-morbid psychotic illness, personality disorder/traits and substance abuse disorder. There is usually a significant trauma history, so these patients can be terribly traumatised; but they can also be terribly traumatising to those who care for them. The index offence is the term used to describe the offence which has led to them being incarcerated and can include murder, arson, serious assault and/or sexual offending against adults or children.
Forensic patients typically rely on primitive unconscious defence mechanisms (e.g. splitting, projection and projective identification) in order to manage internal anxiety. These can be ‘paralleled’ in the social systems used to contain these patients as collective social system defences which, if not attended to, can adversely impact on staff and limit the effectiveness of therapeutic endeavours. 3
Indications and outcomes
Forensic psychotherapy is used in three key areas: assessment, treatment and supervision.
Assessment
A forensic psychotherapy assessment attempts to make sense of how a patient’s early background and experiences (‘there and then’) account for the patient’s current predicament (‘here and now’). The therapist is curious to know what internal state of mind the patient was trying to manage via the external violent act. This includes both conscious and unconscious aspects of the patient, including: the index offence and other offending behaviour; the ‘meaning’, symbolic and otherwise of the index offence; and an assessment of what psychological structures and defences are in place. It would also include an assessment of the patient’s treatability – particularly the ability to withstand and understand their own emotions and minds, as well as other people’s minds. A report is written which can be helpful to the individual patient and teams working with these complex patients, and can assist the court, usually at the sentencing stage, in terms of advice about therapy.3–5
Risk prediction and assessment is complex and divisive6–8; even so, a forensic psychotherapy assessment as part of an overall assessment of the individual patient may offer a more rounded understanding of the patient and contribute to risk management.4,9,10
Treatment
Very few patients would be able to make use of traditional psychoanalysis, but psychodynamically informed therapy has been used to good effect both individually and in groups.4,11 There is now good data on the effectiveness of mentalisation-based treatment (MBT) and dialectical behaviour therapy – for example, to treat borderline personality disorder 12 – and some evidence for different treatment modalities on antisocial personality disorder. 13 Violence is a complex social phenomenon, but there are some types of violence which may result from a failure in mentalisation 14 and there is a current multi-centre study examining the effectiveness of MBT on violent men with antisocial personality disorder.15,16
There is good outcome research from HMP Grendon, a forensic therapeutic community within the UK prison directorate. 17 The introduction of the term ‘dangerous and severe personality disordered’ by the UK government was provocative and controversial. 18 Treatment programmes were established in some prisons and high secure hospitals using a range of therapies, and these were empirically evaluated. The results thus far have been mixed,19,20 but some services organise themselves using psychoanalytic principles, and the importance of supervision and reflective practice continues to be recommended. 21
There are conflicting research outcomes for all types of treatment for sexual offenders,22,23 but psychotherapy has been attempted with those who sexually offend against adults or children.24,25
Supervision
The Forensic Psychotherapist will offer supervision to individual therapists (or trainees) who are directly treating patients. Group supervision is recommended in good practice guidelines and offered to teams in the form of reflective practice groups13,26 or by working directly with teams at clinical meetings using structured tools such as the Operationalised Psychodynamic Diagnostics 27 to examine interpersonal dynamics between the patient and staff members. The aim is to help teams better understand their patient, avoid perverse acting out, and to help manage strong counter-transference reactions and the toll of working with these highly disturbed and disturbing patients. 3
A whole-group, organisational consultant, psychodynamic approach can provide an assessment and offer interventions to institutions such as secure hospitals who are struggling to manage the impact of working with such disturbed patients, help to avoid things going terribly wrong or help organisations recover when things have gone wrong; for example, the aftermath following the inquiry into Ashworth high-secure hospital.28,29
Clinical practice
With ever-competing resources, psychodynamic psychotherapy is under attack, criticised for being outdated and lacking empirical evidence. 30 This view, however, is being challenged, as there is an ever-growing evidence-base for psychodynamic psychotherapy and a sustained and flourishing interest in the application of psychodynamic theory and practice alongside other treatments to the care of forensic patients.30–34
It is hoped that ongoing research will eventually inform individualised care planning and the vexed question: what works for whom, and when?
In order to optimise the delivery of services as indicated, therapists need a thorough grounding in theory, good supervision and time spent in one’s own personal therapy; this provides the best combination for those wishing to specialise in Forensic Psychotherapy. This is a challenging environment to work in, and in order for the therapist to be maximally effective the therapist will need a high level of systemic and individual containment in order to help manage the primitive processes, attacks on thinking and individual patient and systemic defences in place inherent in working in this field. Networking with others in the field through the International Association of Forensic Psychotherapists 35 is a good way to keep abreast of training and treatment developments.
Conclusion
Forensic psychotherapy is a demanding but rewarding and fascinating area to work in. As services continue to develop in Australia and New Zealand, and an increasing number of trainees opt to specialise in forensic psychiatry and psychotherapy, the future of forensic psychotherapy is secure and in good hands.
Footnotes
Acknowledgements
Thank you to the late Professor Gill McGauley and to the two anonymous reviewers for their helpful comments.
Disclosure
The author declares that there is no conflict of interest. The author alone is responsible for the content and writing of the paper.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.