CPN 4TH ANNUAL CONFERENCE

Celebrating Therapy in the Custodial Setting

Therapeutic Communities, The Treatment Regime at HMP Grendon

& Some Ethical Considerations

Professor Michael BrookesDirector of Therapeutic Communities: HMP Grendon

Visiting Professor: Birmingham City University

1939 East-Hubert Report

This report recommended that a special institution be built with its conclusion being that “psychotherapy as an adjunct to an ordinary prison sentence appears to be effective in preventing or reducing the chance of future anti-social behaviour, provided the cases to which treatment is applied are carefully selected”

Rt Hon R.A. Butler, Home Secretary, on laying the foundation stone on

1 July 1960 said:

“The regime must be flexible with the accent on treatment; and success will depend above all on an enlightened staff-inmate relationship, together with close co-operation at all levels between the different members of the staff”

HMP Grendon• 240 bed Category B prison• No Segregation Unit• Opened in 1962• Each of the six wings is an individual therapeutic

community• Fully accredited CSAP intervention• Warren et al (2003) cite TCs as having the ‘most

promising evidence’ in the treatment of severe personality disorder

Prisoner Characteristics (1)• 90% serving life sentences (47% mandatory lifer, 21%

discretionary lifer, 31% IPP, 1% Section 2).• 2% serving 4 - 7 years, 2% serving 7 - 10 years, 6%

serving 10 years or more.• 21% aged 21-30, 31% aged 31-40, 37% 41-50, 11%

over 50. • High % personality disturbance (81% assessed as

having at least 1 personality disorder)• Significant levels of emotional distress (anxiety,

depression, histories of abuse)

Prisoner Characteristics (2)• The majority of residents at Grendon are serving

sentences for murder, manslaughter or violence (including those with sexual elements)

• Many studies have drawn attention to the combination of both the extensive criminal history and disturbed personality profiles of Grendon prisoners

• Grendon receives more psychopaths than any other type of English prison

• Large proportion of the Grendon population (50% to 75%) identified as having Dangerous and Severe Personality Disorder characteristics

Referral Criteria• Has more than 18 months to serve• Has been off Category A status for the last

6 months• Meets ‘drug free’ criteria (within 2 months)• No diagnosis of major mental illness• Comprehension of rules & signs compact• Accepts responsibility for offence• Meets self harm criteria (within 2 months)

Responsivity Criteria• Sufficiently motivated• Necessary insight & psychological mindedness• IQ criteria (29 or over on the Raven’s

Progressive Matrices or 80 and above on the WAIS/WASI)

• Psychopathy criteria: those scoring 25 or over on the PCL-R will be subject to further assessment prior to acceptance for treatment

Therapeutic Community ModelLINKS BETWEEN DIFFERENT THERAPEUTIC ACTIVITIES

THERAPEUTIC CULTURE

WORK

EDUCATION

LEISURE ACTIVITIES

COMPLEMENTARY THERAPIES

WING RELATIONSHIPS

COMMUNITY RESPONSIBILITY

OFFENCE ACCOUNT

THERAPY GROUP

INMATE FEEDBACK

STAFF FEEDBACK

COMMUNITY MEETING

CASE REVIEW

Principles of therapeutic communities (Rapoport, 1960; HMPS, 2007)

• Democratisation• Permissiveness• Communalism• Reality Confrontation• A living learning experience• Culture of enquiry• Confidentiality/No secrets

Guiding Structures of Democratic TCs

Therapeutic

alliancesDebate,

exploration and

enquiry

Decision making and

democratisation

Involvement,

participation and

responsibility

Safety, boundaries

and containme

nt

Theoretical Integration

‘Living learning’

Modelling

Pro social culture

Social feedback

Vicarious learning

Social Learning

AnalyticAttachments

Engagement

Affective experience

DevelopmentalExperiences

Interpersonal dynamics

CognitiveBehavioural

Belief systems

RealityTesting

Appraisals

Perspective taking

Problem solving

Needs Addressed Within Grendon• anti-social attitudes and feelings;• distorted thinking used to justify/minimise offending;• difficulty in recognising relevant risk factors and in

generating appropriate strategies to cope with them;• dependency on alcohol and drugs;• adverse social and/or family histories and

circumstances;• deviant sexual or violent interests, especially arousal

patterns and pre-occupations;• poor social, interpersonal skills which are often offence-

relevant.

Ethical Considerations

• Power relationships: staff vs resident decision-making

• Voluntary engagement, addressing risk factors/treatment targets and process for withdrawing from therapy

• Confidentiality & disclosure of information• Conditioning, compromise & integrity• Staff support

Power relationships: staff vs resident decision-making

• To what extent can power in a Category B prison be truly devolved?

• Should staff vote in community meetings in the same way as residents?

• When should staff overrule votes taken by residents?

• What impact does the personality mix of residents have in the resident decision-making process?

• How does life ‘upstairs’ impact on life ‘downstairs’?

Voluntary engagement, addressing risk factors/treatment targets and process for

withdrawing from therapy • Informed consent? What about ISPs?• Treatment within a TC: awareness of

intensity of group based approach• ‘Opening up’ responsibilities: ‘capacity to

cope’• Impact of RTU & community/staff

deselection• Outstanding risk factors and treatment

needs/targets: divergent views

Confidentiality & disclosure of information

• Staff allegiances to different stakeholders (employing organisation, court requirement, professional body, client)

• Working in multi-disciplinary teams/multi-agency arrangements: information sharing/shared records

• Need to protect the public - risk assessments, report writing, working notes

• Need to ensure the safety of the individual (self-harm disclosure or if someone else at risk)

• Potential for staff compromise/collusion/splitting if told something ‘in-confidence’

• Additional offences • Security of the establishment & SIRs• Establishing the right culture within each TC: ‘encouragement to do

the right thing – share all relevant information’

Conditioning, compromise & integrity

• Closeness of working arrangements• Supportive therapeutic relationships• Impact of hearing distressing material• Maintaining personal boundaries• Role of the staff team• Containing own frustrations/expressed

hostility of residents• Always acting respectfully, competently,

responsibly, decently & with integrity

Staff Support Mechanisms• Pre-group/community meeting briefing• Post group supervision/de-briefing• Post community meeting de-briefing• Weekly sensitivity meetings• Individual supervision (contracted)• Group supervision• Informal (and if necessary formal)

individual/group peer and/or clinical team discussions (particularly if distressed)

Further ReadingBrookes, M. and Shuker, R (Eds.) Grendon 50th Anniversary Edition. The Howard Journal, 49, (5).Jones, D (Ed.) (2004). Working with dangerous people: The psychotherapy of violence. Oxford: Radcliffe Medical Press.Parker, M (Ed.) (2007). Dynamic security: The democratic therapeutic community in prison. London: Jessica KingsleyShuker, R. and Sullivan. E.L (Eds.) (2010), Grendon and the Emergence of Forensic Therapeutic Communities: Developments in Research and Practice, Chichester: Wiley-Blackwell.