2014 Compendium inside

Forensic Update

A compendium of the main articles in issues 114, 115, 116 and 117

ISSN: 1356-5028

Forensic Update Editors

Emily Glorney Rachel Worthington

[email protected] [email protected]

Book Reviews Editor

Debbie McQueirns

Forensic Psychology Solutions Ltd [email protected]

Editorial Team

Geraldine Akerman Laura Caulfield Jane Clarbour

[email protected] [email protected] Department of Psychology, University of York, Heslington, York YO10 5DD. [email protected] Institute of Work, Health and Organisations, International House, Jubilee Campus, University of Nottingham, Wollaton Road, Nottingham NG8 1BB. [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]

Simon Duff

Natalie Leech Louise Maxwell Annette McKeown Jenny Tew Hannah Willis

Statement of purpose Forensic Update is a publication of the British Psychological Society’s Division of Forensic Psychology (DFP). Its aims are to: n communicate current information on professional and practice matters to practitioners and researchers; n publish current and topical research and reviews in forensic psychology and related areas in concise and easily readable form; n act as a forum for discussion and debate on a broad range of practical, professional and ethical issues within criminal and civil justice systems; n act as a forum for dissemination of knowledge from other branches of the criminal and civil justice system, executive and legislature; n act as a forum for discussions with a broad range of other criminal and civil justice professionals and agencies.

Advertisements Advertisements not connected with the DFP are charged as follows: Full Page (20cm x 14cm): £140 Half page (10cm x 14cm): £85 All rates inclusive of VAT. DFP events are advertised free of charge. The British Psychological Society’s terms and conditions for the acceptance of advertising apply. The publishers reserve the right not to accept any advertisement. Publication of advertisements is not an endorsement of the advertiser, nor of the products and services advertised.

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Editorial Emily Glorney & Rachel Worthington

Issue 114 – April 2014 10

Notes from the Chair Ian Gargan 11 Extended induction: Investigating the value of peer-led programmes in prison (An evaluation of the Trust programme at HMP/YOI E) Naomi Rose (Winner of the Third Annual MSc Dissertation Competition) Special Section on Working with Women Offenders 15 Attachment and development considerations when working therapeutically with adolescents who have experienced sexual trauma Emma Fisher 21 Assessing risk in female offenders: A review of the HCR-20 and the FAM Sarah Passmore, Samantha Woodhouse & Susan Cooper 27 Assessment and treatment with women who have committed offences within the family Susan Cooper & Alison Hodgson 31 Intimate relationships between female prisoners: Fact or fiction? Annette McKeown 37 Balancing the therapy role with the prison officer role Sue Devine, Grahame Greener, Karen Laws & Beverley Phillippo 42 Reflections of a trauma intervention with women in prison Michelle Carr, Alison Hodgson, Samantha Woodhouse & Marc Kerry 51 ‘Using CAT’ as opposed to ‘Doing CAT’: Adapting cognitive analytic therapy for use within a forensic patient setting Katie Gilchrist 57 Does adapted DBT have a place in forensic settings? The development of a DBT-informed emotion regulation group for female forensic personality disordered inpatients Claire Thompson Special Section on Becoming a Qualified Forensic Psychologist 65 Review of standards for Stage 1 and Stage 2 training Dee Anand 68 Training routes in Forensic Psychology Roisin Hall 69 How to become a Practitioner Forensic Psychologist Sarah Disspain 80 Pursuing a PhD in Forensic Psychology Dean Fido

Forensic Update 2014 Annual Compendium

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82 85 88

The Qualification in Forensic Psychology (Stage 2) – Getting it done John Hodge Assessment in the Forensic Qualification Dr Julie Harrower The BPS Chartership vs. HCPC Training Route: A Supervisor’s perspective Cerys Miles

Issue 115 – July 2014 91

Notes from the Chair Dee Anand 94 Division of Forensic Psychology Annual Awards Special Section commemorating the centenary of the First World War 98 Applied psychology in the Armed Forces: Current provision Professor Jamie Hacker Hughes 100 The Dstl and the role of the psychologist Fiona Butcher 104 Uniformed clinical psychology in the British Army Captain Duncan Precious 107 Effects of military operational tour on perceptions of mental illness and offending Kathleen Roberts 114 Military reserve service and post-tour work adjustment: Exploring lived experiences to inform applied practice Kevin Wilson-Smith & Elizabeth A. Bates 120 One intervention for ex-service personnel in custody: The Veterans group at HMP Grendon Simon Bonnett, Geraldine Ackerman & M.T. Articles 126 A proactive approach to engaging difficult to reach inpatients: A service evaluation Katherine Crosby, Katie Downsworth, Katie Gilchrist & Kristy O’Hare 132 Using Cognitive Analytic Therapy within a forensic setting: An overarching relational model Jenny Marshall, Kate Freshwater & Steve Potter 138 Following up the outcomes of a CBT-based substance misuse intervention for men in a secure psychiatric setting Faye Baker, Rachel Harwood, Michael Adams, Caroline Baker & Clive Long 145 The effectiveness of the Addressing Substance Related Offending-Secure (ASRO-S) treatment programme in a secure forensic hospital setting: A service evaluation Katie Downsworth & Eric Jones

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Issue 116 – November 2014 152 Notes from the Chair Dee Anand Articles 155 Referrers’ views on the quality of psychological reports on adults in childcare proceedings Tanya Garrett & Rosalind Wilcox 160 A comparison between British and Australian forensic psychology training Mike Berry

Issue 117 – January 2015 168 Notes from the Chair Dee Anand Articles 171 Psychologically Informed Planned Environments (PIPEs): Empowering the institutionalised prisoner Nina Preston 179 Service Evaluation of a Psychology-led Nursing Supervision Group within a Forensic Mental Health Service Donna Haskayne & Katherine Rowell Interview 195 An interview with Rob Paramo Geraldine Akerman


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Editorial Emily Glorney & Rachel Worthington ELCOME to this third annual compendium of main articles from online publications of Forensic Update in the past year. Articles from issues 114, 115, 116 and 117 of Forensic Update represent contributions from the breadth of the Division of Forensic Psychology membership and the diversity of research and practice in forensic psychology. Issues 114 and 115 contained themed collections of papers on working with women offenders (114), routes to qualification as a forensic psychologist (114) and commemorating the centenary of the First World War (115). In the context of national moves towards individualised, gender-specific approaches to working with women offenders, the themed collection of papers in 114 represented practice- and evidence-based recommendations for working with women offenders from a breadth of theoretical and practice perspectives. Emma Fisher reflected on her experiences of working with adolescent complainants of rape and sexual assault and presented examples of how psychological theory can inform an understanding of the experience and management of two cases of young girls presenting to the police. Sarah Passmore, Samantha Woodhouse and Susan Cooper presented an overview of the prevalence of crime perpetrated by women, research into violence risk among women and made recommendations for risk assessment. Susan Cooper and Alison Hodgson discussed issues relevant to the assessment and treatment of women offenders who perpetrate intrafamilial offences, with reference to the challenges of working with factitious disorder by proxy. Annette McKeown explored the prevalence of intimate samesex relationships between female offenders in custody and discussed implications for risk

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management and intervention. Psychologically-informed practice is emphasised in the paper by Sue Devine, Grahame Greener, Karen Laws and Beverley Phillippo, who presented a reflective piece on managing the duality of the discipline-therapy role of a prison officer, with examples of their practice in working with women prisoners and with reference to the value of the Primrose Service. Progressing to interventions, Michelle Carr, Alison Hodgson, Samantha Woodhouse and Marc Kerry described and reflected on the integration of the gender responsive Trauma Recovery and Empowerment Model into the development of a dedicated trauma pathway for women prisoners. Katie Gilchrist applied a Cognitive Analytic Therapy formulation to a case study of a woman in a medium secure unit and described the development of a relationallyinformed care plan and strategies for collaborative team working. Finally, Claire Thompson evaluated the effectiveness of a short-term, DBT-informed group targeting emotion regulation and distress tolerance among borderline personality disordered women in a low secure service. Navigating the early stages of a career in forensic psychology can be confusing and different routes to qualification as a forensic psychologist will suit different people. Furthermore, developments in routes to training can be unfamiliar to long-established psychologists. A collection of papers in 114 aimed to map out the journey of working towards qualification as a forensic psychologist, from multiple perspectives and including information on the BPS Stages 1 and 2, Doctoral routes to qualification and the Health and Care Professions Council routes. Dee Anand – Chair of the DFP Training Committee – set the context for the mapping of BPS Stages 1 and 2 and this was Forensic Update 2014 Annual Compendium

Editorial followed by an introduction to the papers in the training routes section by Roisin Hall, Chair of the Forensic Psychology Qualification Board. Contributions followed from Sarah Disspain (Forensic Psychologist in Training), Dean Fido (PhD student), John Hodge (Registrar and Chief Supervisor), Julie Harrower (Chief Assessor) and Cerys Miles (Supervisor). In complement to this themed issue, Mike Berry wrote in issue 116 on the benefits, disadvantages, challenges and rewards of forensic psychological training in Australia as compared to the UK. In 117, Geraldine Akerman interviewed Robert Paramo, a Senior Advisor and Registered Psychologist in the Office of the Chief Psychologist in the New Zealand Department of Corrections. Robert spoke to Geraldine about his experience of emigrating from the UK to New Zealand and offered some advice for others who might want to follow his professional pathway overseas. The Special Issue on commemorating the centenary of the First World War was introduced in 115 by Professor Jamie Hacker-Hughes, President Elect of the British Psychological Society. A brief historical overview of the relationship between the military and psychology was presented, followed by an overview of an invited symposium – Applied Psychology in the Armed Forces: Current Provision – presented at the British Psychological Society Annual Conference in May 2014. Fiona Butcher provided an overview of the role of a psychologist working in the Defence Science Technology Laboratory of the Ministry of Defence, with examples of applied research in a priority domain of Afghan National Security Forces members perpetrating Insider Attacks on members of the International Security and Assistance Force (Green on Blue). Secondly, Duncan Precious presented a description of the work of a uniformed clinical psychologist in the British Army and offered reflections on the personal and professional benefits and challenges of the dual role of being an Army Captain and a psychologist. Symposium contributions were followed by two Forensic Update 2014 Annual Compendium

research papers. In the first, Kathleen Roberts presented research on the effects of military operational tours on perceptions of mental illness and offending. Kevin WilsonSmith and Elizabeth Bates explored the lived experiences of military reserve service personnel adjustments to post-tour work and offered some unique considerations for applied psychological working with reservists. Finally, Simon Bonnett, Geraldine Akerman and a service user presented a summary of the mental health treatment needs of ex-service personnel, a historical overview of the military genesis of therapeutic communities and development in to forensic services, followed by a description of a group for veterans at HMP Grendon. Following on from the Special Issue papers in 115 were two articles with a focus on enhancing secure hospital service delivery and a further two on outcomes evaluation of group interventions for substance misuse. Katherine Crosby, Katie Downsworth, Katie Gilchrist and Kristy O’Hare described a secure hospital wardbased initiative to enhance therapeutic engagement among men and women patients, with positive outcomes for subsequent engagement with psychological interventions. Kenny Marshall, Kate Freshwater and Steve Potter described an initiative of using cognitive analytic therapy to inform reflection and decision-making within a clinical team working in an adult mental health forensic service, with a view to enhancing the psychological mindedness of the workforce. Thereafter, Faye Baker, Rachel Harwood, Michael Adams, Caroline Baker and Clive Long presented promising outcomes of an adapted CBT-based substance misuse group intervention for men in a low secure setting. Finally, Katie Downsworth and Eric Jones evaluated the effectiveness of the Addressing Substance Related Offending – Secure Treatment Programme for men in a medium and low secure hospital and made recommendations for greater consideration of mental health needs. 5

Continuing the theme of evaluating and enhancing practice in to 116 and 117, Tanya Garrett and Rosalind Wilcox presented findings from an 18-month evaluation of commissioners’ perspectives on the quality of psychological reports for adults in childcare proceedings and they concluded with a positive statement on the value of psychological opinion in court proceedings (116). Thereafter, in 117, Nina Preston presented a brief overview of psychologically informed planned environments (PIPEs) and presented observations of how the positive empowerment of offenders on a high security progression PIPE unit might contribute towards desistance. In the second, Donna Haskayne explored the experiences of nursing staff of a psychology-led clinical supervision group in a forensic mental health service. Donna’s paper highlighted key barriers to engagement in clinical supervision group and balanced these with nursing staff perceptions of value of the supervision. In Issues 114 and 115 we celebrated successes and here we are reminded of the annual Divisional awards that were presented at the Annual Conference in June in Glasgow 2014 (115). Congratulations to Dr Jamie Walton as recipient of the Junior Award in Forensic Psychology and to Dr Jackie Bates-Gaston for achieving the Senior Award for Distinguished Contributions to Professional Practice in Forensic Psychology. Congratulations also to Naomi Rose who was announced as the winner of the MSc dissertation competition in issue 114; Naomi’s paper is re-printed in this annual compendium.

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Within each of the issues of Forensic Update regular news features on developments within the Division, such as updates on training and qualification, Members’ reviews of training, conferences and book reviews are included. These are timely to the point of online publication so are not represented here. Readers are reminded to log in to the BPS Shop to access complete back copies of Forensic Update and to keep email contact details current so as to receive email notifications of new issues of Forensic Update. Strategic overviews presented by the Divisional Chair (Dee Anand, current; Ian Gargan, 2012–2014) are included in this compendium so as to orientate the reader to the strategic development and activities of the Committee. Finally, after four enjoyable years in her role as Co-Editor of Forensic Update, Emily Glorney is moving on. Emily is confident that, under the leadership of the incoming Co-Editor alongside Rachel Worthington, the Forensic Update team will continue to work actively to address the readership requirements of Forensic Update and continue to promote the value of forensic psychology. Please don’t hesitate to get in touch with suggestions for how Forensic Update might address your DFP membership needs and with ideas for themed issues and contributions. We hope that you find inspiration in this annual issue of Forensic Update. Emily Glorney & Rachel Worthington


Exciting New Firesetting Research Oppor tunity

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SAVE THE DATE The Division of Forensic Psychology is pleased to announce the 24th Annual Conference. Manchester Metropolitan University 1st–3rd July 2015

• Professor Don Grubin, Newcastle University • Professor Gabrielle Salfati, John Jay College of Criminal Justice, City University of New York • Professor Andrew Silke, University of East London • Profesor Douglas Boer, University of Canberra, Australia In addition to our confirmed keynote speakers there will be a mix of workshops, symposia, individual papers and posters presented, plus social activities and networking opportunities. Further information will shortly be available at:

www.bps.org.uk/dfp2015 8


Issue 114 – April 2014 10

Notes from the Chair Ian Gargan 11 Extended induction: Investigating the value of peer-led programmes in prison (An evaluation of the Trust programme at HMP/YOI E) Naomi Rose (Winner of the Third Annual MSc Dissertation Competition) Special Section on Working with Women Offenders 15 Attachment and development considerations when working therapeutically with adolescents who have experienced sexual trauma Emma Fisher 21 Assessing risk in female offenders: A review of the HCR-20 and the FAM Sarah Passmore, Samantha Woodhouse & Susan Cooper 27 Assessment and treatment with women who have committed offences within the family Susan Cooper & Alison Hodgson 31 Intimate relationships between female prisoners: Fact or fiction? Annette McKeown 37 Balancing the therapy role with the prison officer role Sue Devine, Grahame Greener, Karen Laws & Beverley Phillippo 42 Reflections of a trauma intervention with women in prison Michelle Carr, Alison Hodgson, Samantha Woodhouse & Marc Kerry 51 ‘Using CAT’ as opposed to ‘Doing CAT’: Adapting cognitive analytic therapy for use within a forensic patient setting Katie Gilchrist 57 Does adapted DBT have a place in forensic settings? The development of a DBT-informed emotion regulation group for female forensic personality disordered inpatients Claire Thompson Special Section on Becoming a Qualified Forensic Psychologist 65 Review of standards for Stage 1 and Stage 2 training Dee Anand 68 Training routes in Forensic Psychology Roisin Hall 69 How to become a Practitioner Forensic Psychologist Sarah Disspain 80 Pursuing a PhD in Forensic Psychology Dean Fido 82 The Qualification in Forensic Psychology (Stage 2) – Getting it done John Hodge 85 Assessment in the Forensic Qualification Dr Julie Harrower 88 The BPS Chartership vs. HCPC Training Route: A Supervisor’s perspective Cerys Miles


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Notes from the Chair Ian Gargan HE Division of Forensic Psychology (DFP) continues to grow in strength and influence. The work of forensic psychologists is promoted by universities, valued by government and sustains treatment within the community, prisons and hospitals with efficacy. Year in year, despite cutbacks in public spending, the voice of forensic psychology is being heard. Increasingly the Houses of Parliament search for consultation and liaison from us to guide their creation of policy. Communication with government and stakeholders is growing through earnest colleagues and the work of the British Psychological Society (BPS) policy team. Universities continue research and the number of doctorate placements is growing. Contact from other forensic psychology experts in various countries is trickling through the Division. Strength of presence is increasing with other specialists in psychology, such as our clinical, health, counselling and organisational colleagues. It has been my pleasure to witness this growth first hand over the past two years as a facilitator of a terrific team on the DFP committee representing all the Division's members. Our presence within the BPS has also been evident and the support from the Leicester office as well as the Board of Trustees has been nothing short of superb. Efforts are continually afoot from the BPS to harness the collective strength of 50,000+ members to offer assessment, treatment and education in forensic psychology through shared forums with our psychology colleagues among other specialties.

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Moreover, the past two years demonstrated the power of ‘THE’, and any, individual to contribute as well as effect change. Growing the presence of Forensic Update, talking with government offices, leading clinical colleagues to enter dialogue with forensic psychology and battling to maintain the quality of qualifications and training has been forged by strong individuals who offer so much. We and I am very thankful and, personally, impressed by their ability to effect change. Thank you, Dee Anand, for your continued support and I speak on behalf of all the DFP membership when we welcome you to the position of Chair. I hope you also witness such progress and humanism. Dee will become Chair at our annual conference in June in Glasgow. I encourage you all to attend if you can (and if you can garner some money from your organisation!) to contribute to the learning, AGM, and intellectual discussion. Your annual conference is so important in making louder the forensic voice nationally. Thank you all for the support in what has been an honour and privilege to serve the membership to promote forensic psychology in learning, practice and, I trust, continued development. The future is a bright sunrise and a collective responsibility. ‘So hope for a great sea-change On the far side of revenge. Believe that further shore Is reachable from here. Believe in miracles And cures and healing wells.’ Seamus Heaney Ian Gargan

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MSc Competition

Extended induction: Investigating the value of peer-led programmes in prison. An evaluation of the Trust programme at HMP/YOI E Naomi Rose Supervised by Dr Jane Wood at the University of Kent. ANY PRISONERS find the experience and the stresses of prison almost unbearable (Fazel et al., 2005). It has led to many suicides and incidents of self-injurious behaviour. Fazel et al. (2005) found that the suicide rate for men in prison is five times greater than men in the community. It has been found that in 20 per cent of self-inflicted deaths in prison, bullying or intimidation from other prisoners were the root cause (Prison and Probation Ombudsman, 2011). This becomes an increased problem when the prisoners have some form of learning difficulty and are deemed vulnerable. Loucks (2007) found that 20 to 30 per cent of all offenders have learning disabilities or other difficulties that interfere with their ability to cope with the criminal justice system. These prisoners are likely to need a lot more support in order to learn to cope with life in prison. These problems indicate that there is a need for appropriate support measures to be put forward. According to Adair (2005), an appropriately designed and supported peerled programme can have positive effects, expressed in enhanced prisoner well-being, reduced rates of self-harm and a calmer and more cooperative social environment. While there have been efforts to introduce peer-led support programmes in prisons, there has been an alarming shortage of research evaluating their effectiveness. The few research

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Forensic Update 2014 Annual Compendium F

studies on the outcome of such programmes indicate their positive effects. For instance, a ‘Pathfinder’ programme funded by the Home Office that incorporated the use of volunteers successfully (Home Office, 2008). Boehm (2012), found positive results from a mentoring scheme used within a mental health setting. One of the most successful elements was ‘the opportunity to relate to a fellow service user through shared understanding.’ The TRUST programme at HMP/YOI E, a local category B/C prison for adult men, is prison-led and aims to address the issue of vulnerable prisoners’ coping in prisons. It is run by prisoners for prisoners under the close supervision of staff. The TRUST aims to help offenders who experience problems due to bullying, notoriety, poor coping skills (e.g. having difficulty relating to other prisoners, getting themselves into trouble), etc. It is designed to address these issues effectively so that the offender is confident enough to relocate back into the main body of the prison. As well as improving knowledge and coping skills, participation in the TRUST programme is believed to reduce a prisoner’s current state of anxiety. The TRUST programme has been evaluated qualitatively (Rose, 2012), indicating prisoners’ satisfaction with the programme, but has not undergone any form of quantitative evaluation. It is for this purpose that the 11

current study was conducted. The aim of the current study was to assess prisoners’ psychological well-being before they embark on the programme and again once they have completed it. The objective was to investigate whether participation in the TRUST programme leads to a significant improvement in the participants’ psychological wellbeing and their ability to be fully reintegrated into the main body of the prison. It was hypothesised that taking part in the TRUST (The Reintegration, Understanding, Support and Training department) pro-gramme will increase prisoners’ understanding of prison related matters, improve their coping skills and reduce their anxiety levels.

Method Design The study involved a within participants, repeated measures longitudinal design. The independent variable was time (time one and time two) and the dependent variable was change (change in understanding, coping skills and anxiety levels).

Materials The materials consisted of an interview designed specifically for this study and questionnaires were used to examine the prisoners’ anxiety and coping skills, as well as feelings of competency in prison related matters. The questionnaire incorporated a modified version of Speielberger’s (1983) ‘State and Trait Anxiety Questionnaire’ to see if high levels of trait anxiety had any effect on change. Procedure Each TRUST course consisted of between five and seven participants and lasted for two weeks. The participants were given the time one questionnaire just before they started the TRUST course. They were then given the time two questionnaire once they had completed the course. This process was repeated for each set of prisoners entering the TRUST programme. The same participants were recruited to participate at time one and time two.

Key results Participants The participants were 16 male prisoners participating in the TRUST programme. All of them were believed to be vulnerable and not coping well in prison. The age range was from 18 to 47, with a mean age of 26. The mean sentence length of the prisoners was nine months, ranging from un-sentenced, as HMP E takes remand prisoners, to 36 months. The average length of time they had been in HMP E was one month, with a range of a few days to five months. Eight of the prisoners were sentenced and eight were on remand.

For each of the measures there was a positive increase in the mean values, with the greatest increase being with understanding, followed by coping strategies and finally anxiety (see Table 1). The significance of this was demonstrated using a paired samples t-test. The questions were divided into the three sections used on the questionnaire; understanding, anxiety and coping skills. The means from each section were used to perform the t-tests for each one, comparing time one and time two. The results from the

Table 1: Means and mean changes. Measure

Mean at time one (SD)

Mean at time two (SD)

Mean change

3.19 (1.02)

5.37 (1.13)

2.18

Coping strategies

3.44 (1.02)

4.46 (1.01)

1.02

Anxiety

3.90 (0.52)

4.41 (0.99)

0.51

Understanding

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t-test for understanding were t(15)=–5.69, p0.1), it was assumed that trait anxiety had no effect on the changes in understanding, anxiety or coping skills.

Discussion The results indicated that taking part in the TRUST programme had a positive impact on the prisoners’ understanding of prison matters; it improved their coping skills, and reduced their anxiety levels. The greatest and the most significant change was for understanding, followed by coping skills and lastly anxiety. It appeared that their base line anxiety, measured by the trait anxiety questions, did not have any significant impact on their ability to change as a result of the course. It is believed that the lower impact on anxiety may be due to the fact that the course is not focused on reducing anxiety directly, but does so indirectly by improving understanding. This takes time to take effect and works in conjunction with the support the prisoners receive on the wing after completion of the course to lead to a more gradual reduction in anxiety. Such effects are believed to be found if a further questionnaire was administered at the end of the prisoners’ stay on the TRUST


wing at time three. In addition, by the time the prisoners were questioned, at the start of the course, they had received the reassurance that they were receiving help in the form of the TRUST programme. This is likely to have already reduced their level of anxiety, making the measured change smaller. Coping strategies described by the prisoners before completing the course included talking to the TRUST peers, making friends, family support, and thinking about release. After they had completed the course there was a slight change to the descriptions they gave about how they coped, with an emphasis towards talking to people and writing things down. Several of them mentioned taking education courses. As the TRUST course advocates these issues, it would seem that the change in strategies occurred as a result of completing the programme. In conclusion, the results of the current study fill the void in the literature regarding research on peer-led programmes in prisons. The results of this study indicated that peerled programmes are effective support systems in prison settings, and thus, may be used as good practice within other prisons.

Acknowledgements I would like to thank the Governing Governor who facilitated this study and all of the prison staff that made it possible. I would also like to thank all of the prisoners that took part in the study and all of the Trust peers who gave me so much help along the way. I would especially like to thank DC, MW, SF and SB, without whose support, this project would not have been possible. Also, a thank you is due to my supervisor for all of her constructive input and support.

Correspondence Naomi Rose University of Kent. Email: [email protected]

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References Adair, D. (2005). Graduate Diploma, peer support programmes in prison. Tasmania: School of Sociology and Social Work. Advice, C. (2007). Locke Out: CAB evidence on prisoner and ex-offenders. London: Citizens Advice Bureau. Bath, C., & Edgar, K. (2010). Time is money: Financial responsibility after prison. London: Prison Reform Trust. Boehm, B. (2012). Mentoring within a high secure forensic establishment. Forensic Update, 106, 28–33. Fazel, S.E. et al. (2005). Suicides in male prisoners in England and Wales 1978–2003. The Lancet, 366. Home Office (2007). Home Office press release P100. London: Home Office. Home Office (2008). Criminal Justice. London: Sage. Loucks, N. (2007). No one knows: Offenders with learning difficulties and learning disabilities, Review of prevalence and associated needs. London: The Prison Reform Trust. Medlicott, D. (2001). Surviving the prison place: Narratives of suicidal prisoners. Aldershot: Ashgate. Ministry of Justice (2007). Deaths in custody 2007. Retrieved from Ministry of Justice website: www.justice.gov.uk/newsrelease010108ahtm. Ministry of Justice (2008). Factors linked to reoffending: A one-year follow-up of prisoners who took part in the Resettlement Surveys 2001, 2003 and 2004. London: Ministry of Justice. Ministry of Justice (2010). Safety in custody 2010 England and Wales. London: Ministry of Justice. Ministry of Justice (2012). Accomodation, homelessness and reoffending of prisoners. Research summary 3/12. London: Ministry of Justice.

Office, N.A. (2010). Managing offenders on short custodial sentences. London: The Stationery Office. Prisons and Probation Ombusman (2008–2009). Annual report. London: COI. Prisons and Probation Ombusman (2011). Learning from PPO investigation: Violence reduction, bullying and safety. London: Prisons and Probation Ombusman. Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self change of smoking: Towards an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. Rose, N.E. (2012). A qualitative evaluation of the TRUST programme. Unpublished manuscript. Spielberger, C.D. (1983). Manual for the State-Trait Personality Inventory. Florida: University of Florida. Spitser, R.L., Williams, J.B. & Kroenke, K. (1999). The primary care evaluation of mental disorders patient health questionaire. Sandwich: Pfizer. Spritzer, R.L., Kroenke, K., Williams, J.B., & Lowe, B. (2006). A brief measure for assessing generalised anxiety disorder. Arch Inern Med, 1092–1097. System, N.O. (2005). Volunteering. Retrieved from unlock.or.uk: http://www.unlock.org.uk/userfiles/file/IAG/Vo lunteering_Guide_for_prisons.pdf Talbot, J. (2007). No one knows: Indentifying and supporting prisoners with learning difficulties and learning disabilities: The veiws of prison staff. London: The Prison Reform Trust.

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Working with Women Offenders

Attachment and development considerations when working therapeutically with adolescents who have experienced sexual trauma Emma Fisher HE AIM OF THIS PAPER is to use my personal experience of working with victims of sexual trauma and link it with the theories of therapeutic work with children. This will enable me to better understand how to work with adolescents on a therapeutic level in my role as a person centred counsellor. I will be looking at various theorists, such as Freud, Winnicott and Bowlby and the more recent model from SACCS; specialists in residential therapeutic treatments for children who have suffered severe abuse. My experience of working with sexual trauma has come from my work at the Lancashire SAFE Centre, which is the Sexual Assault Forensic Examination Centre for Lancashire and Cumbria. As a crisis worker I work directly with the complainants of rape and sexual assault a few hours after the incident has happened. This has allowed me to see how trauma can affect a person. We see men, women and children of all ages, however, the majority are young people. Last year we saw 462 cases which were a mixture of ages. From this number 47 per cent were under the age of 18 and 53 per cent of those were classed as adolescents, between the ages 11 to 17 years. (E. Fisher, SAFE Centre, 15 July 2013) The definition of an adolescent from The Oxford Dictionary is ‘(of a young person) in the process of developing from a child into an adult’ (The Oxford Dictionary, 2013). There is no clear beginning or end to adoles-

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Forensic Update 2014 Annual Compendium 6

cence but it tends to be whilst the young person is going through puberty. Although no one is to blame for being the victim of a sexual assault there are some factors which can increase the likelihood. These include alcohol, drugs, and risk taking behaviours such as being out alone at night. Adolescents can fall prey to all of these; however, there are other factors specific to young people which can increase their vulnerability. These include being under children’s social services, family dysfunctions and a poor social economic standing (Rymaszewska & Philpot, 2006). The following statistics give emphasis to these factors. Looking at the adolescents who attended the SAFE Centre last year, 35 per cent were from a separated family, 27 per cent had consumed alcohol prior to the assault, 24 per cent had pre-existing mental health issues such as self-harm and anger management, 10 per cent were ‘looked after children’ in the social care system and four per cent had attended the SAFE Centre before. (E. Fisher, SAFE Centre, 15 July 2013) Working with adolescents who have been through a traumatic event has shown me how differently each one will react. To show an example of this I will describe two 13-yearold girls who were the victim of rape by an adult male and attended the SAFE Centre for forensic examination with the police. It is important to mention here that these characters are not based on any one individual 15

but on my collective experiences of being a crisis worker at the SAFE Centre for seven years. Client one presents as confident. She is not interested in answering questions and is more bothered about having a cigarette. She is accompanied by a social worker who has brought her from the children’s home she resides at. Her mother is made aware of the allegation as she holds full parental consent but refused to attend and will give consent over the phone. During the initial meeting and history taking she is restless and makes jokes with the social worker. This is not her first sexual experience or the first time she has drunk alcohol. Client two presents as quiet and withdrawn. She does not make eye contact or speak to anyone other than her mother and father who have accompanied her. She has brought a change of clothes and a blanket which is apparently her comforter. During the initial meeting and history taking her mother answers most of the questions. It is understood this is her first sexual experience and the first time she has drunk alcohol to excess. These two teenagers are set to show how children the same age can be completely different in terms of their understanding, maturity, level of puberty and self development. They are both offered the same service at the SAFE Centre and have to answer the same questions, however, their responses and apprehension can be poles apart. This illustrates the multifaceted approach required to work with them therapeutically. According to Freud and his psychodynamic theory back in the 1880s, from the day we are born our lives are a battle to meet our urgent innate needs. We gradually learn these needs cannot always be met so we develop coping strategies (Beckett, 2002). As we move into adult life, taking these strategies with us, we may experience difficulties coping with circumstances such as rejection, loss and love. This is because the strategies formed have been maladaptive. Freud also 16 F

believed that psychological problems in adulthood were born from suppressed phantasies of one’s desires in childhood. John Bowlby, a psychoanalyst in the 1950s, believed the external influences on a child had a more tangible effect on their development than Freud’s internal phantasies. He studied the relationship between mothers and babies in humans as well as mammals and found there was a deep connection between the mother and child. When this connection was broken by separation, for example, the child would become distressed. This created the idea of the secure base and attachment behaviours. Together with Mary Ainsworth, a developmental psychologist, Bowlby categorised attachment behaviours into five types: secure; anxious-avoidant; anxious-ambivalent; disorganised; and non-attached (Beckett, 2002). Looking at our clients from the SAFE Centre, we can suggest the type of attachment behaviours they may convey. Client one has an anxious-avoidant strategy. She does not seem distressed at the knowledge that her mother is not coming and can seem ambivalent to the carer. She may seek attachments with others but will show little distinction in how she acts with her carers and strangers. If she has grown up in a chaotic household she may have had many care givers. She will be ambivalent as to who gives her the love and attention as long as she gets it. This may have lead to her risk taking behaviour and increased vulnerability to perpetrators such as the male who raped her. Anxious attachments in childhood have been linked with substance misuse, eating disorders, early sexual activity and high-risk sexual behaviour in adolescents (Geldard & Geldard, 2004). Client two seems to have a secure attachment strategy. Her parents have both come to her rescue and provided comfort. She may present as immature compared to Client one, however, this is likely due to her secure upbringing. She will not have experienced as much trauma or dysfunction as Forensic Update 2014 Annual Compendium

Client one and has, therefore, been protected from accelerated maturation. It is important that her parents allow her to try new situations to increase her independence whilst continuing a consistent level of parental control. Client two may have been acting more like an adult whilst out drinking with friends but is more likely to revert to being a child at any sign of danger (Geldard & Geldard, 2004). The attachment strategies of these clients is an important consideration when working therapeutically with them. An anxiousavoidant strategy may present challenges such as difficulties in developing a therapeutic relationship. The client may have issues in trusting and so may have a robust defence system. The relationship between the client and counsellor will be an important indicator of the client’s attachment strategy. Transference of the client’s feelings or attitudes towards their carer or the perpetrator may be experienced. The counsellor will need to be aware of their own countertransference to prevent reinforcing the client’s earlier negative experiences (Rymaszewska & Philpot, 2006). The therapeutic relationship can be used as an example of a healthy relationship and an altered attachment experience for the client (Purnell, 2004). Client two may find it easier to create a therapeutic relationship as she will have experienced unconditional positive regard from her parents. This is not to say that therapy will be easier for client one. Client two has still been the victim of a rape which will undoubtedly have an effect on her confidence and her sense of self. Adolescents are in the process of transforming from child to adult. Lesley Day, the Head of the Specialist Personality Disorder Service at Cassel Hospital in London, describes it as ‘a time fraught with different and transient emotions and states of mind, offering a particular kind of freedom to have new ideas and explore one’s identity’ (Day, 2003, p.9).

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The development of one’s self or identity is an essential part of maturation. Object relations theory is another expansion of Freudian thinking. The theory states that to achieve a sense of self and other, one must have experienced a secure relationship with their primary care giver. The care giver becoming the ‘other’ and, therefore, distinguishes the child as a separate self (Beckett, 2002). Winnicott placed emphasis on the parent-infant relationship in the emotional development of the child. He suggested that if the basic needs of the child are met dependably, the carer is ‘mirroring’ the child. Having these needs mirrored allows the child to develop their ‘true self’ (Winnicott, 1984). So it seems that like attachment strategies, the early development of a child’s sense of self is also an important consideration. A child’s ability to cope with changes in their internal world such as emotions and their external world such as family dynamics is based on their experiences in early childhood. There are also biological considerations in terms of an adolescent’s development and their reaction to trauma. Zoe Loderick is a psychotherapist who specialises in the treatment of trauma. Her work describes the part of the brain called the amygdala, which is the part that filters through stimuli in the search for any threats. If a threat is established, the part of the brain called the hypothalamus is immediately stimulated to respond. This response is known as the ‘fight or flight’. Loderick goes on to explain that if these responses are damaged by lack of success, it will be more likely that the person will become traumatised and possibly the repeat victim of trauma (Loderick, 2010). In the case of client one, she has become passive to sexual advances from males. She may have learnt that to stay and fight or to try to run are both futile tasks. This may have led to her being programmed to allow the assault and not to use her active responses. With this perhaps being the first major 17

trauma Client two has faced, her defences will hopefully not be too damaged. Through counselling there is hope she will find adaptive ways of coping to prevent these feelings becoming long-term sequelae (Varma, 1992). After looking at the theoretical considerations for working with adolescents who have experienced sexual trauma, I will now look at the most advantageous conditions for therapy. Carl Rogers, the father of personcentred therapy, believed there are six necessary and sufficient conditions to initiate constructive personality change (Rogers, 1959). These include the counsellor feeling empathy, congruence and unconditional positive regard for the client. To offer a safe and caring space is important to any client but especially for adolescents, and those that have experienced trauma. Winnicott believed that a ‘holding environment’ was essential to counselling. This ‘holding environment’ can be created by providing a nurturing and unconditional space where the client feels secure, this is to simulate the feeling of a child being held in his mother’s arms (Winnicott, 1984). This environment can be strengthened by creating boundaries within the session. Counselling sessions naturally have boundaries of time, place and confidentiality which are very important in retaining the consistency of the session and, therefore, the relationship. With children and adolescents it is important to recognise that they may not want to communicate verbally. They may prefer to play with toys, craft materials or doodle on a piece of paper. Interjections and questions from the therapist should be kept to a minimum so they can experience the ‘not knowing’ and indecision of the play or picture along with the child. This is an example of creating a holding atmosphere for the child to relax in (Rymaszewska & Philpot, 2006). It is significant to mention at this point the legal and ethical side to the boundaries. As a crisis worker in the NHS I am bound by policies and procedures in regards to safeF 18

guarding and child protection. The Children Act 1989, however, does not say we have a general obligation to disclose all suspicion of abuse; therefore, as a counsellor I do not have to report child abuse, if I believe the disclosure to be immediately detrimental to the child’s safety. Ethically I typically come from a consequestional ethical approach where I weigh up the potential outcomes before I make a decision. I also include the client in the process wherever possible. I believe the adolescent should have a clear understanding of the boundaries to confidentiality in the therapy and to be able to negotiate if they wish. This is the only way trust can be created. During the SAFE Centre procedure we are very clear on our boundaries of confidentiality and the client’s own autonomy. We require parental consent to examine a child under 16, however, we will not proceed if the child themselves tells us to stop. The parents and the police often want the child to be examined for evidence but we give the autonomy back to child with the strong message, that no one has the right to do anything to you that you do not want to happen. It seems vital to mention at this point these boundaries relate to the therapist as well. It is paramount that therapists we are aware of and retain their own limitations. Vicarious trauma can be a common result of working with sexual trauma and is where the therapist can experience the same level of trauma as the client by transference. Pistorious (2006) interviewed (as cited in Nen et al., 2006) female therapists who worked with sexually abused children and found that working with victims had an impact on therapists, personally and professionally. It is essential therapists and professionals have regular supervision to reduce the potential of vicarious traumatisation. A more recent approach to working with traumatised children has been the development of SACCS, the Sexual Abuse Child Consultancy Service, in 1987 by Madge Bray and Mary Walsh. Their wealth of experience Forensic Update 2014 Annual Compendium

working in this field has helped them to devise structured therapeutic interventions in residential care and family placements. There are three integrated strands to their work; therapy, life story work and therapeutic parenting. The therapy entails much of what has been talked of above and allows the child to carefully explore their inner world. The life story work helps the child to answer questions about their past such as What? Why? and When? Together with a worker the child collects evidence such as photos to help them understand their history. Finally therapeutic parenting provides a secure base for the child in their day to day life. This experience will hopefully help fill in the gaps in the child development enabling them to feel differently about themselves and the world around them. The SACCS integrated model works with ‘Openness, not secrecy; communication, not avoidance; and predictability, not inconsistency’ (Rymaszewska & Philpot, 2006, p.19). There are a number of different approaches and considerations when working therapeutically with adolescents. The two clients presented have shown how each adolescent will have had a different life experience and it is this experience which can


unlock the path to positive steps in development. It is very important for a therapist to have an understanding of attachment strategy, transference and human development. I believe it is up to the client to choose the best approach for them, whether it is psychodynamic, person-centred or an integrated model. The importance for me is that adolescents have access to express themselves in safety. A multi-agency approach provides the safety net the adolescent will need to be able to explore their inner and outer worlds. Therefore, I believe it is paramount to maintain clear boundaries and open channels of communication with the client and all associated carers and agencies. In this environment the child will hopefully be able to explore their learned behaviours to reach a healthier and more stable state of being.

Correspondence Emma Fisher MBACP Affilicated with Lancashire SAFE Centre for the victims of rape and sexual assault and Circle Counselling Service for the victims of domestic abuse. Email: [email protected]

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References

Bibliography

Beckett, C. (2002). Human growth and development. London: Sage. Children Act 1989 (UK). Retrieved 30 July 2013, from: http://www.legislation.gov.uk/ukpga/1989/41/ contents Day, L. & Flynn, D. (2002). The internal and external worlds of children and adolescents. London: Karnac Books. Geldard, K & Geldard, D. (2004). Counselling adolescents (2nd ed.). London: Sage. Loderick, Z. (2010). Psychological trauma – what every trauma worker should know. Retrieved 30 July 2013, from: http://www.zoelodrick.co.uk/training/article-1 Nen, S., Astbury, J., Subhi, N., Alavi, K., Lukman, M., Sarnon, N. & Mohamad, M.S. (2011). The impact of vicarious trauma on professionals involved in child sexual abuse cases (CSA). Pertanika Journal Soc. Sci. & Hum., 19(s), 148. Retrieved 30 July 2013, from: http://www.pertanika.upm.edu.my/ Pertanika%20PAPERS/JSSH%20Vol %2019% 20%28S%29%20Oct.%202011/25%20Pg% 20147-155.pdf Purnell, C. (2004). Attachment theory and attachmentbased therapy. Retrieved 15 July 2013, from: http://www.thebowlbycentre.org.uk/pdf/ attachment%20and%20attachment%20based %20therapy.pdf Rogers, C.R. (1959). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting and Clinical Psychology (1992), 60(6), 827–832. Retrieved 30 July 30 2013, from: http://psycnet.apa.org/journals/ccp/60/6/827/ Rymaszewska, J & Philpot, T. (2006). Reaching the vulnerable child: Therapy with traumatised children. London: Jessica Kingsley Publishers. The Oxford Dictionary (2013). Adolescent. Retrieved 30 July 2013, from: http://oxforddictionaries.com/definition/ english/adolescent. Winnicott, C., Shepherd, R. & Davis, M. (Eds.) (2012). Winnicott deprivation and delinquency. London: Routledge.

Carr, A. (2009). What works with children, adolescents, and adults? A review of research on the effectiveness of psychotherapy. London: Routledge. Daniels, D. & Jenkins, P. (2010). Therapy with children – children’s rights, confidentiality and the Law. London: Sage. Erikson, E.H. (1963). Childhood and society. London: Vintage UK. Friedberg, R.D. & McClure, J.M. (2002). Clinical practice of cognitive therapy with children and adolescents – the nuts and bolts. New York: Guilford Press. Gerhart, S. (2004). Why love matters. London: Routledge. Karle, H. (1992). The filthy lie. London: Penguin. Mitchell, R. (2011). New shoes – stepping out of the shadow of sexual abuse and living your dreams. Oxford: Lion Hudson.

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Assessing risk in female offenders: A review of the HCR-20 and the FAM Sarah Passmore, Samantha Woodhouse & Susan Cooper N A PRISON SYSTEM largely designed for men there is a need to recognise the issues that women encounter and how they link to their risk. Women represent around five per cent of the total prison population (Home Office, 2013) and although the overall number of female prisoners appear to be reducing (Home Office, 2013), it is important to note that the number of females committing violent offences has risen by 6.2 per cent since 2007 (Home Office, 2011). This paper will explore female pathways in to crime, whilst considering the benefits of a more gender specific approach to risk assessments, in particular the Female Additional Manual (FAM). Pathways into crime have undergone extensive research interest, highlighting what leads an individual into crime (Bloom, Owen & Covington, 2003; Corston, 2007). Whilst it is important to acknowledge that men and women do commit the same offences, it is beneficial to explore how pathways and motives may differ between the sexes. In doing so, this may highlight female specific needs which can inform a more gender sensitive approach to predicting future violence. Female pathways in to offending differ to those of males (Corston, 2007). Research indicates that women experience more traumatic childhoods, including violence in the family home (Rossegger et al., 2009). Around 50 per cent of women in prison have reported experiencing domestic violence, compared with a quarter of men (Corston, 2007). Additionally, one in three women have reported suffering sexual abuse, compared to one in 10 men (Corston, 2007).

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Experiences of abuse have been linked to an increased risk of committing violent offences, and although this link exists for men, research suggests that this link is more evident for women (de Vogel et al., 2012). Subsequently, victimisation can be a major cause in future criminal activity, drug use and relationship difficulties. As quoted in Baroness Corston’s report, ‘A vicious circle of victimisation and criminal activity develops, creating a toxic lifestyle that is extremely difficult to escape’ (Corston, 2007). Interestingly, histories of trauma and abuse are associated with a higher prevalence of substance misuse (de Vogel et al., 2012). It could be considered that women may use substances in an attempt to reduce or suppress negative affect and memories of abuse (Briere, 2002; Swadi, 2000). Drug offences make up around 21 per cent of all offences committed by females, making it the second most common offence in 2007. It has been reported that women are often first introduced to illicit substances by partners, who can then encourage the women into sex work as a means to fund their addictions (Bloom, Owen & Covington, 2003; Scott & Dedel, 2006). It is important to note that women’s involvement in crime often occurs through their relationships with family, friends and intimate partners (Bloom, Owen & Covington, 2003). The characteristics of violence committed by women are different to men (de Vogel, 2011). For example, violence perpetrated by a women is often more subtle and can occur in the context of relationships, families and child abuse (Monahan et al., 2001). Research indicates 21

that women perpetrate a similar level of intimate partner violence to that of men (Dutton, Nicholls & Spidel, 2005). It is noteworthy, however, that women have different motives for intimate partner violence than men, including jealousy and self-defence (Kruttschnitt & Carbone-Lopex, 2006) and women can use violence towards their partner as a reaction to ongoing violence by the male (Allen, Swan & Raghavan, 2009). Major mental illness has been found to be more prevalent in women than in men, and it is estimated that approximately 80 per cent of women in custody are found to have a mental health problem (Corston, 2007). Mental illnesses which are mainly or solely prevalent in females include post natal depression, postnatal psychosis and Fabricated or Induced Illness (also known as Munchausen by Proxy Syndrome) have been found to have a link to violence, especially towards children. It is important to note that although Fabricated or Induced Illness is evident in males, in most cases the perpetrator is the mother (Motz, 2001). Women are often the primary carers for their children and are at a higher risk of experiencing postnatal depression if they have a lack of social support, have experienced abuse, have low self-esteem or have experienced previous mental health difficulties (Mind, 2013). As previously discussed, a large percentage of women in prison have experienced abuse and enter prison with diagnosable mental health problems, potentially putting them more at risk of developing postnatal depression in the future.

Risk assessments In order to explore gender and risk of violence, it is important to consider the benefits of using a gender specific risk assessment. The prediction of violent behaviour has been subject to considerable clinical and research interest over the last three decades, and has seen several controversial debates regarding the actuarial vs. clinical approach to the inter-rater reliability and predicted validity of these methods (Monahan & F 22

Steadman, 1994; Mossman, 1994; Webster et al., 1997). The development of the Structured Professional Judgment approach (SPJ) by Webster et al. (1997) is widely used when assessing risk of violent behaviour. It is important to note that until recently there was no violent risk assessments developed specifically for the use with female offenders. Buss (1961, cited in Bjokqvist, 1994) stated ‘women are so seldom aggressive, that female aggression is not worth the trouble to study’. Aggression was, according to his view at that time, typically a male occurrence (Bjokqvist, 1994), and research indicates that ‘being male is one of the best predictors of violent and criminal behaviour’ (de Vogel, 2012). In addition, women historically committed fewer violent offences then men; although, as noted, violence perpetrated by women appears to have increased (Home Office, 2011). It has been reported that women experience aggression differently to men (Dittmann, 2003) and use more indirect aggression such as gossiping, spreading rumours, or other ways of damaging a person’s sense of self (deVogel, 2012). Men present more physical violence then women (Bjorkqvist, 1991); however, it is important to not underestimate a woman’s risk of committing physical violence. Men have been seen to be aggressive outside of the relationship, whereas women are more prone to aggression inside a relationship and within families (Monahan et al., 2001), again highlighting gender differences in the experience and perpetration of aggression and violence. The HCR-20 was developed by Webster et al. (1997) and it set to achieve a comprehensive way to assess to risk of violent behaviour and the first using the SPJ approach (Guy, 2008). The HCR-20 consists of 20 items across three domains including Historical, Clinical and Risk Management, which also can be seen as past, present and future (Table 1). It was created to be used with specific populations including forensic and psychiatric individuals and refers to a specific definition of violence throughout Forensic Update 2014 Annual Compendium

Table 1: Historical, Clinical and Risk Management-20 items (Webster, Douglas, Eaves & Hart, 1997). Historical (past)

Clinical (present)

Risk Management (future)

H1: Previous violence

C1: Lack of insight

R1: Plans lack feasibility

H2: Age of first violent incident

C2: Negative attitudes

R2: Exposure to Destabilises

C3: Active symptoms of major mental illness

R3: Lack of Personal Support

H3: Relationship instability H4: Employment problems

C4: Impulsivity

H5: Substance misuse problems

C5: Unresponsive to treatment

R4: Non-compliance with remediation attempts R5: Stress

H6: Major mental illness H7: Psychopathy H8: Early maladjustment H9: Personality disorder H10: Prior supervision failure

the manual. ‘Violence is defined as ‘actual, attempted, or threatened harm to a person or person’ (Webster et al., 1997, p.24). The reliability and validity of the HCR-20 has been of great interest to researchers around the world. Many researchers have focused on the use of the HCR-20 with male offenders as it has been highly validated as a good predictor of violent behaviour (Douglas & Weir, 2003; Gray, Taylor & Snowden, 2008) and a well known instrument used when assessing risk of violence. There have been concerns with the use of this instrument with female offenders in regards to the predicted accuracy of the tool (de Vogal & de Ruiter, 2005). As previously noted, it can be argued that females offend for different reasons from those of men. It is important to note that although some items are similar in the HCR-20 for males and females such as mental illness and psychopathy, additional guidelines may be needed for women (Blanchette, 1997; Harer & Langan, 2001). It is important to capture factors that may increase the risk of violence that are exclusive to or more prevalent in women, including postnatal depression, fabricated or induced illness (previously Munchausen by Proxy Syndrome) and prostitution. 1Forensic Update 2014 Annual Compendium

Debates and research into the factors that influence woman into committing crimes have been long over due and the introduction of the Female Additional Manual (FAM) is a recent development into violent risk assessments for females. The FAM was based on the HCR-20 and developed by de Vogel, de Vries Robbe, van Kalmthout and Place (2011). Although it has been found that there are many risk factors attributable to females and males in the HCR-20, they felt that additional items and guidelines were needed to work in partnership with the HCR-20 to develop a more gender specific approach to assessing female’s risk of violent behaviour.

Discussion The research into female risk assessment is a recent development and an important issue to understand and acknowledge. It has been seen that the number of crimes, specifically of a violent nature, have increased (Home Office, 2013), and research in to the differences between male and female violence continues. In order to approach female risk more specifically, the Female Additional Manual incorporates additional items and guidelines to assist in the assessment of 23

Table 2: Female Additional Manual items (de Vogel, de Vries Robbe, van Kalmthout & Place, 2011) Historical (past)

Clinical (present)

Risk Management (future)

H6: Major mental illness (additional guidelines)

Specific risk factors for women

Specific risk factors for women

C6: Covert/manipulative behaviour

R6: Problematic child care responsibility

C7: Low self-esteem

R7: Problematic intimate relationship

H7: Psychopathy (additional guidelines) H8: Early Maladjustment (additional guidelines) H8a: Problematic circumstances during childhood H8b: Problematic behaviour during childhood H9: Personality disorder (additional guidelines) H10: Prior supervision failure (additional guidelines) Specific risk factors for women H11: Prostitution H12: Parenting difficulties H13: Pregnancy at young age H14: Suicdality/Self-harm H15: Victimisation after childhood

violent risk in females by using a more gender specific approach. However, it is important to acknowledge the recent development of the HCR-20 version three (HCR-20v3), which incorporates a wider, more comprehensive variety of risk factors. Additionally, the HCR-20v3 allows the clinician to think more psychologically about the individual by including opportunity to formulate the person’s risk, and plan for likely scenarios in which violence may occur. The revision of the HCR-20v3 is recommended for use on both men and women, and in a recent study, gender was not considered to be predictive of future violence (Douglas & Strub, 2013). This would suggest that the sole use of the HCR-20v3 would be sufficient when assessing women’s risk of violence. Many of the additional guidelines 24 F

and items included in the FAM are now highlighted within the HCR-20v3, for example, there is now a more extensive description of mental health difficulties, and victimisation following childhood is now covered. That said, the FAM continues to provide specific items that could be overlooked when scoring the HCR-20v3, including prostitution, parenting difficulties, low self-esteem and pregnancy at a young age, which highlights the need to use each in conjunction with the other. Increased numbers of violent offences committed by women have highlighted the need for risk assessments to capture a diverse range of risk factors, in order to ensure risk of future violence is not underestimated. It is important to understand the importance of female pathways into crime and how they Forensic Update 2014 Annual Compendium

differ in terms of prevalence, characteristics and motives to their male counterparts, in order to accurately predict risk. By using traditional risk assessment such as the HCR-20 alone, clinicians may underestimate a female’s level of risk by excluding female specific items. The FAM has only recently been developed and, therefore, further research and clarification into the validity of these items is required. It would be beneficial to expand upon findings used to develop the FAM in order to develop our knowledge of female specific risk factors. As research on the FAM has focused specifically on forensic psychiatric females in the Van der Hoeven Kliniek, it would be valuable to widen this further and use a variety of populations, including age groups and nationalities, in order to assess predictive validity. As noted within the FAM manual, as the majority of risk items are historical, it would be beneficial to explore more recent and future risk items that could be affected by treatment and interventions. Additionally, it would appear that more research is needed around specific items, particularly in relation to prostitution and

how this is linked with violence in women. Following this, we may develop more insight and understanding in to why women commit violence and how we can effectively predict and manage this within our services.

The Authors Sarah Passmore, Samantha Woodhouse & Susan Cooper Primrose/PIPE Programme, Tees Esk and Wear Valleys NHS Foundation Trust, HMP & YOI Low Newton.

Correspondence Sarah Passmore Higher Assistant Psychologist. Email: [email protected] Samantha Woohouse Higher Assistant Psychologist. Email: [email protected] Dr Susan Cooper Lead Psychologist. Email: [email protected]

References Allen, C.T., Swan, S.C. & Raghavan, C. (2009). Gender symmetry, sexism, and intimate partner violence. Journal of Interpersonal Violence, 24(11), 1816–1834. Belknap, J. (2001). The invisible woman: Gender, crime, and justice. Belmont, CA: Wadsworth. Benda, B. (2005). Cited in de Vogel, V., de Vries Robbe, M., Van Kalmthout, W. & Place, C. (2012), The Female Additional Manual (FAM). Additional guidelines to the HCR-20 for assessing risk for violence in women. Van der Hoeven: Stichting. Bjokqvist, K., Lagerspetz, K.M.J., Kauklainen, A. (1991). Do girls manipulate and boy’s fight? Developmental trends in regard to direct and indirect aggression. Aggressive Behaviour, 18, 117–127. Buss, A.H. (1961) The psychology of aggression. Cited in Bjokqvist, K. (1994), Sex differences in physical, verbal and indirect aggression: A review of recent research. Sex Roles, 30, 3/4 Blanchette, K. & Brown, S.L. (2006). Cited in de Vogel, V., de Vries Robbe, M., Van Kalmthout, W. & Place, C. (2012), The Female Additional Manual (FAM). Additional guidelines to the HCR-20 for assessing risk for violence in women. Van der Hoeven: Stichting.

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Blanchette, K. (1997). Comparing violent and nonviolent female offenders on risk and need. Cited in Poels, V. (2005), Risk assessment of recidivism of violent and sexual female offenders. Rotorua: Department of Corrections, Psychological Service: Bloom, B., Owen, B. & Covington, S. (2003). Genderresponsive strategies: Research, practice, and guiding principles for women offenders project. Guiding principles and strategies draft document. Washington, DC: National Institute of Corrections. Corston, B. (2007). The Corston Report. London: Home Office. de Ruiter, C. & de Jong, E.M. (2005). Cited in de Vogel, V., de Vries Robbe, M., Van Kalmthout, W. & Place, C. (2012), The Female Additional Manual (FAM). Additional guidelines to the HCR-20 for assessing risk for violence in women. Van der Hoeven: Stichting. de Vogel, V., de Vries Robbe, M., Van Kalmthout, W. & Place, C. (2012). The Female Additional Manual (FAM). Additional guidelines to the HCR-20 for assessing risk for violence in women. Van der Hoeven: Stichting.

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Douglas, K.S & Weir, J. (2003). HCR-20 Violence risk assessment scheme: Overview of annotated bibliography. Cited in de Vogel, V. & de Ruiter, C. (2005), The HCR-20 in personality disordered female offenders: A comparison with a matched sample of males. Clinical Psychology and Psychotherapy, 12, 226−240. Funk, S. (1999). Risk assessment for juveniles on probation: A focus on gender. Criminal Justice & Behaviour, 26, 44–68. Garcia-Mansilla, A., Rosenfeld, B. & Nicholls, T. (2009). Risk assessment: Are current methods applicable to women? International Journal of Forensic Mental Health, 8, 50–61. Gray, N.S., Taylor, J. & Snowden, R.J. (2008). Predicting reconvictions using the HCR-20. British Journal of Psychiatry, 192(5), 384–387. Guy, S.L. (2008). Performance indicators of the structured professional judgment approach for assessing risk of violence to others: A meta-analytic survey. Canada: Simon Fraser University. Harer, M. & Langan, N. (2001). Gender differences in predictors of prison violence: Assessing the predictive validity of a risk classification system. Crime & Delinquency, 47, 513–36. Home Office (2011; 2013). Retrieved from: http://www.justice.gov.uk/statistics Kruttschnitt, C. & Carbone-Lopez, L. (2006). Patterns of intimate partner violence and their associations with physical health, psychological distress, and substance use. Public Health Rep., 121(4), 382–392. Loucks, N. (2004). Women in prison. Cited in de Vogel, V., de Vries Robbe, M., Van Kalmthout, W. & Place, C. (2012), The Female Additional Manual (FAM). Additional guidelines to the HCR-20 for assessing risk for violence in women. Van der Hoeven: Stichting. Messer, J., Maughan, B., Quinton, D. & Taylor, A. (2004). Precursors and correlates of criminal behaviour in women. Crime Behaviour Mental Health, 14(2), 82–107.

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Mind, (2013). Retrieved from: http://www.mind.org.uk/mental_health_a-z/ 8007_postnatal_depression Monahan, J., Steadman, H. (2004). Violence and mental disorder: Developments in risk assessment. Cited in Dolan, M.(2000), Violent risk prediction, clinical and actuarial measures and the role of the Psychopathy Checklist. The British Journal of Psychiatry, 177, 303–311. Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T. & Banks, S. (2001). Rethinking risk assessment: The MacArthur study of mental disorder and violence. Oxford: Oxford University Press. Morgan, M. & Patton, P. (2002). Gender-responsive programming in the justice system: Oregon’s guidelines for effective programming for girls. Federation Probation Journal, 66(2). Mossman, D. (1994). Assessing predictions of violence: Being accurate about accuracy. Journal of Consulting Clinical Psychology, 62(4), 783–792. Motz, A (2001). The psychology of female violence. Crimes against the body. East Sussex: Brunner-Routledge. Scott, M. & Dedel, K. (2006). Retrieved from: http://www.nij.gov/topics/crime/prostitution/ pathways.htm Swan, S., Gambone, L.J., Fields, A.M., Sullivan, T.P. & Snow, D.L. (2005). Women who use violence in intimate relationships: The role of anger, victimisation, and symptoms of post-traumatic stress and depression. Violence and Victims, 20, 267–285. Vollm, B.A. & Dolan, M.C. (2009). Self-harm among UK prisoners: A cross-sectional study. The Journal of Forensic Psychiatry & Psychology, 20, 741–751. Webster, C., Douglas, K., Eaves, D. & Hart, S. (1997). HCR-20 Assessing Risk for Violence. Version 2.



Assessment and treatment with women who have committed offences within the family Susan Cooper & Alison Hodgson VER RECENT YEARS there has been a greater recognition of gender differences in the pathways to offending and the specific needs of female offenders (e.g. Belknap, 2001). Female offenders often have a history of trauma and abuse; domestic violence; and current mental health issues including personality disorder, substance misuse and self-harming behaviour (Bloom, Owen & Covington, 2003; Corston, 2007). Such factors can be relevant when trying to understand their offending behaviour (Blanchette & Brown, 2006; Chesney-Lind, 1997). In response to these needs, the Corston report Review of Women with Particular Vulnerabilities in the Criminal Justice System (Home Office, 2007) highlighted the need for a holistic, individualised, ‘womencentred’ approach to working with women. More recently, the need for gender specific approaches is as outlined in the NOMS document, A distinct approach: A guide to working with women offenders (NOMS, 2012). This paper will focus on a distinct group of women offenders, those who have committed an offence against a person in the family, including violence against a partner and offences related to the physical and sexual abuse of children. It is widely accepted that women are victims of domestic abuse; research indicates over half the women in prison report being a victim of domestic violence (Norman & Barron, 2011), but over recent years research has started to reveal the extent to which women are perpetrators as well as victims. Some studies indicate levels of domestic violence

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perpetrated by females were comparable or in excess of those perpetrated by men (e.g. Archer, 2000, 2002; Bookwala, 2002; Dutton, 2006; George, 1999). Research also indicates that women perpetrate physical aggression against children in the home; Cawson et al. (2000) found in a sample of young adults reporting violence in home that the mother is more frequently reported as responsible (49 per cent) compared to the father (40 per cent). Similarly, women are also becoming identified as perpetrators of sexual offences. Data indicates four to five per cent of all sexual abuse is committed by females (Cortoni & Hanson, 2005), although it is likely that this is an underestimate of the actual figure; there are many reasons victims might not report this type of abuse including the victim’s dependence on the mother as a caretaker and the stigma associated with this type of abuse. The Criminal Justice System and Family Courts often require guidance from psychologists in relation to this group of women offenders, such as the risk factors associated with re-offending; the relationship between intrafamilial offending and general offending; and the likelihood of reoffending. The assessments provided by psychologists can assist with decision making, such as sentencing, suitability for release from prison and whether a mother can have contact with or care for her children. It is, therefore, important that psychologists take a valid and reliable approach to assessment and treatment with this group to ensure sound decision making. In this paper 27

some of the issues relevant to assessment and interventions will be considered.

Assessment and formulation Generally within forensic practice there has been a move toward standardised, structured risk assessment tools (Khiroya, Weaver & Maden, 2009). There has, however, been some controversy in the past about using standardised tools with women if they have not been developed specifically for this population (de Vogel et al., 2012). More recently there has been a drive currently to address this with gender sensitive risk assessment tools such as the Female Additional Manual. Additional guidelines to the HCR-20 for assessing risk for violence in women (de Vogel et al., 2012). Many standard risk assessment tools have limited focus on early life experiences, but for women who have harmed their children, this area is extremely important when trying to formulate an understanding of risk. It is recognised that early attachments form the templates for adult attachments and attachment theory is useful in understanding both normal and abnormal care eliciting behaviours (Bowlby 1988); early childhood experiences with parents can consciously and unconsciously influence care behaviours (Adshead & Bluglass, 2001). This type of exploration of early life can help contextualise and make sense of a woman’s offending behaviour and therefore make it more likely she will engage in further assessment and intervention work. One of the issues with using structured risk assessment tools with women who perpetrate offences within the family is that recognised risk factors do not always apply in the same way as they do with other groups of offenders. For example, failure to comply with professionals is a recognised risk factor, yet a woman with Factitious Disorder by Proxy (FDBP), a condition in which a person deliberately produces, feigns or exaggerates symptoms in a person in their care (often a child), might seemingly comply with professionals and perversely thrive on this contact, attending all appointments offered, but this F 28

might actually be a feature of high risk behaviour rather than an indication of a reduction in risk. For such reasons it is important not to rely on published risk assessment tools that are not designed specifically for this population when making assessments of risk. Offence paralleling behaviours (OPBs) can be useful indicators of risk, particularly in the absence of reliable risk assessment tools. OPB is defined by Jones (2004) as ‘any form of offence related behavioural (or fantasised behaviour) pattern that emerges at any point before or after an offence. It does not have to result in an offence; it simply needs to resemble, in some significant respect, the sequence of behaviours leading up to the offence’ (p.38). Using OPBs allows behaviour to be explored in a sequential way to allow us to work with a broader range of processes that are helpful in risk assessment. For example, one of the features of FDBP is the compulsive nature of the offending behaviour; even when the parent is aware that professionals have become suspicious, the abusive behaviour often continues (Lasher & Seridan, 2004). Thus, when the opportunity to offend against a child is removed as the parent is placed in a secure setting, she may engage in offence paralleling behaviour such as encouraging other prisoners to self-harm and then appearing to take on a caring role. Similarly, women who have perpetrated abuse within the home can be skilled at conning and manipulating professionals, convincing others they are a caring parent when beneath this façade they are actually perpetrating abuse; such offenders might continue to relate to professionals in this way, trying to present in a positive light. The complex needs of this group of women offenders should be considered and incorporated into the assessment and formulation. With this population, there are often underlying personality disorder problems with issues of abuse, abandonment and neglect evident in their own childhood. For example, Matthews, Matthews and Speltz Forensic Update 2014 Annual Compendium

(1989) found women who abuse children are likely to have experienced severe childhood trauma and sexual abuse, their adult relationships frequently unhealthy or abusive; and they have low self-esteem, anger and distorted thinking. Attention to the motivations for offending is clearly important. For example, survival is highlighted by Bloom, Owen and Covington (2003) as a common pathway into offending for women. Women sometimes engage in intra-familial offending with a male co-defendant, often a partner. In a study including a cross-national sample of 227 women arrested for a sexual offence, approximately half acted with another person (Vandiver, 2006). This raises questions about this group of women’s motivations to offend, the extent to which they are influenced by a male offending partner and why they might offend only within the context of a relationship, although it is important not to become influenced by stereotyped views of women as passive victims who are coerced by men. Formulation is an essential part of the assessment process and used for guiding treatment strategies and interventions. The process of formulation involves working towards a psychological explanation of an individual’s problems that can inform treatment. Although it is accepted that formulation is a hypothesis or series of hypotheses about an individual, the work should be grounded in psychological research and theroy related to this client group (such as, Adshead & Brooke, 2001; Gannon & Cortoni, 2010; Saradjian & Hanks, 1996) and, importantly, clinical experience of working with this group of women. As mentioned, important areas to cover include early life experiences, beliefs about children, relationship with others, and stressors and coping mechanisms. Formulation of sexual offending needs to take into account the offender’s experiences of sex and also her experiences of sexual abuse in their own childhood (Saradjian & Hanks, 1996).


Treatment As with assessment and formulation, treatment should be gender sensitive and take into account the specific needs of female offenders. For example, it might be necessary to address abuse history and associated trauma. Helping women cope with their trauma in a more adaptive way will not only reduce subjective distress, but also reduce risk of re-offending by targeting maladaptive and/or criminogenic coping strategies. Women who offend in the family can be resistant to psychological work, like many other types of offenders. A dominant construction of motherhood is the idealised mother in which women are constructed as selfless, nurturing and subsuming their own needs to care for their children (Phoenix, Woollett & Lloyd, 1991). The idealisation of motherhood can deny the negative or difficult aspects of mothering and can be experienced as oppressive to women whose experiences differ from the ideal. Thus for women who have not only failed to meet the ideal standard of motherhood, but have behaved in a way that is antithesis of this ideal, to actively harm their child, can lead to overwhelming feeling of shame, self loathing and failure. These feelings can be a barrier to engagement. Women who have harmed a child might struggle to disclose such abuse and might even deny responsibility for the offences altogether. Developing the motivation to explore these issues is likely to take time and highlights the need to attend to the therapeutic process. Attention to the therapeutic process and relationship is important. For example, Ashfield, Brotherston and Eldridge (2010) also suggest directness, establishing openness, flexibility and appropriate use of self-disclosure can help develop the therapeutic alliance with females who have sexually offended against children. It is also important clinicians attend to their own emotional response to individual women and use this to inform therapy; strong feelings of anger, disgust, and rage can be invoked and need to be processed within a dynamic framework; it is also important to 29

be aware of the potential for the therapeutic relationship to repeat previous relationship dynamics. One particular problem for treatment of FDBP is that women often do not present for therapy as they insist reported physical symptoms are genuine. Rather than focus on trying to explore the offences, which can further entrench the offender’s denial, therapy might focus on unresolved traumatic stress and psychological distress in response to their own previous childhood illness or loss, which are common in FDBP (Main & Hesse, 1990). The initial formulation process will be vital to appropriately inform therapy. The notion that female offenders are both victims and perpetrators of harm has important implications for treatment. Treatment programmes are often designed in such a way that victims and perpetrators are treated as if two distinct groups. Programmes for perpetrators of violence are often designed for male offenders and seem to focus on the offender taking responsibility for the offence and empathising with the victim, which can be difficult when there are complicated victim/perpetrator issues, especially in cases of domestic violence where a woman has offended against an abusive partner. Likewise, it might be difficult to fully understand a women’s harmful behaviour towards her child without first understanding her own experience of abuse. We would suggest that interventions for this group of women offenders should attend to offender’s experiences as a victim of aggression as well as a perpetrator.

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Conclusions Assessments and interventions with women who commit offences against members of their family should be gender sensitive. It is important that clinicians are able to identify relevant risk factors using appropriate psychological guides and underlying psychological theory and then formulate an understanding of risk; this might include relevant issues such as attachments and relationships, prior trauma, personality disorder and mental health problems. Offence-paralleling behaviours can be useful proxy markers to inform assessments of risk. Treatment interventions need to be able to respond to the complex needs of this client group and go beyond traditional offending behaviour programmes. The therapeutic dynamics can be complex and need to be attended to if any work is going to be effective; it is also important to approach this group of women with sensitivity and empathy as these women are often struggling with intense feelings of shame and failure.

The Authors Susan Cooper & Alison Hodgson Primrose Service, Tees Esk & Wear Valleys NHS Foundation Trust.

Correspondence Susan Cooper Email: [email protected] Alison Hodgson Email: [email protected]



Intimate relationships between female prisoners: Fact or fiction? Annette McKeown This paper explores the prevalence of intimate same-sex relationships between female offenders in custody. In the female prison estate, this phenomenon is often discussed but has rarely been studied. The prevalence of relationships between female offenders in custody in the UK is generally unknown and this paper seeks to develop the evidence-base in this under-researched area. In this study, female prisoners (N=92) completed a questionnaire exploring their relationship status; gender of partner; prison relationships; length of current relationship; number of previous relationships and previous relationships with prisoners. Results indicated that of those currently in a relationship, 27 per cent were in a relationship with another female prisoner and eight per cent were in a relationship with a female in the community. Some of the implications of relationships between female offenders are examined including complex risk management issues, duty of care, as well as the function of these relationships.

N THE GENERAL COMMUNITY, there are varying figures indicating the prevalence of same-sex female relationships although a recent survey of 420,000 respondents from the UK found that approximately 1.5 per cent of respondents described themselves as gay, lesbian or bisexual (Office for National Statistics, 2011). If these estimates are representative of the prison population, similar estimates should exist although there is notable lack of literature on the subject. What is noteworthy, however, is that there is much anecdotal knowledge that same-sex relationships are quite overtly present in female prison establishments (Bennett, 2000). What is less clear is the prevalence and nature of such relationships and whether these relationships are underpinned by sexual preference or more linked to availability of partners. Management of some of the challenges associated with samesex relationships in custody is also an area that warrants further discussion. In the US, there has been some research exploring the prevalence of same-sex female relationships in custody. There have been estimates of prevalence which have varied between 25 per cent and 60 per cent

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(Forsyth, Evans & Foster, 2002; Owen, 1998). There has also been discussion about the difference between women who would define themselves as ‘gay’ in terms of their general sexual preference as opposed to those who have only engaged in same-sex relationships in custody (Bennett, 2000).

Theoretical considerations A number of theories have also been used to attempt to understand these relationships. Deprivation theory (Sykes, 1958) suggests, in the case of women who have engaged in same-sex relationships only in custody, these relationships may be used as a temporary substitute to male relationships. There is also literature suggesting women may become involved in intimate relationships due to loneliness and in an attempt to help them manage distance from loved ones (Devlin, 1998). Sexual fluidity theory (Diamond, 2008) focuses less on this behaviour as a substitution to male relationships. It focuses on how gender preferences can become fluid in custody, and that contextual factors can result in some women discovering attractions towards other women. It could be argued, however, if the above theories 31

explained both male and female intimate relationships in custody similar patterns of intimate relationships would be observed in male prison establishments. Anecdotal evidence and preliminary research findings would suggest lower levels of intimate relationships in male prison establishments. For example, research findings suggest between 1.6 per cent and 3.4 per cent of a random sample of male prisoners indicated they had sex with another prisoner in custody (Strang et al., 1998). Therefore, it may be worth considering gender-sensitive explanations of intimate relationships. Research highlights that relationships and attachments to others have particular importance for women in comparison to men (e.g. Covington, 2007). Relational theory (Hartling, 2009; Miller, 1988) emphasises the importance women place on feeling empathically understood and emotionally close to significant others. Intimate relationships in custody may thus provide a sense of attachment and emotional closeness for women. It has also been suggested that supportive social relationships are often fundamental components of women’s coping mechanism to deal with stress (Taylor & Master, 2011).

Risk management issues Intimate sexual relationships between female prisoners present a number of challenges in custody. There can be jealousy present between female prisoners and this can result in difficulties including aggression and self-harm (Bennett, 2000). This can also create discipline issues including instigation of procedures to manage these behaviours including adjudication measures and ACCT (Assessment, Care in Custody, Teamwork) plans which are used for prisoners at risk of self-harm and/or suicide. When relationships break down this can also present environmental difficulties as women in relationships may be located on the same prison wing. It may be argued that breakdowns in relationships represent every day life. When these relationships potentially 2 32

involve women with a history of violence, self-harm, and emotional difficulties this presents a somewhat greater challenge, however. The case study below is a fictional representation based on clinical experience. It seeks to capture some of the complexities that same-sex relationships can present in custody. Case Study 1: Rachel Rachel Rachel is a 24-year-old woman and has a history of trauma in the form of sexual abuse as a child and domestic violence in her adult relationships. She has an index offence related to violence towards her female partner. Since her reception into custody, Rachel has formed a number of different female relationships with other prisoners. Many of these relationships have been short-lived. Rachel had planned to marry at least two of these partners, and legally changed her surname to match one of these partners. Rachel is no longer in a relationship with any partner she planned to marry, or who she took a name of. Rachel often self-harms when a relationship breaks down and she had received adjudications for being violent towards partners. She is aware her intimate relationships are a problem for her but seems to repeatedly become involved in similar relationships.

This case study highlights intimate relationships between prisoners clearly present an array of challenges to staff in terms of management. Although sexual relationships between prisoners are prohibited, anecdotal evidence suggests such relationships still continue. An influential document, Guidance on the Management of Issues arising out of Relationships between Women in the Women’s Custodial Estate (NOMS Women’s Team, 2010) outlined a number of these challenges and Forensic Update 2014 Annual Compendium

strategies of dealing with these relationships in custody. In this document staff are encouraged to be aware of potential coercive and abusive relationships. These more abusive characteristics may be more prevalent in psychopathic and personality disordered prisoners. This document also encourages staff to be particularly aware of potentially vulnerable women in custody as relationships of this nature can be particularly harmful. For example, concerns have been noted that disabled prisoners can become involved in intimate relationships with other prisoners who then act as their carers despite have no training to undertake such a role. The potential of vulnerability in the case of the both parties cannot be ruled out. The importance of female prisoners wearing appropriate clothing has also been highlighted as a potential issue and dress codes were suggested. Strategies to manage overt expressions of affection were also outlined in this document. Increasing understanding of the prevalence of relationships between female prisoners in custody is likely to help inform risk management strategies. There is little knowledge, for example, about the prevalence of the use of sex as a commodity to pay for substances or to obtain material goods. This is particularly important when considering the management of some of the potentially more complex implications of this behaviour. The potential of sexually transmitted diseases also present an important consideration. Understanding the prevalence of relationships between female prisoners in custody would provide greater knowledge of the potential prevalence of some of these challenges.

cipation would be completely voluntary and anonymous. Of the 336 female prisoners in the establishment, 92 prisoners consented to participate. Of the 92 prisoners, 55 per cent were convicted of a violent offence and 45 per cent convicted of a non-violent offence. Measures Demographic Questionnaire This self-report questionnaire was devised by the researcher and consisted of items including: age; index offence; relationship status; relationship gender; prison relationships; length of current relationship; number of previous relationships and previous relationships with prisoners.

Results Ninety female prisoners provided information about their relationship status and 67 per cent indicated they were currently in a relationship (N=60). Of those currently in a relationship, 65 per cent (N=39) reported being in a relationship with a male and 35 per cent (N=21) reported being in a relationship with a female. As outlined in Figure 1, of the 21 women, five women indicated they were in a relationship with a woman in the community; 16 women indicated they were in a relationship with another female prisoner. Thirty women indicated they were in a relationship with a male in the community; nine women indicated they were in relationship with a male prisoner. Of those who responded regarding previous relationships, 38 per cent (N=33) of respondents indicated they had previous relationships with female prisoners whilst in custody. As outlined in Figure 2, most of these women reported having between two and five previous relationships with female prisoners.

Method Participants All female prisoners in a female prison establishment were invited to participate in a broader study which explored violence in relationships. This study also explored the prevalence of relationships in custody. Female prisoners were informed their partiF Forensic Update 2014 Annual Compendium

Discussion This study provides preliminary indications of the prevalence of relationships between female prisoners in a custodial environment. Approximately one-third of female prisoners currently in a relationship reported their relationship was with another female 33

Figure 1: Percentage of women in relationships according to gender and location of partner.

Figure 2: Number of previous relationships with females in custody.

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prisoner. Over one-third of the overall sample also indicated having previous relationships with female prisoners. Future research would be useful to examine this further to consider the function of intimate relationships in custody and whether they merely link to sexual orientation. Given the relatively high prevalence it seems likely that female prisoners attribute positive characteristics to these relationships. It would be useful to explore further these positive attributes further and whether these relationships can be protective factors as anecdotal evidence tends to focus on the potential negative consequences of relationships in custody. Consideration of potential risk management issues seem warranted, however, given observations in the literature of the risk of violence between female prisoners in intimate relationships (Bennett, 2000). It is perhaps noteworthy that approximately half of the sample was imprisoned for offences of violence. It is clear that violent women being in a relationship with each other may become a risky situation for both women involved, other prisoners, and staff if conflict arises. The potential of domestic violence within this context is also possibility and staff vigilance for this becomes imperative. This is particularly important given community findings that gay women (29 per cent) and bisexual women (49 per cent) experience higher levels of domestic violence than heterosexual women (Bureau of Justice Statistics, 2010). There is also the potential of offence-paralleling behaviour within a relationship context with a number of women incarcerated for offences of violence towards partners (Hamel, 2012). There is also a noteworthy gap in treatment interventions for female offenders as there are no existing interventions focussed primarily on promoting healthy relationships. It is clear that some focus must be placed on same-sex relationships in such interventions, as well as consideration of maladaptive cycles in relationships and how these may parallel in

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custody. Psycho-education into healthy relationships also seems imperative as female offenders’ experiences are often characterised by patterns of unhelpful relationships throughout their lives. Additional research is required with both male and female prisoners to explore the prevalence of intimate relationships in custody across the prison estate. Further research is also needed exploring the dynamics within these relationships including prevalence of violence, controlling behaviour, bullying, psychological aggression and whether indeed in some cases whether these relationships may be of a supportive nature. Recent research has found over 57 per cent of a female prisoner sample reported they had physically assaulted their partner in their most recent relationships in the past year (McKeown, in press). This clearly has implications for the management of such behaviour. Further assisting staff with strategies to deal with behaviour in this context would be beneficial as staff have been noted to present with uncertainty on how to deal with these issues (Bennett, 2000). Exploration of the function of relationships in prison is also an area which warrants further consideration. There are a number of limitations to this study including the sample size and that it is focussed solely on one female prison establishment. Further areas could be explored as previously noted including comparing male and female establishments, sexual orientation of prison populations, characteristics and functions of relationships in custody amongst many other domains.

Correspondence Annette McKeown Chartered & Registered Forensic Psychologist, Primrose Service, Tees Esk & Wear Valleys NHS Foundation Trust. Email: [email protected]

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References Bennett, L. (2000). Managing sexual relationship in a female prison. Paper presented at the Women in Corrections: Staff and Clients Conference convened by the Australian Institute of Criminology in conjunction with the Department for Correctional Services SA and held in Adelaide, 31 October to 1 November 2000. Bureau of Justice Statistics (2010). Intimate Partner Violence, 1993–2010. Washington, DC: Bureau of Justice Statistics. Covington, S. (2007). The relational theory of women’s psychological development: Implications for the Criminal Justice System. In R. Zaplin (Ed.), Female offenders: Critical perspectives and effective interventions (2nd ed., pp.135–164). Sudbury, MA: Jones & Bartlett Devlin, A. (1998). Invisible women. Hook, Hampshire: Waterside Press. Diamond, L.M. (2008). Sexual fluidity: Understanding women’s love and desire. Cambridge, MA: Harvard University Press. Forsyth, C. J., Evans, R.D. & Foster D.B. (2002). An analysis of inmate explanations for lesbian relationships in prison. International Journal of Sociology of the Family, 30(1), 66–77. Johnson, A.M., Mercer, C.H., Erens, B. et al (2001). Sexual behaviour in Britain: Partnerships, practices and HIV risk behaviours. Lancet (358), 1835–1842. Hartling, L.M. (2009). Strengthening resilience in a risky world: It’s all about relationships. In J. Jordan (Ed.), The power of connection: Recent developments in relational-cultural theory (pp.51–70). New York: Taylor & Francis.

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Hamel, J (2012). ‘But she’s violent, too!’ Holding domestic violence offenders accountable within a systemic approach to batterer intervention. Journal of Aggression, Conflict and Peace Research, 4(3), 124–135. McKeown, A. (in press). Female offenders who commit domestic violence: Aggression characteristics and potential treatment pathways. Journal of Forensic Practice. Miller, J.B. (1988). Connections, disconnections, and violations. Work in Progress No. 33. Wellesley, MA: Stone Center, Working Paper Series. NOMS Women’s Team (2010). Guidance on the management of issues arising out of relationships between women in the Women’s Custodial Estate. London: NOMS Women’s Team. Office for National Statistics (2011). Integrated Household Survey April 2010 to March 2011: Experimental statistics. London: Office for National Statistics Owen, B. (1998). In the mix. Albany, NY: State University of New York Press. Strang, J., Heuston, J., Gossop, M., Green, J. & Maden, T. (1998). HIV/AIDS risk behaviour among adult male prisoners. Home Office Research, Development and Statistics Directorate, Research Findings No. 82. Sykes, G.M. (1958). The society of captives. Princeton, NJ: Princeton University Press.



Balancing the therapy role with the prison officer role Sue Devine, Grahame Greener, Karen Laws & Beverley Phillippo HIS IS THE VIEW of four individual people who all decided upon the same career in HM Prison Service but for very different and varied reasons. Why you may ask? Let us give you some insight into the reasons why we joined the Prison Service. For some of us we wanted what we thought would be a job for life with financial security for our families. For others we have partners who have been employed in the Prison and Police Service for many years. A thought we all had in common was ‘If I could make a difference to one person then I have done a good job’. We all had different thoughts and opinions on what skills we initially thought would be needed for the role of a prison officer. These ranged from opening and locking doors, helping prisoners to understand what had led them to offend, and rehabilitate them to reduce the risk of reoffending in the future.

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As the Prison Service Statement of Purpose states: ‘Her Majesty’s Prison Service serves the public by keeping in custody those committed by the courts. Our Duty is to look after them with humanity and help them lead lawabiding and useful lives in custody and after release.’ We also thought the role involved being firm but fair, giving instructions, and listening and supporting prisoners with their concerns and worries. Further skills we thought we would need included having a patient and empathetic manner but also being aware of how dangerous and dishonest some prisoners could be in order to get their needs met. Working with women prisoners, we would all agree it was very difficult to be able to manage the time some prisoners needed with the day-to-day running of the prison regime.

Joining the Primrose Programme With over 50 years’ prison experience between us and after spending many years on residential wings and the physical education department we decided it was time to change direction. We wanted to do something different, a new challenge. After experiencing ‘landing life’ and witnessing first-hand the problems that some women had, we started to ask ourselves questions such as, ‘Are we doing enough?’ and ‘Do we understand what these women need?’. Looking after a wing full of prisoners with limited staff can be very time consuming. Also, making sure the prison regime runs Forensic Update 2014 Annual Compendium F

smoothly gives little opportunity and time to listen to women and to be responsive to their individual needs. We were all surprised to learn that there are a lot of people with mental health issues and personality disorders in prison who need specialist care and support. This is something at the very beginning of our careers we would never have thought about. At the beginning we thought surely people who are sent to prison have done something very bad therefore they should be punished. This raised various questions. What if some people have a personality disorder that affects their ability 37

to deal with situations or manage their emotions in a negative sometimes destructive way? We wondered what we could do to help. We thought surely more can be done. There must be more than opening and locking doors. A new integrated pilot programme was up and running; The Primrose Service, located at HMP/YOI Low Newton, which was specifically designed for women who had severe personality disorders. We thought this could be the answer to some of our questions regarding what we could do and how we could help. We saw the Primrose Service offering a new opportunity for a multi-disciplinary team to work with women to address a range of individual needs not just focus on one specific area. We thought being involved in the Primrose Service would help us to understand the women better. We thought we could have the opportunity to help them practice skills in real life situations. Like any person starting a new job we were filled with a mixture of excitement and anxiety. How would we fit into a programme running psychological interventions and treatments? How would we mix with doctors, psychiatrists and psychologists? People who were knowledgeable about mental health? People who had numerous qualifications and letters after their names?We also had not considered the number of acronyms that were used. More importantly, what they meant in full and when were they used. An example of a typical conversation may possibly go like this: ‘As discussed at the MDT, Miss X has now completed her SCID and HCR-20. We will soon be starting the PCL-R. She still engages in the Officer Led Programme’ 1 Then, there were each woman’s traits, ‘Histrionic, Obsessive Compulsive, Schizoid, Schizotypal’. What was IPDE or a HCR-20 we wondered? The list was endless but we were willing to learn. 1

We have been able to learn this new knowledge and the role of the Primrose Prison Officer is seen as vital. We have developed an Officer Led Programme (OLP), facilitated Prim-role Play, which is psychodrama sessions, and facilitated Mobile Team Challenge (MTC). We also co-facilitate on treatment programmes including Life Minus Violence Enhanced (LMV-E™), Motivation and Engagement, Dialectical Behaviour Therapy Skills Training Groups, TREM (Trauma Recovery Empowerment) and individual offence-focussed Work.

Learning and supervision To understand the ‘jargon’ we have group supervision and individual supervision with clinicians. Supervision was a new experience for us and we have embraced this over time. At the beginning we did not understand the purpose of supervision but through experience we all learnt about how valuable it is for our role and personal development. We learnt about personality disorders and considered whether any of the traits were linked to any of the women in the service. Other supervision sessions spent time looking at assessment tools and the aims of treatment programmes. Being released to attend training also had a positive effect on our development, as did working together to help each other. Understanding psychological language is a large part of our daily routine and like learning any other skill becomes easier as time progresses. More importantly, we can now link this terminology to the female offenders, which in turn makes us, as officers understand them and the role we have on the Primrose Programme better.

Balancing the therapy role and the discipline role When working on the Primrose Programme, balancing the therapy role with the disci-

MDT refers to Multi-Disciplinary Team Meeting; SCID refers to Structured Clinical Interview for DSM-IV; HCR-20 refers to the Historical, Clinical and Risk Management structured assessment of violence risk; PCL-R refers to the Psychopathy Checklist – Revised.

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pline role has proven both challenging and rewarding. One minute we may find ourselves in a treatment session being empathic and offering support listening to a prisoner disclosing traumatic childhood memories. Ten minutes later we may find ourselves restraining the same prisoner to keep them safe in order to stop them from harming themselves. To the prisoner this could be very confusing and feel like one minute we are trying to help them, the next minute we are fighting with them. We cope with this through always being aware of our dual role in the service. We have learnt a lot about our own behaviour and the impact and impression that this can have upon others. Prison culture historically dictates discipline staff use ‘prison banter’ day-to-day, in different ways, for different reasons. For example, previously when enforcing prison rules we may have used humour in a sarcastic way without realising. We never really understood how this may be looked upon from a therapeutic perspective. Our views have altered. Since facilitating programmes such as Life Minus Violence – Enhanced® we have realised some of the ‘banter’ we have previously used, for example, could be deemed sarcastic which is a form of aggression. This was never our intention, we thought it was just the way prison works and most prisoners responded well. We are not saying do not use banter any more but we are just more aware of when and how we use it. It is our aim as facilitators to encourage participants on the courses to live pro-social lives without aggression and violence. At times throughout our careers we have all raised our voices when dealing with difficult situations and conflicts. We have felt angry and frustrated thinking to ourselves ‘How dare they speak to us like that’. Previously we did not know or understand transference and the effects that others’ emotions can have. We now understand this more. Difficulties balancing the prison officer role and the therapeutic role can include volatile situations when control and restraint techniques F Forensic Update 2014 Annual Compendium

are used as a last resort to de-escalate. This can be particularly challenging if you are undertaking a therapeutic role with the same person involved in the incident. Being aware of both roles and considering the effect this can have on everybody is vital. At times it may be necessary to strip search a prisoner. They may become angry and aggressive in response to this and make threats to harm themselves or a member of staff. Their aggressive behaviour may link to their own past experiences of abuse and the only way that they think they can resolve the situation is to act in this manner. It could also be related to their personality disorder. As prison officers we would all agree aggressive behaviour is not acceptable. As Primrose officers working on the programme we look at underlying reasons for their behaviour. This is not always understood by our colleagues for a range of different reasons, the biggest being they simply do not have the time or have had the training we have. Our training has helped us value the importance of making time to reflect and encourage other staff to do so.

Healthy mind healthy body Balancing the therapy and discipline role is also important for physical education officers. In the Primrose Service we understand the importance of physical exercise in improving the women’s overall well-being. When the decision was made to introduce the role of a facilitator who was also trained as a Physical Education Officer, this was an ideal opportunity to promote the importance of overall well-being to women with complex needs. The variety of exercise helps the individual to improve self-esteem and motivation by helping them to set and achieve personal targets. We have noticed that physical exercise has also helped the women to improve group cohesion and their coping skills. This gives opportunities to practice communication skills to interact, tolerate and accept others which help to prepare them for future group treatment programmes. The science of any physical 39

activity will tell you that endorphins in the brain give us an uplifted feeling of well-being and this helps to stabilise our mood. Therefore, this can help the women get through the different phases of the Primrose Programme keeping them stable while they may be going through a difficult time.

Coping with challenges Pro-social modelling is a vital part of the work we do with prisoners. Our awareness and insight have increased and we now understand the reactions we may have given in the past are not only promoting aggression but behaving inappropriately to the person we are may be working with. We are by no means perfect and at times still feel angry and frustrated, but our insight into how we behave and manage this has changed thankfully for the better. Insight into why someone behaves the way they do, does not excuse behaviour but it does explain a lot of things. It is possible to promote pro-social behaviour through modelling positive behaviour ourselves. At times working therapeutically with a prisoner can lead to them pushing boundaries or trying to ‘split’ staff. This could be over familiarity or asking to work with certain staff because they are the only person they can talk to. It is vital we are aware of this and be honest with them explaining what is and is not acceptable. This can sometimes have a negative effect as the prisoner may feel they are being rejected, controlled or criticised. This could link to past experiences when they have been rejected, abused or controlled as a child. It can be challenging but also important that reassurance is given in an empathic manner whilst maintaining professional boundaries. Prior to working in the prison service we had never come across self-harm. Women in prison talked about ‘cutting up’. We were not familiar with this terminology but quickly learned the language of the women and began to understand this was their way of communicating with us. Why would someone want to deliberately hurt themselves? We had 340

no concept as to the reasoning behind this act. Experience and training has taught us that the individual will normally self-harm when they are in a state of heightened emotions and inner turmoil. We also realised that self-harm can in some cases help make them feel more in control and less tense – possibly a ‘quick fix’ for feeling bad or helping them to connect with reality and not their bad memories. It is important to listen to the individual without being critical or judgemental and try to understand their feelings. There have been occasions when we have felt frustrated as some individuals, by their own admission, have used self-harm as a means to get their needs met. In these particular situations we learned the importance of understanding why the women may have self-harmed, being mindful and remaining professional in our approach.

Thoughts for the future Based on our experience there are a number of important thoughts for the future we would recommend. These include the importance of having debriefs after sessions, attending supervision, and developing further staff training and awareness in areas such as mental health, personality disorder and therapeutic skills for staff across the prison estate. Having the opportunity to become involved in treatment gave us a completely different perspective, making us wonder why only limited mental health training is offered in our initial training. As prison officers we are trained in a specific way, however, there is a need to be open to thinking about and understanding situations in a very different way. We feel we have gained from the introduction to a therapeutic environment the ability and insight to recognise that not all prisoners, never mind officers, understand what it is like to have mental health issues or learning difficulties. ‘Our New Way’ is the new modern approach in the prison service, and we believe would benefit from prison officers receiving more mental health and psychological training to equip them for the challenges they face today. Forensic Update 2014 Annual Compendium

In conclusion, we feel as prison officers it is possible to balance the discipline role with the therapeutic role. In our opinion, each role complements the other in our day-today work. This has enabled us to promote the Primrose Programme and encourage understanding of what the programme is trying to achieve to the broader prison. Balancing the therapeutic role with the prisoner officer role is possible. Change is possible. Embrace it.


The Authors Sue Devine, Grahame Greener, Karen Laws & Beverley Phillippo Primrose Prison Officers, Primrose Service, HMP & YOI Low Newton.

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Reflections of a trauma intervention with women in prison Michelle Carr, Alison Hodgson, Samantha Woodhouse & Marc Kerry Introduction to the Specialist Women’s Personality Disorder Service, part of the Personality Disorder Offender Strategy HIS SERVICE has been specifically developed to address the needs of women prisoners with severe personality disorder in England and Wales. The women’s service offers intensive assessment and treatment to help participants reduce the impact of personality disorder and reduce the risk of re-offending. Thus the treatment offered is designed to address criminogenic needs in order to reduce risk. The importance of addressing any additional non-criminogenic and/or mental health needs is recognised, especially if these needs interfere with the ultimate goal of reducing risk. It is also imperative that the treatment offered by this specialist women’s service can meet the varying needs of a relatively small group of women. The treatment model adopts a focused approach to address the components of the participant’s personality functioning and risk factors associated with offending, including cognitions, emotional responding, and interpersonal and social functioning. The treatment model is guided by Livesley (2012), who suggests ‘a framework of combining eclectic treatment methods and delivering them in a co-ordinated way’. The treatment model is also gender sensitive and responsive, taking into account the specific needs of female offenders, for example, that abuse history and associated trauma should be addressed when working with women offenders (Bland, 1999) and consideration given to gender differences in offending behaviour, as

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women can often present with unique treatment needs. The typical, for want of a better word, woman that accesses the service presents with some form of abuse and or history of trauma. Many of the women use dysfunctional strategies for dealing with this trauma including self-harm and substance misuse, and it is also possible that these dysfunctional ways of coping have led to them being in contact with the Criminal Justice System (CJS). It is highlighted that access to opportunities to deal with the effects of abuse is crucial in maximising a woman’s ability to avoid future involvement in crime (Blud, 2007; Cortson, 2007; Norman & Barron, 2011).

Interventions for trauma There has been much debate about how to tackle the issues and complexities of trauma. The Cognitive-Behavioural Therapy (CBT) model has received a great deal of attention in the trauma literature. This model posits that irrational beliefs and negative feelings develop from experiencing traumatic events. Treatments using the cognitive-behavioural model include several different treatments, such as cognitive processing, exposure procedures and anxiety management training (Foa & Rothbaum, 1998). Cognitive processing involves exploration and challenging negative perceptions and beliefs about self, others and the environment (Blud, 2007). According to Pennebaker and Forensic Update 2014 Annual Compendium

Campbell (2000), writing about an upsetting event can aid reduction of psychological distress. Schema-focussed therapy (Young, 1994) is also used to treat trauma and focuses on dysfunctional beliefs or maladaptive schemas. It has been suggested that maladaptive schemas are linked to extensive trauma histories (Blud, 2007). Dialectical Behaviour Therapy (DBT; Linehan, 1993) combines other techniques, including cognitive, behavioural, interpersonal and experiential techniques. DBT also uses practices of mindfulness, emotional regulation and distress tolerance. It is well documented that DBT has shown effectiveness for treating Borderline Personality Disorder (Linehan, 1993; Palmer, 2002). In terms of exposure approaches, the aim is to diminish traumatic memories by confronting the thoughts, feelings and memories of the feared situation. Some research supports the efficacy of exposure techniques (Foa & Meadows, 1997; Foa & Rothbaum, 1998), however, it has been suggested that some traumatic events are too upsetting to process using exposure techniques (Briere & Scott, 2006). Eye Movement Desensitisation Reprocessing (EMDR) involves the individual focussing on visual images, negative beliefs, bodily sensations and emotions associated with a traumatic event, whilst the patient visually tracks the therapist’s finger as it moves back and forth (Blud, 2007). Research into the effectiveness of EMDR has yielded mixed results. Another psychological approach to treating trauma is the psychodynamic approach. The psychodynamic approach focuses on cognitive distortions, but instead of replacing them with more helpful thoughts it seeks to interpret the meaning and the reason that it arose (Blud, 2007). The evidence for psychodynamic treatment of trauma is mixed and is limited by methodological weaknesses (Roth & Fonagy, 2005). Cognitive Analytical Therapy (CAT) is also used to treat trauma and is informed by cognitive and psychodynamic approaches. In short, CAT is an individually delivered therapy which emphasises the collaborative F Forensic Update 2014 Annual Compendium

relationship between the therapist and patient. CAT focuses on helping the client understand their maladaptive behaviours, including the patterns and origins of the behaviours so that alternative strategies can be learnt. The evidence for the effectiveness of CAT is also mixed, however, it is increasingly used. For women with very complex backgrounds and multiple problems, classic trauma therapies are not advocated. Furthermore, research has advocated a more present focussed approach based on psycho-education, coping skills and anxiety management when working with women who have experienced prolonged and severe trauma (Blud, 2007). Several authors have pointed out that exploration of past traumatic material is not always appropriate (Adshead 2000; Briere & Scott, 2006; Bryant & Harvey, 2000) and present focussed treatments, such as psychoeducation and those aimed at developing coping skills as a safer and more effective option (Najavitis, 2002). Additionally, during the early stages of recovery, highly structured groups can facilitate feelings of safety, predictability and group therapy has been used in the treatment of survivors of abuse, and trauma. Furthermore, traumatised individuals have also been shown to benefit from group treatment as it can reduce feelings of stigma, isolation, and shame. Whilst allowing opportunities for observation, learning, modelling, and sharing of new coping skills (Zlotnick et al., 1997). The full Trauma Recovery and Empowerment Model (TREM) programme was initially developed by Maxine Harris and the Community Connections Trauma Work Group (1998). TREM is a group intervention designed to address the enduring cognitive, emotional and interpersonal problems that have developed as a result of suffering sexual and/or physical abuse. TREM uses a cognitive-behavioural approach that has psychoeducational elements and teaches coping skills. The TREM programme consists of 33 group sessions. One group session a week is facilitated and this is broken down into four 43

modules. The first module called Empowerment encompasses 12 sessions of basic education of skills in self-regulation, boundary maintenance, and communication. Sessions also include discussions around how to look after yourself, how to develop positive prosocial healthy relationships and ultimately to increase the woman’s level of hope for a future which is not characterised by abuse. The second module is called Trauma Recovery and again it is based on psycho educational skills around physical and sexual abuse and how current behaviours are linked to this past abuse. It also provides the women with an opportunity to rediscover and reconnect with repressed memories, feelings and views. Additionally, it allows space to develop and appreciate the steps needed to solve problems and difficult situations safely. The third module, Advanced Trauma Recovery, is a more in-depth exploration of trauma with opportunities to continue to develop more helpful ways of communicating and being assertive with others with the aim of allowing the woman to keep herself safe and in control of the situation. Finally the fourth module, Closing Rituals, consists of three sessions which are designed to give the programme a definite ending. This aspect of the programme is especially important as often women do not have good experiences of endings, which may have been aborted prematurely or particularly painful. It also gives the group time to evaluate and assess their progress and what changes they will make following the programme. As far as the team were aware the TREM programme had not yet been piloted in any environment within England or Wales. This programme had been widely evaluated in community settings within the US and preliminary results are positive. A multisite project has been reported which ran for five years (1998–2003) in a community setting in the US. Findings demonstrated that participants within the exposed to the integrated trauma intervention reported significantly less mental health symptoms and trauma 344

symptoms at 12-month follow-up (Morrisey et al., 2005). Other studies have also shown a reduction in trauma symptoms using the Trauma Symptom Scale when comparing the TREM group to treatment as usual at 12-month follow-up (Amaro et al., 2007; Fallot, McHugo & Harris, 2005; Toussiant et al., 2007). Furthermore, Fallot et al. (2011) conducted a quasi-experimental study with 251 women which measured the integration of the addition of the TREM programme compared with trauma services as normal. Outcomes were resoundingly positive in that there were changes in trauma recovery skills which were positively associated with engagement in the additional TREM programme. What’s more, the women who engaged with the TREM programme reported significantly greater reduction in the severity of their alcohol and drug use, anxiety symptoms and current stressful events. Additionally, they showed increased levels of perceived personal safety. Furthermore, previous literature advocates the use of CBT for the treatment of trauma (Blud, 2007) and this has been further advocated by the National Institute for Clinical Excellence (NICE Quick Reference Guide, March, 2005). In addition, the psycho-educational element of TREM is supportive of the present day approach. Thus due to the positive supportive findings and in line with published guidelines for the treatment of trauma and specifically PTSD it was decided that the service would integrate the gender responsive TREM programme into the beginning of the dedicated trauma pathway.

Integration into the treatment model and facilitation of TREM Nine women from the specialist women’s service were approached and given a TREM awareness session as part of a service user meeting. Three women were excluded from this as they were already accessing DBT which also forms part of the trauma pathway. Of the nine women who received the awareness, six women self-selected to take part in a pre-group assessment with the potential to Forensic Update 2014 Annual Compendium

move onto module one of the group programme. All participants who selfselected were chosen to continue on to module one of the TREM intervention, five of the individuals experienced the module in a group format. One individual was offered the TREM sessions on an individual basis, this had been care planned for the individual in question as there were concerns about her IQ level and presentation in a group setting. All nine women who were approached have a diagnosis of one or more personality disorders and this has been formulated as linked to their risk of reoffending. Additionally, some of the women have high scores on the PCL-R which has been linked to difficulties in therapeutic groups and forensic environments (Hare, 2003). Consent was obtained from all participants prior to the programme. It was sought within the week following the awareness and self-selection session. The individuals were asked to read and sign a consent form, complete four psychometric assessments, [Coping Styles Questionnaire (CSQ; Roger, Jarvis & Najarian, 1993), Trauma Symptom Inventory (TSI-2; Briere, 2011), Culture Free Self-Esteem Inventory (CFSEI-2; Battle, 1992), Social Problem-Solving Inventory (SPSI-R; D’Zurilla, Nezu & Maydeu-Olivares, 2002)], and take part in a short semi-structured interview. When facilitating the group in a prison environment there were a number of factors which had to remain at the forefront including safety, security and the prison regime. It is worth considering that confidentiality is difficult to maintain when conducting group-work in prisons and, therefore, some group members are less likely to share experiences and engage. Other factors include operational prison staff not subscribing to the effectiveness of group therapy. It is for the aforementioned reasons that there is a school of thought that custodial settings are not suited for specialist trauma treatment.


Following completion of the group the same psychometrics and a similar semi-structured interview was completed with each individual. An interview guided approach was employed, as it is a widely used format for qualitative interviewing allowing flexibility whilst maintaining structure, boundaries and consistency. In this approach the interviewer has an outline of the topics or issues to be covered, but is free to vary the wording or order of the questions and can probe when necessary (Patton, 1990). These were completed in order to capture any shifts which may have been triggered by engagement in the TREM module.

Qualitative results from Module One The women who engaged with the programme and the facilitators noted a number of these benefits following conclusion of the module and some of these are highlighted: ‘Yeah it taught me to have more self-esteem about my body image and how to pick a partner. I compared this time to last time and I want more this time.’ Member 4 ‘Yes it helped me understand a little more that trauma can be the littlest thing.’ Member 2 It is important to note that often for the women engaging with the Women’s service, being a woman has not always been a positive experience and has, at times, been scary, degrading and humiliating. Therefore, this opening module allows the women a forum to explore themselves as a woman and the associated feelings, in a safe, nurturing space. Within this space the women were exposed to constructive feminist perspectives and ideologies built on a foundation of positive psychology. Research has shown that not only can positive emotions and narratives increase physical health; they can also greatly improve psychological health. Some of the positivity which was shared has been captured in the dialogue with the women on follow-up:

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‘Value and respecting myself more.’ Member 5 ‘It taught me to have more self-esteem about my body image.’ Member 4 Based on these fundamentals the members of the group were asked what they hoped to achieve; some members stated that they hoped they would learn and build upon essential skills such as communication, whilst others hoped to grow and develop personally. On follow up it is positive to note that these aims appear to have been achieved; ‘Able to say no, I feel more confident.’ Member 2 ‘Yeah I don’t get dragged in to other peoples thinking; regardless of their influence I am not swayed.’ Member 4 ‘I am who I am, I’m accepting myself.’ Member 5

Reflections following a brief trauma group intervention (TREM) A number of ideas have been suggested as to why and how therapeutic groups can facilitate such positive outcomes. For many groups, including that of TREM, the therapeutic relationship is suggested as a catalyst, it begins with the facilitator taking an active role within the group to maintain boundaries, make sense of difficult emotions and experiences through the narrative form and validate experiences where necessary. Throughout the group there was a significant ease to which the information flowed. This may have been due to the milieu which was put in place initially by the facilitators and maintained throughout the module by all. The positives of this are captured in the following quotes: ‘It was really relaxed, not forced and not intense. We were able to have a laugh, you didn’t feel pressured; speak when you want to speak.’ Member 4 ‘I was allowed to go at my own pace and the facilitators were softly spoken and also being told that everyone was welcome to stay until the 346

end even if they didn’t want to speak was helpful.’ Member 2 ‘There was trust in the group which made me speak out, the group helped build trust.’ Member 2 Additionally, there are vast amounts of research surrounding the importance of the relational component for women and this is felt to be even more important within a therapeutic group in a prison setting. As women in the prison system often have unhealthy, illusory or unequal relationships with spouses, partners, friends and family members. For that reason, it is important to model healthy relationships, among both staff and participants, providing a safe place and a container for healing. In addition it is noted that it is crucial to create an environment in which the women can experience consistent, reliable and mutual relationships with the facilitators and each other (Covington & Beckett, 1988). Just as was hoped in the manual, connections were certainly made (Fallot & Harris, 2002). This was demonstrated in the verbal feedback from operational staff, clinical staff and women in the group. Some of the factors which may have triggered these new connections appear to have been captured in the following quotes: ‘It felt good being in a group.’ Member 3 ‘There was trust in the group which made me speak out, the group helped build trust.’ Member 2 ‘There was a nice bond which was also practiced on the wing.’ Member 6 This is promising as this can be a difficult element to nurture especially in a prison environment. Helpfully, the manual allowed for mediating factors against the barriers which can be faced within a prison environment. To mediate against some of the common difficulties for women in prison of a number of adaptations are suggested in the appendix of the manual. These were extremely helpful and were well received by Forensic Update 2014 Annual Compendium

the women. It also emphasised the gender responsiveness of the intervention. The team had to think extensively about responsiveness prior to implementation as one of the women deemed suitable for the module has diagnosed learning difficulties and a high level of suggestibility. Due to this her treatment has mostly been facilitated on an individual basis and this was also recommended for module one of TREM. Due to this it could be questioned whether this woman experienced as much benefit as those who experienced the module in a group setting which assists with peer support and development of new connections. Additional benefits of a supportive group setting, wherein members are able to narrate their stories, include the process of desensitisation to the trauma, as well as a ‘communalisation’ (Pennebaker & Seagal, 1999; Tedeschi & Calhoun, 1995). This connection between two or more human beings reduces feelings of isolation and allows the individual to create structure and meaning to a trauma, which also aids the processing element of the event. The effects of allowing an individual to form a narrative around their own personal trauma, has been shown within diverse groups of people and in a variety of settings. The group of women engaged with the first module of TREM were diverse. The women varied in age from 26 to 62, they had significantly different life experiences, relationship history and education. Notably the individuals had been engaged with the specialist service for different lengths of time, ranging from a number of weeks to five years. This would hopefully not be the case in future as the women would be offered the empowerment module on entering the service so the difficulties associated with lengths of engagement would not have such a profound impact and be less of a confounding factor. The impact of this factor is highlighted by the following example in which, one group member had only recently completed the assessment and treatment needs analysis stage, whereas two group members were nearing the end of F Forensic Update 2014 Annual Compendium

their treatment. Although there are many positive elements to this, it was found that having women at different stages of treatment meant that they had either limited or more developed coping skills to assist in managing themselves in a group environment. For example, the newer group member was very vocal, struggled to contain her emotions and opinions within the group, and would often control group discussions. Difficulties become apparent when trying to manage this without being dismissive or invalidating to the survivor. Due to the nature of the group, discussions about traumatic experiences were inevitable and were not discouraged. It was felt that by discouraging the women to discuss the trauma and difficult life experiences they had experienced this would only serve to reinforce the negative response which had been previously received about their experiences. However, this did cause some difficulties as some of the women found disclosures difficult to hear and deal with. There was also an incident of broken confidentiality in which some of the women entered another group intervention and began to discuss details from a previous TREM session. Upon reflection this incident led to engagement difficulties in that the group members became reluctant to share experiences. It had also affected another group intervention and this was unhelpful for the group and unfortunate for the individuals involved. Overall, it was found that the women did feel comfortable enough to open up and share experiences in the group environment; this is highlighted in the following quotes: ‘I’m usually in my own little self, so to get something out of me was a miracle. I tend to be a bit shy and untrustworthy and more comfortable with myself.’ Member 3 ‘It was really relaxed, not forced and not intense. We were able to have a laugh, you didn’t feel pressured; speak when you want to speak.’ Member 4 47

This incident emphasised the importance of boundaries and containment for the women, from the use of a mutually signed contract to experienced facilitators who were able to manage and contain distressing narrative. It was also important for facilitators to reiterate the importance of a positive mental attitude throughout all discussions. The benefits of including positive emotional content in disclosures have been reported (Pennebaker & Francis, 1996). This finding was supported by qualitative findings from the TREM group and is highlighted in the following quotes: ‘Because I talked about my childhood it allowed me to let some of it go.’ Member 1 ‘I have come through a lot of trauma; I now have the skills to cope with future trauma.’ Member 4

Conclusion It has been highlighted that a woman’s experience of trauma can be linked to future offending; therefore, it is imperative that women are provided with an opportunity to cope with the effects of traumatic experiences in a more positive way. By delivering the first module of TREM, the specialist women’s service hoped to empower participants and provide a supportive environment in which they could learn. The Empowerment module offered the participants a short-term therapeutic intervention based on psycho-education, which hoped to provide them with more knowledge about themselves as women. Research highlights the link between traumatic life experiences and the later onset of personality disorder (Livesley, 2003). More specifically individuals diagnosed with BPD can present with difficulty in developing and maintaining trustful relationships, developing a positive self-image and managing interpersonal relationships (DSM-IV, 2001). It is noteworthy that following TREM, some of the participants

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reported a positive shift in terms of trust and a greater understanding about factors which can affect the trust we have for someone. The participants were able to link education about the biological aspects of being a woman and how this had contributed to a rise in their self-esteem. Furthermore, it is positive to note that the participants reported gaining a better understanding of what a safe relationship involved, and reported having more stable boundaries following completion of module one. The findings support previous research, that it is not always appropriate to explore traumatic experiences in detail (Adshead, 2000; Briere & Scott, 2006; Bryant & Harvey, 2000), and that focusing on educating and developing coping skills can be more beneficial. It is also valuable to have further research findings that support the use of TREM with women and also for the purpose of treatment with women in a secure environment in the UK.

Recommendations and future directions It is positive that the participants were able to provide feedback regarding the first TREM module. An important recommendation involved the participants having the option of a catch-up session, in which they could review the material covered, in order to reinforce it. The specialist women’s service will continue to offer the initial empowerment module to all of the women entering the service, and are planning on implementing the full TREM programme to those women who have more complex trauma difficulties and would benefit from a more in-depth exploration of their life.

The Authors Michelle Carr, Alison Hodgson, Samantha Woodhouse & Marc Kerry HMP YOI Low Newton, Primrose Service, Tees Esk and Wear Valley NHS Trust.


Correspondence Dr Michelle Carr Email: [email protected] Alison Hodgson Email: [email protected]

Samantha Woodhouse Email: [email protected] Marc Kerry Email: [email protected]

References Adshead, G. (2000). Psychological therapies for posttraumatic stress disorder. British Journal of Psychiatry, 177, 144–148. Amaro, H., Dai, J., Arevalo, S., Acevedo, A., Matsumoto, A. & Nieves, R. (2007). Effects of integrated trauma treatment on outcomes in a racially/ethnically diverse sample of women in urban community-based substance abuse treatment. Journal of Urban Health, 84(4), 508–522. Battle, J. (1992) Culture free self-esteem inventories (2nd ed.). Austin: TX: PRO-ED. Blud, L. (2007). Literature review and recommendations – treatment interventions dealing with trauma: What will work with personality disordered women offenders? Prepared for the Primrose Project Team by LMB Consultancy Ltd. Briere, J. (1995). Trauma Symptom Inventory Professional Manual. Odessa, FL: Psychological Assessment Resources. Briere, J. & Scott, C. (2006). Principles of trauma therapy. Thousand Oaks, CA: Sage. Bryant, R.A. & Harvey, A.G. (2000). Acute stress disorder: A handbook of theory, assessment and treatment. Washington, DC: American Psychological Association. Corston Report (2007). A review of women with particular vulnerabilities in the criminal justice system. London: The Home Office. Covington, S. & Beckett, L. (1988). Leaving the enchanted forest: The path from relationship addiction to intimacy. San Francisco: Harper & Row. DSM-IV-TR (2001). Diagnostic and Statistical Manual of Mental Disorders (4th ed.), text revision. Washington, DC: American Psychiatric Association. D’Zurilla, T.J., Nezu, A.M. & Maydeu-Olivares, A. (2002). Manual for the Social Problem-Solving Inventory – Revised. North Tonawanda, NY: MultiHealth Systems. Fallot, R.D. & Harris, M. (2002). The Trauma Recovery and Empowerment Model (TREM): Conceptual and practical issues in a group intervention for women. Community Mental Health Journal, 38(6), 475–485.


Fallot, R.D., McHugo, G.J., Harris, M. & Xie, H. (2011). The Trauma Recovery and Empowerment Model: A quasi-experimental effectiveness study. Journal of Dual Diagnosis, 7(1–2), 74–89. Foa, E.B. & Meadows, E.A. (1997). Psychosocial treatments for post-traumatic stress disorder: A critical review. In J. Spence., J.M. Darley & D.J. Foss (Eds.), Annual Review of Psychology (Vol. 48). Palo Alto, CA: Annual Reviews. Foa, E.B. & Rothbaum, B.O. (1998). Treating the trauma of rape. New York: Guilford Press. Harris, M. & The Community Connections Trauma Work Group (1998). Trauma recovery and empowerment. A clinician’s guide for working with women in groups. New York: The Free Press. Linehan, M.M. (1993). Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford Press. Livesley, W.J. (2003). Women and dangerous and severe personality disorder: Assessing, treating and managing women at risk. Issues in Forensic Psychology, 4, 41–53. Morrisey, J.P., Jackson, E.W., Ellis, A.R., Amora, H., Brown, V.B. & Najavitis, L.M. (2005). Twelvemonth outcomes of trauma informed interventions for women with co-occurring disorders. Psychiatric Services, 56(10), 1213–1222. Najavitis, L.M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. Norman, N. & Barron, J. (2011). Supporting women offenders who have experienced domestic and sexual violence. Bristol: Women’s Aid Federation of England. National Institute for Clinical Excellence (NICE) (2005). Quick reference guide to post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care. Clinical Guideline 26. London: National Institute for Clinical Excellence. Palmer, R.L. (2002). Dialectical behavioural therapy for borderline personality disorder. Journal of Continuing Professional Development, 8, 10–16. Pennebaker, J.W. & Campbell, R.S. (2000). The effects of writing about traumatic experience. National Center for PTSD Clinical Quarterly, 9, 17–21.

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Pennebaker J.W. & Francis, M.E. (1996). Cognitive, emotional, and language processes in disclosure. Cognition & Emotion, 10, 601–626. Pennebaker, J.W. & Seagal, J.D. (1999) Forming a story: The health benefits of narrative. Journal of Clinical Psychology, 55, 1243–1254. Roger, D., Jarvis, G. & Najarian, B. (2003). Detachment and coping: The construction and validation of a new scale for measuring coping strategies. Personality and Individual Differences, 15(6), 619–626. Roth, A. & Fonagy, P. (2005). What works for whom? A critical review of psychotherapy research (2nd ed.). New York: Guilford Press. Tedeschi, R.G. & Calhoun, L.G. (1995). Trauma and transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage.

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Toussaint, D.W., VanDeMark, N.R., Bornemann, A. & Graeber, C.J. (2007). Modifications to the Trauma Recovery and Empowerment Model (TREM) for substance-abusing women with histories of violence: Outcomes and lessons learned at a Colorado substance abuse treatment center. Journal of Community Psychology, 35(7), 879–894. Tugade, M.M., Fredrickson, B.L. & Barrett, L.F. (2004) Psychological resilience and positive emotional granularity: Examining the benefits of positive emotions on coping and health. Journal of Personality, 72(6), 1161–1190. Young, J.E. (1994). Cognitive therapy for personality disorders: A schema-focussed approach. Sarasota, FL: Professional Resource Exchange. Zlotnick, C., Shea, M.T., Rosen, K., Simpson, E., Mulrenin, K., Begin, A. & Pearlstein, T. (1997). An affect-management group for women with post-traumatic stress disorder and histories of childhood sexual abuse. Journal of Traumatic Stress, 10, 425–436.



‘Using CAT’ as opposed to ‘Doing CAT’: Adapting cognitive analytic therapy for use within a forensic patient setting Katie Gilchrist ITHIN THIS PAPER I intend to outline an adapted model of Cognitive Analytic Therapy (CAT) whereby CAT is used as a reflective practice for frontline staff, instead of the more traditional one-to-one therapeutic approach. The aim of implementing this way of working was to enhance relational awareness and to develop greater insight and understanding of ward based interactions, day-to-day dynamics and critical incidents (Marshall, Freshwater & Potter, 2013). CAT has been a useful tool in working with offenders as it can help the offender to identify their own reciprocal role procedures and thus, have a say in risk management (Shannon, 2009). Reciprocal role procedures within CAT are highlighting the past patterns of relating, and the effect these patterns are having on our relationships, our work and the way we are with ourselves. For example, in childhood you may have learnt the only way to stop being picked on by others is to become tough and intimidating, resulting in the other person feeling intimidated and afraid. These procedures help to form an understanding of the world we live in and can lead individuals to strive for these roles in future interactions. Case studies of the use of CAT with a forensic population have indicated that having an understanding of an individual’s procedures can help to formulate the motivations and nature of offending behaviour (Pollock, Stowell-Smith & Gopfert, 2006). Using the previous example, if the individual who becomes tough and intimidating towards others then

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also uses physical violence to ensure that they remain in the more powerful dominant role, the motivation for doing so may be due to a fear of being vulnerable. Therefore, reducing the likelihood of offending may involve focusing upon the individual’s selfconfidence and image, as well as traditional offending programmes like problem solving and anger management. CAT, typically, involves working alongside the client in a side-by-side manner. However, this is not always possible. Potter (1999) looked at ‘using’ CAT as opposed to ‘doing’ CAT and asked ‘Can people in other therapies use CAT to inform or aid their own model of practice?’ ‘Can CAT be used with only an introductory grasp of its principles and methodology?’ (p.2). My first awareness of CAT occurred when I began working as a nursing assistant in a forensic mental health setting. I enjoyed working alongside patients, however, struggled to fully understand some of the behaviours displayed within the ward setting. I attended a two-day CAT skills awareness course and felt that the concepts of CAT gave me a framework for making sense of patient behaviour in terms of understanding how we can learn responses in childhood and the impact of these on our adult behaviour. As I was a nursing assistant on a female medium secure admissions ward, I did not have the professional qualification required for the traditional CAT skills course. Yet I was part of a ‘frontline’ team that acquired a high percentage of patient contact on a daily basis. It is plausible that nursing staff could 51

benefit from the development of additional therapeutic skills using a relational model like CAT. Marshall et al. (2013) created a tier modelled adaptation of the skills course and describe the aim as the development of skills based on CAT but with care and treatment by staff as the main focus and vehicle for change. Marshall et al. (2013) make the distinction between ‘using’ CAT and ‘doing’ CAT, with the focus being on ‘using’ CAT. Within this article I will demonstrate how you can ‘use’ CAT on an inpatient ward with a female offender pseudo named Isobel.

A case example of ‘Using CAT’ Isobel was in her 40s and had a long history of involvement with mental health services. Case history identified that Isobel lost her brother when she was a teenager, she was bullied at school and that she was aggressive toward others and property. Isobel began to have increasing obsessive thoughts about harming others and contacted services for assistance. However, when no immediate response occurred, she set fire to her flat and was charged with arson. Isobel had made little progress despite intense pharmacological treatment, psychological intervention and close nursing on the ward. She was perceived to be ‘stuck’ and there was concern over her care pathway. I wondered if applying CAT to her presentation would enable a greater insight into her behaviours and open an area for progression. Isobel’s presentation at the beginning of the skills course was that she was fearful of and unwilling to progress, as she was seeking constant reassurance around her medical diagnosis for fear that if she did not have it then her identity would not remain and she could not stay in hospital where she feels safe. She was assessed for individual psychological therapy; however, she would become distressed within sessions, as well as presenting as highly anxious. Therefore, it was agreed by the clinical team that she would benefit from a more consultationbased approach.

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Acknowledging Isobel’s zone of proximal development (Vygotsky, 1978), in terms of what she could achieve independently in comparison to what she could achieve with support from others, it was agreed that I would work alongside staff, in consultation, using CAT as a framework to understand some of the difficulties experienced by them and Isobel. By implementing CAT in this way, Isobel would be given care without having to further exacerbate her distress through one-to-one work.

Implementing the Adapted Cognitive Analytic Model 1. Mapping the moment with staff Ryle and Kerr (2002) describe CAT as a social model of the self and suggest that reciprocal roles created in childhood can be seen in current behaviour and interactions with others. Using this theory, I explored the interactions staff entered into with Isobel. I began to map these interactions, as demonstrated in Figure 1. CAT posits that there is a ‘third rule’ and behaviour expressed is influenced by the individual themselves, staff and the environment. Mapping moments on the ward with the staff team, I began to create a ‘here and now’ map of an incident they recalled where Isobel was asking staff members the same question constantly regarding a possible move to a new ward. I asked staff to think about their responses and how this may have made Isobel feel. The first reciprocal role was ‘silencing, protecting, reassuring → safe, reassured, secure’. I asked how the above interaction with Isobel made them feel and the reciprocal role ‘constant questions, seeking reassurance → tired, fed up, worn out’ was formed. Mapping alongside staff indicated that they were tired of Isobel’s presentation and I was concerned that this could affect Isobel’s behaviour and her stay on the ward. To investigate this further, I created an ‘action’ map looking at action, impact and response (Ryle & Kerr, 2002). This indicated the procedural sequences that we observed Isobel entering in to and it was identified Forensic Update 2014 Annual Compendium

Figure 1. Forensic Update 2014 Annual Compendium

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that staff felt they were adopting ‘encouraging’ and ‘prompting’ roles in their interactions. However, mapping allowed me to think therapeutically about Isobel and I recognised that she could instead feel ‘pushed’ and ‘rejected’ by staff. This awareness created a shift within my maps and encouraged the team to reflect upon what Isobel’s perception may be of interactions on the ward. 2. Patient life history Ryle and Kerr (2002) describe a reciprocal role procedure as a stable pattern of behaviour that originates in early internalised relationships which determine current patterns of relation with others and self. Using this theory I clarified if the reciprocal roles I identified for Isobel were suitable by looking at her history to see if a common reciprocal role internalised in childhood could be identified. Isobel’s experience of loss, bullying, aggression and her act of arson suggested to me that she had experienced rejection and separation as a child. Her offence of arson could be understood as a way of communicating her distress around feeling isolated and uncared for by others. By starting a fire, she was immediately recalled and placed back into hospital where she felt safe and supported. Adding this to the map, I identified a link between Isobel feeling rejected and her constantly asking questions due to obsessive thoughts around her diagnosis of schizophrenia and anxiety, which she used as a way of identifying herself as a person. From her early experience of separation and anxiety Isobel could have developed a dependency on others to care for her and thus, created a strong mothering reciprocal role. It was highlighted by nursing staff that Isobel seemed dependent upon others, stating that she was incapable of doing anything independently and presenting as so anxious when asked to do so, that staff tended to respond by rescuing or mothering her. She may have created the belief that she feels safe and secure when cared for and that she 454

needs to be in hospital for this to occur, due to the community feeling such an unsafe place, where she could be alone and ignored. Spending long periods of time in hospital being looked after due to mental ill health could have led to a fear of being alone or independent. This may have influenced her current coping strategies of needing reassurance, a wish to be mothered and a wish to remain in a safe, cared for environment. Whilst these reciprocal roles may have helped as a child, they were now leaving Isobel with an identity that was formed through her reliance on others; that to have independent thought or action could leave her isolated which was something to avoid at all costs. This may have created an over reliance on staff to tell her what to do. 3. Creating an over-arching map demonstrating key roles I mapped many moments on the ward concerning Isobel’s interactions with staff and her environment and reading Isobel’s case history confirmed her reciprocal roles. Combining all of these, I created an overarching map that demonstrated the key roles staff entered in to as demonstrated in Figure 1. The development of a sequential diagrammatic reformulation gave me a tool for attempting to understand Isobel’s behaviour without having to subject her to the anxiety and distress of doing CAT on a one-to-one basis. Whilst staff felt they were being consistent in their approach, the map highlighted subtle differences in the way they interacted with Isobel. The map identified that Isobel was dependent on staff and that at times staff responded in a reassuring way which we observed left her feeling cared for and mothered. However, this was not sustained as staff became frustrated with Isobel’s lack of progress and increasing dependency. This led staff to neglect or ignore Isobel’s dependency which may have left Isobel feeling rejected. Alternatively, staff reassured Isobel and tried to encourage her independence; however, when reflecting upon this, staff felt she may have perceived this as Forensic Update 2014 Annual Compendium

attacking and smothering, feeling pushed to be independent when she did not feel ready. It was felt that Isobel did not recognise the positives of independent behaviour, only believing that she would return to the community where she would be alone. Isobel felt bullied, which led her to feeling angry and to attack staff who then felt like they were being bullied. This was, therefore, a key area to focus upon when looking at how we as a staff team could work with Isobel. 4. Recognition of key areas within reformulation The exploration of reciprocal roles developed in childhood and the creation of an over-arching map demonstrating key roles were invaluable in explaining Isobel’s behaviour. A written reformulation was created so that the team could clearly identify Isobel’s childhood influences, current coping strategies, roles they were being pulled into and areas for intervention. This narrative formulation created an area for intervention, as I was able to demonstrate subtle differences in staff approaches to Isobel’s behaviour. Staff had not recognised the impact of doing everything Isobel wished had on fellow team members who did not ‘mother’ her. Staff could now recognise when they were being pulled into a negative reciprocal role. They could identify how ‘mothering’ Isobel was unhelpful as it reduced her independence. 5. The creation of a ‘relationally informed’ care plan From this, a ‘relationally informed’ care plan was devised and shown to Isobel’s multi-disciplinary team. This followed a trans-diagnostic approach, highlighting the dynamics affecting Isobel and considering her upbringing, interaction with staff and interaction with the ward environment. The care plan recognised Isobel’s zone of proximal development and stressed the importance of consistent staff responses that promoted independence in a supportive way. For example, instead of coming across as pushy when promoting independence, staff began to explain why they were encouraging Isobel F Forensic Update 2014 Annual Compendium

to do things for herself. This enabled Isobel to better understand why staff were promoting her independence and develop more autonomy over her life and what she wants to achieve. Furthermore, adopting a relationally informed care plan altered staff practice on the ward as everyone could identify with Isobel’s behaviour. There was a nonblaming, non-mothering approach toward Isobel and this fostered Isobel’s independence. Examining the CAT map allowed for exit points to be created. These were new ways of interacting; reciprocal roles not currently present on the diagram that could help Isobel’s presentation (see Figure 1). For example, staff were encouraged to work alongside Isobel in a ‘let’s do it together’ approach as illustrated in Figure 1. Staff began to reassure Isobel in times of anxiety and this empowered Isobel to complete little tasks in stages, for example, making her own drink of juice. Staff prompted Isobel to tend to tasks independently in a nurturing way, recognising that there may be areas she needed assistance with and supporting her in this. For example, Isobel would be prompted to change her bedding, a task she originally perceived she was unable to do. Staff would remain at the room door, encouraging and supporting Isobel through giving verbal instruction when needed and offering praise throughout. Isobel felt supported and helped in a safe way so began to make her bed independently. Isobel did not display any awareness of a change in her interactions with others, however, she began to present with more autonomous behaviour; eating meals, making her bed and tending to her personal hygiene independently. Her presentation improved positively and it was noted through staff reflective groups and weekly MDT meetings that there was a reduction in the frequency of Isobel’s obsessive questions around medication. Isobel’s ability to now utilise assisted leave into the community encouraged a move to a less intensive setting.

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Conclusion The construction of a sequential diagrammatic reformulation allowed for the creation of a relationally informed care plan and the development of exit points to improve Isobel’s current situation. The implementation of CAT provided a common language for understanding Isobel’s behaviour and this created a more psychologically informed environment. Mapping moments and developing reciprocal roles allowed the team to become attuned to Isobel’s behaviour and thus, better understand why she displayed the behaviour she did. The development of the sequential diagrammatic reformulation allowed the team to recognise the impact of Isobel’s upbringing on their own interactions with her. The development of exit points clearly demonstrated interactions that were more beneficial in helping Isobel to progress. CAT changed the culture of the ward as the team were now able to better understand patient behaviour. A nonblaming, non-judgemental approach was adopted as CAT allowed everyone to think

trans-diagnostically and therapeutically. There was a reduction in staff splits as everyone altered from mothering or pushing Isobel to working alongside Isobel. This created a stronger working environment as everyone adopted a consistent approach. Ultimately, the implementation of CAT principles allowed for all to fully grasp Isobel’s presentation, identify areas for improvement and to help Isobel move on to a less intensive setting. Whilst it is optimal to work alongside an individual in a side by side manner, I hope that I have demonstrated that ‘using’ CAT in an adapted form can change an individual’s behaviour and improve their current situation.

The Author Katie Gilchrist works within Adult Forensic Mental Health at Roseberry Park Hospital, Middlesbrough. This article was completed under the supervision of Dr Lauren Moon, Highly Specialist Clinical Psychologist. Email: [email protected]

References Marshall, J., Freshwater, K. & Potter, S. (2013). Adaptations of a CAT skills course. Reformulation, Winter. Pollock, P., Stowell-Smith, M. & Gopfert, M. (2006). Cognitive analytic therapy for offenders: A new approach to forensic psychotherapy. London: Routledge. Potter, S. (1999). A personal view of CAT. Reformulation, ACAT News, Winter 103, 1–4. Ryle, A. & Kerr, I. (2002). Introducing cognitive analytic therapy: Principles and practice. West Sussex: John Wiley & Sons Ltd. Shannon, K. (2009). Using what we know: Cognitive analytic therapy’s contribution to risk assessment and Management. Reformulation, Winter, 16–21. Vygotsky, L. (1978). Interaction between learning and development. In M. Gauvain & M. Cole (Eds.), Readings on the development of children (pp.29–36). New York: W.H. Freeman and Company.

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Does adapted DBT have a place in forensic settings? The development of a DBT-informed emotion regulation group for female forensic personality disordered inpatients Claire Thompson This study explores the impact of a DBT-informed emotion regulation group upon female personality disordered inpatients detained within a forensic low secure psychiatric service. Emotion regulation is a core feature of borderline personality disorder, dialectical behaviour therapy having been developed on this premise. Adapted sessions (20) were devised primarily from the DBT modules of emotion regulation and distress tolerance to meet the needs of both the inpatient setting and patient group. The group was run twice with eight patients in each group. Pre- and post-incident rates were used as an indication of potential treatment change in addition to measures of emotional control and altered states of capacity. Results indicated significant reduction in post-intervention rates of violence and self-harm, results from the psychometric data did not indicate such a degree of treatment change. Methodological limitations and implications for future practice are discussed. Keywords: Female offender; DBT; BPD; dialectical behaviour therapy; female psychiatric service; borderline personality disorder.

IGURES published by the Ministry of Justice in November 2013 reported 3956 women incarcerated in England and Wales, representing just under five per cent of the overall prison population. (Ministry of Justice, 2013). The female prison directorate currently appears to currently be in a state of flux, HMP Askham Grange and HMP East Sutton Park closing in 2014 with further imminent changes expected. This is a concern for the potential impact on secure forensic mental health services when a significant number of female offenders with borderline personality disorder is well evidenced (Newhill et al., 2009; Sansome, 2009) and there is a noted lack of women only community mental health services (Ministry of Justice, 2013). The Corston Report (2013) also comments specifically on the disconnect between forensic

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and mental health services for female personality disordered offenders, especially those deemed to present a significant level of risk to others. Due to a lack of specialist services one option for female personality disordered offenders is to be admitted to independent hospitals providing secure health care services aiming to address both the risk and mental health needs of service users though this generally requires being sectioned under the Mental Health Act.

Borderline personality disorder and offending The relationship between personality disorder and offending behaviour whilst complex and multi-faceted, is somewhat unsurprising given that a trait of antagonism or hostility is characteristic of a number of personality disorders within the Diagnostic 57

and Statistical Manual 5 (DSM-5). This relationship is supported by studies which have examined the prevalence of personality disorders amongst offenders which has consistently reported prevalence rates ranging from 10 to 15 per cent for primary clinical diagnoses of personality disorder (Anderson et al., 1996; Birmingham, Mason & Grubin, 1996; Duggan & Howard, 2009). In relation to borderline personality disorder the strong correlation with offending is not new, Coid in 1998 found that offenders with cluster B personality disorders (e.g. antisocial, borderline, histrionic) were 10 times more likely to have a criminal conviction and almost eight times more likely to have spent times in prison. A more recent but smaller scale study by Konstantinos et al. (2008) corroborated these results. This lead the authors to suggest that borderline personality disorder is strongly related to the manifestation of violent acts, predominantly thought due to the anger dyscontrol that is in both the DSM-5 and the International Classification of Diseases 10 (ICD-10) classification systems for BPD. Frequent, intense anger and aggressive outbursts are also included in both sets of criteria meaning borderline personality disorder has been found to be specifically correlated with violent acts (Duggan & Howard, 2009). The biosocial theory of BPD by Linehan (1993) proposes that this dysfunction of emotion results from biological irregularities combined with certain dysfunctional environments, as well as their interactions over time. Ultimately, this results in individuals that react quickly to perceived threats and have a low threshold in terms of their emotional reactions, such responses contributing to the increased likelihood of offending behaviour (Logan & Blackburn, 2009). Researchers have also demonstrated links between BPD and the risk of reoffending (Nee & Farman, 2007) indicating a need to explore ‘what works’ with mentally disordered offenders, particularly female disordered offenders to reduce risk to the women 58

themselves and to others. In July 2013, the Justice Select Committee published findings and recommendations in an attempt to ensure that the differing needs of females in the Criminal Justice System are both met and recognised. In response to this the Ministry of Justice commissioned a Review of the Women’s Custodial Estate in 2013. One of their key recommendation’s was the need to improve access to psychological interventions, namely learning from the Offender Personality Disorder Pathway with the potential for joint commissioning of services to meet both mental health and criminogenic need of the female prison population.

Borderline personality disorder and DBT Within the DSM-5 (2013), BPD is defined as an amalgamation of behaviours that includes the following: efforts to avoid abandonment; a pattern of unstable and intense personal relationships; identity disturbance; markedly and persistently unstable self image or sense of self; impulsivity in at least two areas that are potentially self damaging (e.g. substance misuse, spending or eating behaviours); recurrent suicidal or self harm behaviour; affective instability; chronic feelings of emptiness; and inappropriateness, intense anger or difficulty controlling anger. Dialectical Behaviour Therapy (DBT) was devised as a psychological intervention focused on addressing some of the symptoms or behavioural manifestations of BPD (Linehan et al., 1991). It aims to help participants develop skills in relation to four core areas of deficit within BPD: emotional regulation, interpersonal effectiveness, distress tolerance and mindfulness. These maladaptive patterns are considered to stem from the interaction between an individual who is emotionally vulnerable and an invalidating environment; or rather an environment that pushes, ignores or corrects behaviour independent of the actual validity of the behaviour. It is felt that by developing tolerance and coping techniques as well as encouraging cognitive and emotional change, DBT aims to address both emotional dysregulaForensic Update 2014 Annual Compendium

tion and the range of cognitive and emotional issues related to BPD. It combines standard cognitive behavioural techniques for emotional regulation and reality testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. All of these areas in combination have a main goal of achieving some measure of stability and cohesiveness in respect of emotions and mood, the dysregulation reported to be the underpinning of a proportion of violent and impulsive crime committed be female personality disordered offenders (Sansone & Sansone, 2009). Enhanced DBT provides several formats of therapy. Skills training in a group to teach the skills and Enhanced one-to-one sessions to assist the client to apply these skills to their own life. The client is also provided with emergency telephone support for when they deem they are in crisis and their treatment team must attend weekly consult supervision to ensure best practice. DBT has for a number of years been acknowledged as the psychological intervention of choice for BPD. It is a treatment option recommended by the National Institute for Health and Clinical Excellence (NICE) guidance (2009) for therapists working with female BPD suffers. However, only in recent years has DBT been considered potentially suitable in female forensic services (Nee & Farman, 2005; Van Den Bosch et al., 2012) as there are a number of factors that limit its usage in secure settings. The original modality of DBT devised in the 1990s focuses on a community setting, with one treatment goal being to maintain safety so as to assist clients to build community based lives that do not require hospital admissions (Dimeff, Monroe-DeVita & Paves, 2006). This, therefore, could be seen as potentially restricting its relevance to an inpatient environment, let alone a forensic one. ‘The impression that an individual’s hospitalisation has prevented his or her suicide can paradoxically increase the likelihood of his or her future suicidal behaviours Forensic Update 2014 Annual Compendium

that prompt hospitalisation’ (Dimeff & Koerner, 2007, p.70). Contrastingly, an offender’s detention can allow for the carefully controlled management of a crisis, bring a new perspective to diagnosis and treatment and allow for a compassionate and clear understanding for the offender of their disorder. These issues aside, forensic units present a number of practical challenges to the implementation of enhanced DBT. For example, an integral part of the programme is emergency telephone consultations between patient and therapist. For security and practicality reasons this may not sometimes be possible within a forensic inpatient service, restricting coaching of the skills. It is, however, acknowledged that is becoming increasingly used within forensic settings. Some of the original skills techniques are also not instantly implementable within a secure environment, however, adaptations for offenders are becoming more common place. For example, self-soothing activities such as petting an animal or going for a walk on the shore of a lake may not be an option if Section 17 leave has not been granted, however cuddly toys, comforting textures and soothing pictures to aid the mastery of the varying skills can all be viable options. The NICE guidance highlights that offenders should have the same access to health care as those not detained or imprisoned at first glance the judgement could be made that enhanced DBT within forensic settings would not be thought potentially feasible due to the reasons already detailed. In addition, the duration of a patient’s detention in forensic inpatients settings is becoming increasingly ruled by contextual factors such as the relevant section of the Mental Health Act and funding. Patients may not, therefore, be able to commit to or complete the full DBT programme, which in its entirety can take over a year. In light of these restrictions of Enhanced DBT within forensic settings, a number of adaptations have been trialled and implemented within more challenging settings, 59

including secure psychiatric units and prison environments (Robins & Chapman, 2004). Despite all the aforementioned issues, the evidence still suggests that DBT may be an effective intervention with female offender populations within secure settings (Nee & Farman, 2005; Van Den Bosch et al., 2012). There are varying reasons for this; DBT addresses both short-term management and longer-term goals of overall behaviour change, social reintegration and consequential risk reduction. The bio-social theory used to explain the pathology of borderline personality disorder can also be related to the varying disorders that are often found in forensic facilities such as antisocial personality disorder and staff burnout which can occur in secure settings, and may be lessened by DBT (McCann, Ball & Ivanoff, 1996). Notwithstanding the small sample sizes, the results of these studies supported the positive effect of DBT upon BPD-related behaviours such as deliberate self-harm, aggression and mental illness related symptoms. The current study aims to examine the effectiveness of a DBT-informed programme within a women’s low secure service in the East Midlands of England.

also assessed by willingness to engage in the 12-week psychological assessment process completed upon their admission. This includes clinical interviews and a battery of psychometric assessments, with recommendation for attendance at the group being made following a detailed formulation and as part of an individualised treatment pathway. Patient commitment was also continually assessed throughout the programme, with patients being informed that they would be excluded if they missed any three sessions in a 10-session module. Further exclusion criteria assessed prior to the commencement of the programme included active psychosis and a primary or secondary diagnosis of a learning disability. Of the 16 women who commenced the DBT-informed group, 14 completed the full programme. One patient was excluded from the programme shortly after it commenced due to her unstable mental state, which significantly affected her ability to commit to the programme. A second participant left the programme after completing one module due to being transferred to another low secure unit nearer her home.

Assessment measures Method Participants Sixteen patients aged between 21 and 54 (Mage=38.2, SD=5.8) from a female low secure psychiatric service were assessed as meeting the inclusion criteria for the group. The inclusion criteria was similar to that of the enhanced DBT programme in that all partcipants had a history of self-harm and demonstrated problems in at least one of the following areas; interpersonal relationships, emotional regulation, impulsivity and risky behaviours. Furthermore, all patients had a current diagnosis of Borderline Personality Disorder as outlined in the DSM-5, or Emotionally Unstable Personality Disorder as outlined in the ICD-10. In addition, all patients were required to demonstrate a level of willingness to change by agreeing to attend the course. Patient commitment was 60

A number of outcome measures were identified to assess the effectiveness of the group. Incident data for each patient was collected centrally by the hospital for a month prior to and a month post the intervention. As part of the requirements for the hospital reporting process these are already classified into categories, that is, violence or self-harm, therefore, this did not have to be done by the study author. In addition to incident data, self-report questionnaires were administered both pre- and post-intervention. The questionnaire felt most aligned to the treatment aims and, therefore, used as the psychometric measure of treatment change was the Inventory of Altered Self-Capacities (IASC). The IASC is a 63-item self-report measure of an individual’s psychological functioning in three important areas: Capacity to form and maintain meaningful Forensic Update 2014 Annual Compendium

relationships, Capacity to maintain a stable sense of personal identity and self-awareness and Capacity to modulate and tolerate negative affect. The various scales of the IASC assess the following domains: Interpersonal Conflicts (IC), Idealisation – Disillusionment (ID), Abandonment Concerns (AC), Identity Impairment, Susceptibility to Influence (SI), Affect Dysregulation (AD) and Tension Reduction Activities (TRA). Descriptions of each of the scales are shown in Table 1.

Intervention Due to the service not providing an Enhanced DBT programme, it was decided that it would be beneficial to provide an initial adapted DBT 10-session module, based predominately on DBT emotion recognition principles and basic skills. An additional 10-session module looking primarily at building emotional resilience through distress tolerance skills was then devised, also facilitating a session on mindfulness which within the Enhanced DBT programme is a module in its own right. The two modules, each containing 10 sessions (20 sessions overall) are shown in Table 2 (overleaf).

Table 1: Description of the Inventory of Altered Self Capacities (IASC) Scales. Self-Capacities

Descriptions

Interpersonal Conflicts (IC)

Evaluates the extent to which the respondent endorses problems in his or her relationships with others and the tendency to be involved in chaotic, emotionally upsetting and sometimes short-lived relationships

Idealisation-Disillusionment (ID)

Assesses the respondent’s tendency to dramatically change his or her opinions about significant others, generally from a very positive view to an equally negative one.

Abandonment Concerns (AC)

Evaluates the respondent’s overall sensitivity to perceived or actual abandonment by significant others and the tendency to expect and fear the termination of important relationships.

Identity Impairment (II)

Measures the extent to which the respondent has difficulty maintaining a coherent sense of identity and self-awareness across contexts.

Susceptibility to Influence (SI)

Assesses the respondent’s tendency to follow the directions of others without sufficient self-consideration, and to accept uncritically others’ statements or assertions.

Affect Dysregulation (AD)

Evaluates problems in affect regulation and control, including mood swings, problems in inhibiting the expression of anger, and inability to easily move out of dysphoric states without externalisation.

Tension Reduction Activities (TRA)

Evaluates the respondent’s tendency to react to painful internal states and effects with externalising behaviours that may distract, soothe, or otherwise reduce internal distress. May suggest a tendency to externalise when feeling frustrated, angered, maltreated, or otherwise internally stressed.


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Table 2: Session plans for both modules. Module 1

1. Group introduction/review

2. What is an emotion?

2. Distraction

3. Reasons for emotions

3. Self sooth

4. Problems with emotions

4. Doing the opposite

5. Emotions, feelings, moods

5. Negative automatic thoughts

6. Where do emotions come from?

6. Grief

7. Recognising emotions

7. Shame

8. Naming emotions in others

8. Anger

9. Naming emotions in ourselves

9. Happiness

10. Ending and evaluation

The extended length of the modules enabled patients to consolidate key skills and concepts, and allowed a greater focus on the use of practical and relevant examples from patients themselves, to which they could apply the skills. The group occurred on a weekly basis for approximately one hour and was run by a Chartered Psychologist and a Forensic Psychologist in Training both of whom had received previous standardised DBT training.

Results Due to the limited sample size non-parametric tests (Wilcoxon signed rank tests) were used. The mean pre- and post-treatment scores across the differing domains of the IASC are displayed along with the mean pre- and post-incident data scores in Table 3. The results of the Wilcoxon signed rank tests indicate that there were expected changes across all domains of the IASC, as well as significant reductions in deliberate selfharm, aggression and overall incidents. Effect size analysis, using Cohen’s d demonstrated either medium or large effect sizes. 562

Module 2

1. Group introduction

10. Ending and evaluation

Discussion This study aimed to evaluate the effectiveness of a DBT-informed emotion recognition and regulation group facilitated at a women’s low secure psychiatric unit. The results indicated that there was a statistically significant difference in patient’s pre- and post-treatment scores on measures of deliberate self-harm, violence and overall incidents. Whilst the intervention may not be felt to target all these specific areas as directly as say anger management or selfharm management groups, the issue of emotion regulation and distress tolerance is felt to underpin strongly all three, and seen as evidence for a positive treatment change. Pre- and post-psychometric scores also indicated a positive treatment change. Not surprisingly the two self-capacities related to affect control; Affect Dysregulation (AD) and Tension Reduction Activities (TRA) were noted to show the most significant positive changes. The usefulness of some of the other scales such as susceptibility to influence could be questioned as this is not a capacity targeted within this treatment. Forensic Update 2014 Annual Compendium

Table 3: Mean pre- and post-treatment scores and incident rates (with Standard Deviations), significance levels and effect sizes. Measure

Pre-group mean (SD) N=16

Post-group mean (SD) N=16

Sig

Effect Size

Interpersonal Conflicts (IC)

22.6 (8.8)

16.2 (6.3)

0.010

0.38

Idealisation-Disillusionment (ID)

21.3 (9.1)

16.4 (6.4)

0.026

0.52

Abandonment Concerns (AC)

21.8 (10.9)

18.7 (8.2)

0.041

0.30

Identity Impairment (II)

22.9 (11.8)

19.1 (10.9)

0.037

0.28

Susceptibility to Influence (SI)

19.6 (10.0)

16.5 (5.8)

0.028

0.44

Affect Dysregulation (AD)

22.4 (11.0)

10.4 (3.8)

0.002

0.61

Tension Reduction Activities (TRA)

17.3 (8.2)

10.3 (2.6)

0.004

0.68

Deliberate Self-Harm (average per patient)

14.0

4.0

0.029

0.86

Violence (average per patient)

7.5

0.25

0.006

0.62

Total Incidents (for all 16 patients)

172

34

0.005

0.83

Despite the acknowledged methodological limitations of this study (including the small sample size), overall it is felt to highlight the potential for an adapted version of DBT within secure settings if the full enhanced programme is not viable due to financial or staffing restraints. A number of factors suggest the need for caution when drawing conclusions from the results. These include variables such as engagement in previous treatment, most patients having engaged in some form of previous psychological therapy at differing hospitals. Whilst all 16 patients had recently been admitted into this specific unit, previous treatment could not be controlled for. Another factor was the variance in medication administered throughout the sample, with none of the 16 patients being medication free throughout the intervention. The sedation effect, for example, could potentially affect their ability to engage with the course material and consequential results. The small sample size is also recognised as a limitation of the study, as is the lack of a control group which would have Forensic Update 2014 Annual Compendium F

allowed for more rigorous assertions from the results to have been made. There were a number of environmental factors that also mean care needs to be taken in interpreting the results. The hospital setting itself may be a cause of instability, for example, dynamics on the ward and influence and role of nursing staff potentially impacting on a patient’s mood and incident rates. In relation to this latter variable in particular, the lack of adequate knowledge and training of nursing and other support staff on the unit is considered to be a limitation of the treatment that is likely to have impacted on the current study. If the full DBT programme were to be implemented this would be considered vital for assisting patients in generalising their skills as well as reinforcing skill usage on a daily basis. The implementation of a DBT-informed programme within a low secure unit has served as an opportunity to conduct preliminary investigations into the potential effectiveness of the enhanced DBT programme for female forensic inpatients with a diagnosis of BPD. The positive results shown 63

within this study are important in relation to planning future treatment, adding weight to the argument that the potential therapeutic benefits of DBT within secure settings and forensic populations in general should not be overlooked. The fact enhanced DBT targets criminogenic needs such as poor problem solving, poor self-management, antisocial beliefs, anger and emotional dysregulation means there is scope for it to be used to target offending and ultimately reduce risk to both service users and the wider community.

The Author Dr Claire Thompson is a Senior Forensic Psychologist working as a Lecturer at Nottingham Trent University as well as with Raphael Healthcare.

Correspondence Dr Claire Thompson Division of Psychology, Chaucer Building, Nottingham Trent University, Burton Street, Nottingham, NG1 4BU. Email: [email protected]

References Birmingham, L., Mason, D. & Grubin. (1996). Prevalence of mental disorder in remand prisoners; Consecutive case study. British Medical Journal, 313, 1521–1524. Briere, J. (1998). Inventory of Altered Self-Capacities. Professional Manual. Odessa, FL. Psychological Assessment Resources. Coid, J. (1998). Axis 2 disorders and motivation for serious criminal behaviour. In A.E. Skodol (Ed.), Psychopathology and violent crime (pp.53–96). Washington, DC: American Psychiatric Association. Duggan, C. & Howard, R. (2009). The functional link between personality disorder and violence. In M. McMurran & R. Howard (Eds.), Personality, personality disorder and violence (pp.19–38). Chichester: Wiley-Blackwell. Justice Select Committee (2013). Women offenders: After the Corston Report: Second Report of Session 2013–2014. London: Justice Select Committee. Koerner, K. (2013). What must you know and do to get good outcomes with DBT? Behavior Therapy, 44(4), 568–579. Linehan, M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D. & Heard, H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060. Logan, C. & Blackburn, R. (2009). Mental disorder in violent women in secure settings: Potential relevance to risk for future violence. International Journal of Law and Psychiatry, 32, 31–38.

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Ministry of Justice (2013). Government response to the Justice Committee’s Second Report of Session 2013–2014: Female offenders. London: Ministry of Justice. Ministry of Justice (2013). Weekly Prison Population Bulletin – Week commencing 22 November. London: Ministry of Justice. Nee, C. & Farman, S. (2005). Female prisoners with borderline personality disorder: Some promising treatment developments. Criminal Behaviour and Mental Health, 15(1), 2–16. Nee, C. & Farman, S. (2007). Dialectical behaviour therapy as a treatment for borderline personality disorder in prisons: Three illustrative case studies. The Journal of Forensic Psychiatry & Psychology, 18(2), 160–180. Newhill, C.E., Eack, S.M. & Mulvey, E.P. (2009). Violent behavior in borderline personality. Journal of Personality Disorders, 23(6), 541–554. Robins, C.J. & Chapman, A.L. (2004). Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders, 18(1), 73–89. Sansome, R. & Sansome, L. (2009). Borderline personality disorder and criminality. Psychiatry (Edgmont), 6(10), 16–20. Van den Bosch, L.M.C., Hysaj, M. & Jacobs, P. (2012). DBT in an outpatient forensic setting. International Journal of Law and Psychiatry, 35(4), 311–316.


Becoming a Qualified Forensic Psychologist

Review of standards for Stage 1 and Stage 2 training Dee Anand HE Division of Forensic Psychology Training Committee (DFPTC) was tasked by the Partnership and Accreditation Committee with reviewing standards for both Stage 1 and Stage 2 training. Two working groups were established with Sarah Brown leading the Stage 1 standards review and Roisin Hall Stage 2, and DFPTC Chair Dee Anand overseeing both groups. One outcome of the review was that the model of thinking that Stage 1 and Stage 2 are discrete enterprises came under scrutiny; a model presenting common themes that run through both Stage 1 and Stage 2 with differential emphases was deemed to be more appropriate. Across both Stage 1 and Stage 2 demonstration of a critical understanding of theories, knowledge and evidence (both current and emerging) is required, as well as core skills and capabilities, along with the application of ethics/standards, guidelines, legal contexts, and skills of evaluation and communication. This is outlined in a comprehensive model with a thematic approach that identifies the common themes that will inform the evidence required to demonstrate outcomes across the dimensions specified (see Figure 1). Demonstrating ability across these themes at both a theoretical/academic level (Stage 1) and an applied/practice level (Stage 2) will assist in preserving the ‘gold standard’ of Chartership as a quality standard rather than a minimum requirement threshold as required for Health and Care Professions Council (HCPC) registration, and allow the British Psychological Society (BPS) to continue to make the case for Chartership as achieving this standard.

T


It should be noted that the BPS is the only body that offers a qualification in Stage 2 standards for forensic psychologists with the role of the HCPC primarily as a regulator. Stage 1 training programmes fulfil the important role of enabling graduates to fulfil the Standards of Proficiency outlined by the HCPC as representing the key concepts and bodies of knowledge that are relevant to the practice of forensic psychologists. Practitioner psychologists (forensic psychologists) who are entrants to the HCPC Register must: G understand the application of psychology in the legal system; G understand the application and integration of a range of theoretical perspectives on socially and individually damaging behaviours, including psychological, social, and biological perspectives; G understand theory and its application to the provision of psychological therapies that focus on offenders and victims of offences; G understand effective assessment approaches with individuals presenting with individual and/or socially damaging behaviour; G understand the application of consultation models to service-delivery and practice, including the role of leadership and group processes; G understand the development of criminal and antisocial behaviour; G understand the psychological interventions related to different client groups including victims of offences, offenders, litigants, appellants and individuals seeking arbitration and mediation. 65

Figure 1.

The underpinning principles of the Stage 1 criteria is that students/trainees develop a range of transferrable skills that are relevant to forensic psychology practice and to a range of other areas/employment. The criteria have been developed with a problem-based learning approach in mind, such that students develop the appropriate skills and capabilities and ways of working such that they approach each task by reviewing the current knowledge/theoretical/evidence-base, identifying and developing the appropriate skills and capabilities and applying these within appropriate prac66 F

tice, ethical and legal frameworks. They then evaluate and reflect on this work and communicate it appropriately. These core skills at Stage 1 which transfer more transparently to Stage 2 include: assessment and formulation, intervention, legal and criminal justice context, client groups, forensic settings, advice and consultancy, development and training and of course the inclusion of research. Hence, rather than discriminating between skills and capabilities, the profile and understanding of ‘What is a forensic psychologist?’ and ‘What does a forensic psychologist do and where?’ is made clear Forensic Update 2014 Annual Compendium

from Stage 1 through to Stage 2. The central idea of this revision of standards was to make clear to the profession how we might best function and equip new entrants with the best tools, knowledge and ideas to operate with improved adaptability in a changing world. Fortunately, we were able to bring Programme Directors with us in this process and while the philosophy and standards were clarified with strong input from them and the DFPTC, it has been done in such a way as to require minimal changes within the core programmes being delivered and will roll out through the accreditation process with reference to the new standards. This has been a challenging and extensive piece of work involving consultation with and participation of stakeholders. My thanks go out to all Programme Directors who have been involved in this process and the sterling and efficient work of all members of the DFPTC. It has been with a sense of achievement in the ongoing development of the profession that we have reached the stage where we were able to bring these recommendations to the Partnership and Accreditation Committee. Without the involvement of Roisin Hall and the Forensic Psychology Qualifications Board (FPQB) along with Lucy Horder and Susan Quinn at the BPS this would not have been possible. I am grateful to them for all of their input.


The challenge for us now is to ensure that Chartership retains its value and becomes increasingly transparent and streamlined with a clear focus on standards and professional development which would tie in with the revised standards for Stage 1 programmes. This is the beginning of the process, having effect at the beginning of the career of future forensic psychologists and ongoing development through the career pathway. I am convinced that a combination of the positive steps taken to this end, being steered by Roisin Hall and the FPQB and the work of the DFP will mean that the goal of retaining the value and merit of the Chartership qualification will be achieved in a reasonable timeframe. Dee Anand Chair – DFP Training Committee Chair Elect – DFP

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Training routes in forensic psychology Roisin Hall T THE DFP Strategy Day in December 2013 a working party was established to collate material on the different training routes available to those wishing to become registered or chartered as a practitioner psychologist. It is clear that there is a lot of interest in this matter amongst trainees, as well as those on the MSc courses and undergraduates, whilst key employers such as the prison services are keenly evaluating the relative merits of supporting training for Health and Care Professions Council (HCPC) registration vs. British Psychological Society (BPS) chartered status. The pieces you have in this edition of Forensic Update cover all the routes and more and, in my opinion, bring some much needed clarity. As well as information about what is available, contributors have written about the process from a reflective viewpoint and described their own experiences. The DFP Training Committee has recently carried out a revision of the standards for accreditation for the academic courses and the resulting model, as seen in the piece by Dee Anand, Chair of the Training Committee, can be seen to provide a framework for the competencies required for both Stage 1, the MSc stage and Stage 2, the Doctorates and the Forensic Psychology Qualification. It is fascinating to read the reflections from supervisors and trainees involved in the quite different routes. Sarah Disspain’s review of all the routes to registration and chartered status includes trainees’ views,

A

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whilst Cerys Miles gives a supervisor’s perspective and Dean Fido writes about entering forensic psychology through a PhD. Trainees are encouraged to follow up this information by logging on to the trainee forum, or by contacting one of the in-training representatives, Sarah Disspain and Sarah Senker, and by keeping a look out for DFP training events. The BPS Qualification has gone through some major revisions over the years and there is still important work to be done to simplify and clarify this route and to ensure it is adequately resourced and supported. John Hodge’s paper highlights how the Qualification provides a form of apprenticeship training which maps onto the scientist practitioner concept of applied psychology. Julie Harrower’s paper discusses the assessment process and exemplifies the move to a more holistic approach. The DFP has established a further working party to consider what the future employability prospects may be for those who wish to pursue a career in forensic psychology at a time when cutbacks may be limiting job opportunities. Given the number of training courses and the increase in interest, it may be prudent to explore what long-term opportunities there may be for employment as a forensic psychologist in the future. Roisin Hall Chair, Forensic Psychology Qualification Board



How to become a Practitioner Forensic Psychologist Sarah Disspain ITH CHANGES to the regulatory bodies and the introduction of different training routes, I thought it would be helpful to share some personal experiences of the training routes from trainees that are living them every day. I have also managed to get those responsible for the different routes to provide answers to some of the important questions potential trainees may be wondering about when deciding which route to undertake. These are collated in Table 1 below. In 2009 the Health and Care Professions Council (HCPC) became the regulating body for Forensic Psychologists. In order to practice as a Forensic Psychologist you now need to be registered with the HCPC. This means you must meet and continue to meet the standards they set for the profession in order to demonstrate your ‘fitness to practice’. In order to register with the HCPC, you must successfully complete an approved programme. Completing an approved programme does not guarantee someone will become registered. Rather, it indicates

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that the person meets the HCPC’s professional standards and is eligible to apply for registration. Prior to the introduction of the HCPC, the British Psychological Society (BPS) was the only regulatory body for qualified Forensic Psychologists. In order to become qualified you were required to be ‘chartered’ with the BPS. So what does being ‘chartered’ or ‘chartership’ mean? The Division of Forensic Psychology state that ‘Chartered Psychologist status is the benchmark of professional recognition for psychologists and reflects the highest standards of psychological knowledge and expertise. If a professional is chartered it is a mark of experience, competence and reputation for anyone looking to employ, consult or learn from a psychologist.’ One of the ways to achieve chartership is to undertake BPS accredited postgraduate qualifications and training. Information about the different routes is provided in this article along with accounts by Forensic Psychologists in Training on the various routes in order to give you a first-hand insight into the experience below.

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The BPS Qualification in Forensic Psychology (Stage 2) This Qualification (Stage 2) involves a length of time spent in ‘supervised practice’ following the completion of an MSc (Stage 1). This means that, with support and guidance from one or more experienced colleagues, you can gain experience and develop your competence to work as a Forensic Psychologist within a real context. The training route requires candidates to submit portfolios of written evidence to demonstrate competency development in relation to four core roles. These core roles relate to: (i) Conducting applications and interventions; (ii) Research; (iii) Communicating with other professionals; and (iv) Training other professionals. Two exemplars (example pieces of work) for each core role

are submitted along with supporting evidence of competency development. The supporting evidence includes a Practice Diary, detailing your reflections and learning on daily tasks and a Competence Logbook, detailing how you have developed and demonstrated your competence within each core role. Usually Forensic Psychologists in Training undertake relevant work as part of their paid employment. However, trainees can also undertake this route independently. This requires more co-ordination on the part of the trainee but can provide further breadth of experience. Two trainees reflect on their experience below.

Reflections and experiences of the BPS Qualification in Forensic Psychology (Stage 2) route As an HMPS Trainee: Contributed by Sarah Disspain (Forensic Psychologist in Training) This training route is often considered to be labour and time intensive. Indeed, at times the route has felt painstaking and I have had times where I have questioned my ability to complete it. However, the rewards of the route for me have outweighed the negatives. Whilst the route gives guidance on the process of becoming a Chartered and in turn Registered Practitioner Psychologist, the content of the training route is flexible, although is mainly dependant on your current employment or placement opportunities. At times I have experienced difficulty in accessing opportunities to undertake work related to particular competencies. However, it has also pushed me to think creatively, helped me to develop professional relationships with various Practitioner Psychologists and related disciplines and allowed me opportunities to develop the breadth of my practice. In turn I have had opportunities to work with a variety of populations in a variety of psychological roles, which has helped to shape me as a Practitioner Psychologist. Submitting my portfolio of competence when it has been completed and deemed competent by my supervisor(s) has allowed me the time and opportunity to comprehensively develop the relevant competencies. The autonomy that you have over your learning can be empowering. Finally the feedback process on your portfolio, which can again take some time, is something that has allowed me to develop my practice further. Having objective impartial feedback on my work has been an important part of my development. Whilst initially I have defended against my various negative emotional states in different ways when I have been required to resubmit additional work, when I have reviewed the feedback I have always found it useful in developing my practice. In summary, whilst the route is extensive and challenging, the breadth and depth of experience I have achieved has helped ensure that I become a competent future Practitioner Psychologist. I believe having such an extensive training route is important when working within such an important field. 70 F


As an Independent Trainee: Contributed by Sarah Senker (Forensic Psychologist in Training) I undertook an accredited Stage 1 MSc and then went on to start a PhD on the recovery of substance misusing offenders. I wanted the work I was doing during my PhD to be able to contribute to Stage 2 so put forward a case to the funders of my PhD to see if they would fund my enrolment on Stage 2 and my supervision costs. Upon approval, I sought a co-ordinating supervisor from the approved register and compiled the necessary documentation to enrol. I am not attached to a workplace and am not in a traditional ‘trainee’ post within a forensic setting. That being said, doing Stage 2 with the BPS has permitted a level of flexibility and freedom in that I can source my own placement and training opportunities across a range of settings and cohorts. The Practice Diary can feel overwhelming at times but it is a useful way to reflect on the work being done. I recommend keeping it up-to-date and creating entries as soon as work has been completed. I have found the BPS to be entirely supportive whenever I have sought clarification on exemplars. I have been limited by the work I can undertake in addition to my PhD but Stage 2 does require much time, dedication and effort although the reward at the end is what keeps me going.

The Academic Practitioner Routes to Chartered Status or Registration A more structured alternative is to work towards chartered status or registration with an academic institution. At present such

courses are running at the University of Birmingham, University of Nottingham and Cardiff Metropolitan University.

The Doctorate in Forensic Psychology (University of Nottingham) At the University of Nottingham there are two routes to a Doctorate which confers eligibility for chartered status or registration. Students may apply for the full Doctorate which is a three-year course where the first year is the equivalent of a Master’s degree. Or they may complete a Master’s elsewhere before applying to complete their training in Nottingham. In this case, candidates would apply for the two-year ‘top-up’ Doctorate’. Year 1 mainly consists of academic work where students work through a range of modules focussing on different aspects of forensic theory, practice and treatment. Students are required to attend all lectures, complete all module assignments as well as complete an individual applied research project (ARP) under supervision. Currently


(as at 2013), there is a requirement for first year students to have completed at least one hundred days of a forensic placement under the supervision of a clinical or forensic psychologist in order to progress onto Year 2. If students do not have this experience, this observational placement must be completed during their first year. Years two and three primarily consist of placement and research. Trainees are required to work on placement across three different forensic settings and with three different forensic populations. Alongside the practical work, trainees are required to complete assignments which fulfil the core roles involved in becoming a forensic psychologist, as set out by the BPS. Finally, a Doctoral Research Thesis will be completed.

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Reflections and experiences of the Doctorate in Forensic Psychology (University of Nottingham) route Contributed by Amy Tostevin (Forensic Psychologist in Training) I have just completed the first year of the full three-year doctorate and will be beginning second year and placement in October 2013. When beginning the Doctorate, it is tempting to look forward to the placement years where you can really begin to train practically as a forensic psychologist. However, beginning with an academic and research year has meant that I now feel as though I have a strong theoretical base from which to begin the practical work. As with any form of training, I believe that practical work experience will be the most valuable in terms of helping someone to become a good psychologist. In years 2 and 3, I am hopeful that learning on the job alongside doing research will be the most valuable parts of the course, supported by the core theoretical information obtained during year one. The variety of highly qualified and distinguished lecturers, supervisors, guest speakers, etc., is what I feel has made this year so valuable; I can genuinely say that every topic we have been taught, I have enjoyed and found useful. I have developed good relationships with my supervisor and lecturers which has really helped my confidence in this stage of training. Overall, I think there is a feeling of unity amongst my fellow trainees and the department as a whole. From what I have experienced so far, I would definitely recommend this course for people with a strong forensic interest in both clinical work and research.

The Doctorate in Forensic Psychology (University of Birmingham) The three-year full-time programme at the University of Birmingham was the first of its kind to be accredited by the BPS. The course combines academic teaching, research and practice in order for the trainee to receive the Professional Doctorate (ForenPsyD). Trainees spend three days a week across each year in forensic placement lasting for a minimum of 120 days (40 weeks) that are across different settings and/or client groups. The university offer a range of placements (mainly in the West Midlands) that include inpatient settings, prisons, private practice and community settings. It is a requirement that the trainee’s practice is supervised whilst on placement for at least one hour per week by a qualified psychologist. A reflective Practice Diary, Supervision Log and professional case study is submitted each year to provide evidence of competency development upon which feed-

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back is given. In addition, trainees attend the university one day per week for the first two years along with three sets of three-day teaching blocks across all three years and reflective practice groups. The aim is to provide the trainee with a knowledge base of therapeutic models, risk assessment tools, psychometrics and gain understanding of current literature and research relating to specific client groups. One day a week is for the trainees to conduct and write up research. All trainees are allocated an academic supervisor who is an experienced qualified psychologist within, or attached to, the university. Academic assignments are submitted across all years, providing an opportunity for development of academic knowledge and application of theory to practice. A substantial research project is conducted in Year 3 as part of the Doctoral Thesis.


Reflections and experiences of the Doctorate in Forensic Psychology (University of Birmingham) route Contributed by Samantha Goswell (Final Year Doctorate Trainee) I have found that the combination of academic teaching and supervised practice has enabled me to build my confidence and competence to work as a Forensic Psychologist. The range of placements has provided an opportunity to develop my knowledge and skills when working across different client groups and offence types. My placements included an adult male prison, a medium secure setting for adolescent males, and a community setting for children and adolescents. I consider that this allowed me to have a broader awareness of the role of a Forensic Psychologist in various environments in addition to enabling me to expand my skills of working within different psychological models. I consider that the level and quality of supervision within each placement was important for me in that it allowed for consistent opportunities to consider best practice, receive feedback and reflect on my work to further develop my competency. Whilst starting a new placement each year was anxiety-provoking, the length of time on placement and the placement structure allowed me to build positive and supportive relationships with colleagues and carry out longer-term assessment and treatment of clients. I have been able to work with, and learn from, colleagues from a variety of professional background as well as experienced Practitioner Psychologists. The academic component has allowed me to enhance my knowledge of current literature, theory and research whilst being supported by the university’s highly experienced researchers and practitioners within a structured academic programme. Meeting with other trainees at the university on a weekly basis provided a strong sense of mutual support and the ‘reflective practice’ groups ensured that there are forums for sharing positive experiences and struggles relating to my practical and academic work. I have found that the academic elements of the course demanding at times, however, they have proved helpful in me developing and receiving feedback on my writing skills, in critically evaluating literature and research and in practising formal report writing. This part of the course requires a strong sense of self-motivation with a commitment to completing research and academic assignments outside of the hours outlined above. The cost of the course is something for trainees to consider realistically in relation to taking this training route as this can add further pressure, particularly if trainees take on part-time employment in addition. For me, the benefits of this route far outweighed this aspect due to the supervised practice opportunities available and being part of the university has brought a sense of pride and accomplishment. I feel the time limited structure of this route training has been beneficial in providing me with a definitive end point that I can work towards, which I found motivating. At times I have found the training overwhelming and challenging but I feel that this is necessary given the nature of the field I wish to practice in. Overall, I have found that the components of the Doctorate in Forensic Psychology Practice qualification has provided me with the skills required to work as a competent Forensic Psychologist.


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Postgraduate Diploma in Practitioner Forensic Psychology (Cardiff Metropolitan University) In line with the introduction of the HCPC registration requirements Cardiff Metropolitan University has also developed a practitioner training route. Successful completion enables graduates to apply for HCPC registration as a Practising Forensic Psychologist. It is also planned to offer a top-up Doctorate which would enable students to work towards eligibility for Chartered status. Students on this route acquire the knowledge, skills and experience necessary to be competent practitioners of forensic psychology through engagement in at least two years of practical learning (through placement/s with appropriate services). Students are required to evidence competency through completion of a port-

folio comprising of a Practice Diary, a Supervision Log, a CPD Log and at least two case study examples (involving assessment, intervention, evaluation and recommendations with forensic service users). Students are also required to submit reflective reports in four key areas of practice (Ethical and Professional Practice, Teaching and Training, Functional Assessment and Formulation, and Consultancy) and attend 10 workshops. These are intended to support students in developing knowledge and skills related to the areas of competency. At completion of the training you are eligible to apply for Registration with the HCPC.

Reflections and experiences of the Postgraduate Diploma in Practitioner Forensic Psychology (Cardiff Metropolitan University) route Contributed by Louise Herring (Forensic Psychologist In-Training) One of the main advantages of the practitioner programme is the flexibility of the route. The programme allows graduates to apply for Registration with the HCPC without completing the full Doctorate. However, those that want to gain further qualifications can choose to complete a ‘top-up’ Doctorate with the university. This was one of the main reasons I chose the programme, as it gave me the option to complete the Doctorate at a later date without impacting on my ability to practice independently. This has a number of advantages, including fitting in with my personal circumstances and allowing me to gain post-Registration experience before completing the Doctorate. Additionally, it helped to allay concerns I had about the potential impact of not having a Doctorate or Chartership on future career progression. A further advantage of the course is the high level of supervision and feedback provided. Having regular meetings with my clinical (placement-based) and academic (university-based) supervisors ensured that I had the opportunity to discuss any practice issues, respond to feedback and that I was clear on how I could demonstrate competency from the outset. As someone who responds well to having regular and clear feedback, this has helped me to increase my confidence and competence. Whilst specific competencies need to be evidenced, an advantage of the course is that students can decide how many of these are demonstrated. As I was already working as a Forensic Psychologist in Training involved in a number of different areas of practice, this meant that I rarely had to seek out specific pieces of work for the sake of submissions and could start evidencing competency from the outset. I found this a motivational way to complete training as it enabled me to see the progress I was making towards Registration from the beginning. However, it is important to note that this is from the perspective of

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someone who already had experience of being a trainee, and this may be more difficult for people starting a new placement who may need to build a breadth of experience. A further strength of the route is the balance between practical and academic work. Whilst it is a placement course, demonstrating competency has meant focusing on how my practice is driven by literature and research in the area, and ensuring that I am engaging in best practice. This was enhanced by the completion of workshops which encouraged the further development of clinical skills and the consideration of issues that may occur in practice. This has been beneficial as it has ensured that I critically evaluate and reflect on my practice, and understand the importance of CPD. Whilst my experience of the course has been a positive one, it has been challenging. Completing the course has required commitment and sacrificing personal time to ensure that submissions are completed to a high standard within the deadlines. Whilst this is expected in many training routes, I needed to consider how to balance personal and work commitments. In addition, as the majority of the work is self-directed, the level of autonomy involved may not suit students who prefer high levels of guidance.

Table 1: Question and Answer Survey with those leading the different routes. The BPS Qualification in Forensic Psychology (Stage 2) 1. Can you describe training route(s)? The Qualification is an independent route to full membership of the Division of Forensic Psychology (DFP). It is accredited by the HCPC and confers eligibility for BPS chartered status and HCPC registration. It is not a course but rather an extended period of supervised practice in a forensic psychology work setting. During this time, candidates submit evidence drawn from their work to demonstrate their competency on the four core or key roles expected of a practitioner forensic psychologist. Some 360 candidates are currently enrolled on this programme. 2. What is expected of the trainees on the course in terms of work undertaken and submitted? Candidates submit exemplar reports evidencing their work and competence in each of the four core roles: Conducting Applications and Interventions; Undertaking Research; Communicating with Other Professionals; and Training Other Professionals. They also submit Practice Diaries, detailing their reflections on their learning and a Competency Logbook covering each core role. Where a candidate is working as a trainee time to undertake training is usually allocated. 3. How is it different from the other training routes offered? The independent route is a form of apprenticeship training, learning ‘on the job’. The unique emphasis on supervised practice ensures that those who qualify have a lot of in depth experience of working in forensic psychology and, to quote several employers, ‘particularly able to hit the ground running’. The independent route requires a lot of the candidates and their supervisors, but gives them considerable flexibility and enables them to undertake the work whilst in employment. 4. How long is the course for? Candidates enrol for a minimum of two years, following an accredited MSc course. The current completion mean is five years which includes the MSc. The range is wide, with some candidates completing in two to three years, others taking very much longer, often with gaps in their enrolment due to maternity leave or moving jobs. Forensic Update 2014 Annual Compendium 6

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5. Can you do the course part-time and full-time? The candidate and their co-ordinating supervisor design their Training Plan which is then approved by the Chief Supervisor and subject to ongoing review. This enables individual flexibility as to how the work is completed. 6. How much does it cost? £4794 (BPS total average figure based on three-year enrolment, allowing for fees charged and an element of resubmissions). This and any other training costs are normally covered by employers. 7. What are the requirements to apply? Graduate membership of the BPS. A BPS-accredited MSc in Forensic Psychology. An approved Co-ordinating Supervisor. Partial exemptions may be granted on the basis of competence developed and demonstrated prior to enrolment on the Qualification. 8. What does it mean for those who complete the course successfully? Eligibility to apply for G HCPC registration. G Full membership of the BPS Division of Forensic Psychology. G Chartered membership status of the BPS. Provided by Roisin Hall (Chair of the Forensic Psychology Qualification Board)

Professional (Practitioner) Doctorate in Forensic Psychology (University of Nottingham) (full and ‘top-up’ programmes) 1. Can you describe training route(s)? The full three-year programme is split into two parts – the Master’s component (Year 1) and the doctorate component (Years 2 and 3). Year 1 comprises six theoretical modules, two research methods modules and a research project. Years 2 and 3 are dedicated to supervised research and practice in forensic settings, working directly with clients, conducting research and evaluation, communicating psychological knowledge and training other professionals. Those already with a relevant BPS-accredited Master’s in Forensic/Criminological/Investigative Psychology and work experience are able to apply for the ‘top up’ programme which fast tracks trainees on to Years 2 and 3. 2. What is expected of the trainees on the course in terms of work undertaken and submitted? The Master’s component in Year 1 is examined by continuous assessment of module assignments. Each trainee is required to successfully complete the Stage 1 Master’s component to merit standard (60 per cent +) before continuing onto the Doctorate. The Doctorate component is examined by thesis and viva voce, focused on a specific topic area in forensic psychology. In addition, the trainee submits a Practice Portfolio consisting of four placement reports with a diary of client contact and a supervision log; a second practice case study on a topic not related to the thesis; and a training report on the design, delivery and evaluation of a training workshop made to professionals in other disciplines. 3. How is it different from the other training routes offered? The programmes uniquely offers a one-year Master’s followed by two year’s practice and research on placement anywhere in the British Isles. In relation to the ‘top-up’ programme it offers trainees already holding a relevant Master’s the opportunity to undertake Stage 2 training in

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Table 1: Question and Answer Survey with those leading the different routes (continued). forensic psychology to Doctorate level. Opportunities to train abroad where international placements are feasible are also possible. Placements cover a wide variety of forensic settings and work with a minimum of three different client groups. The Nottingham programme is run by a range of experienced Forensic psychology practitioners supported by forensic psychiatrists and mental health professionals. The University of Nottingham is rated in the Top 10 of UK Universities and in the Top 100 internationally. 4. How long is the course for? For the full programme, trainees will register for a minimum of three year’s full-time (or six year’s part-time or a combination). They can leave after one year (or two year’s part-time) with the MSc in Criminological Psychology. For the ‘top-up’ programme trainees will register for a minimum of two year’s full-time (or four year’s part-time or a combination). A maximum of one year extension if necessary is available for both programmes. 5. Can you do the course part-time and full-time? Yes; please see above. 6. How much does it cost? Home/EU Full-time; £7300 per annum (inclusive). Overseas Full-time; £16,110 per annum (inclusive). Home/EU Part-time; £4380 per annum (inclusive). Overseas Full-time; £9670 per annum (inclusive). 7. What are the requirements to apply? Individuals with a first or upper second class honours degree (or an international equivalent) from a psychology programme (single or joint honours) accredited by the BPS and some relevant experience may apply for the full doctorate programme. In addition, to apply for the top-up programme, applicants would normally be expected to hold a Master’s degree in forensic, criminological or investigative psychology or an international equivalent to Merit standard (60 per cent or above). Those applicants currently employed in a forensic setting are allowed to register full-time (or part-time) and use their employed setting for the placement work where possible. 8. What does it mean for those who complete the course successfully? Successful trainees are conferred the title of ‘Dr’ after being awarded the D.Foren.Psy. The award leads to eligibility for registration with the HCPC and chartered membership with the BPS Division of Forensic Psychology. All trainees complete the programme with a minimum of one conference presentation and one publication. Provided by Kevin Browne (Course Director)


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Professional Doctorate in Forensic Psychology Practice (University of Birmingham) 1. Can you describe training route(s)? The programme combines a number of theoretical and practical approaches and emphasises a developmental and domestic perspective to the study of offending behaviour and criminal activity. The principal objective is to equip trainees in forensic psychology with research and practice skills based on recognised theory and evidence-based practice and to offer a sound understanding of criminal behaviour, its effects on victims and appropriate approaches to intervention with both offenders and victims. 2. What is expected of the trainees on the course in terms of work undertaken and submitted? Trainees attend placements, university, and are allocated time for research. For each academic taught module, trainees submit written assignments for and complete research work which goes towards their final year thesis. This is examined by viva voce. Trainees will receive appraisals with their placement supervisor and core competencies and standards of proficiency are assessed via case study reports, placement reports and practice diary. In order to progress to the next year, trainees must reach an average grade (e.g. B– from year 2 to 3) and have successfully passed their placement. 3. How is it different from the other training routes offered? The programme is an equivalent to Stage 1 and 2 of training as a Chartered Psychologist and is approved by the HCPC. As well as offering the Doctoral route, the programme includes victim focused workshops and teaching about a range of therapeutic models. The part-time Doctoral route is not commonly available but provides a good opportunity for individuals who are already employed and whose employers wish to retain them/assist their development. The full-time route benefits from our well-developed relationships and the good reputation the course has with our placement providers. 4. How long is the course for? It is available as a three-year full-time course or as a four-year part-time course for those currently employed in a forensic setting, where their employer allows them to work as a trainee forensic psychologist with a variety of client groups. 5. Can you do the course part-time and full-time? Yes; please see above. 6. How much does it cost? Three year’s full-time: Home/EU: £7290 Overseas: £13,200 Trainees would normally require an additional £8000 per annum approximately for personal living expenses. Four year’s part-time: Doctorate fee 2014/2015: Year 1: £7290; Year 2: £7290; Year 3: £3645; Year 4: £3645 7. What are the requirements to apply? The entry requirements are a good honours degree in psychology (2.1 and above), which confers Graduate Basis for Chartership from the BPS, English language proficiency (Standard equivalent to IELTS level 7.0 with no element below 6.5), experience working with clients in a forensic

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5. Can you do the course part-time and full-time? Yes you can – part-time can take up to five years. Many people employed as trainee forensic psychologists use their job as their placement, so you don’t need to leave work to do the qualification. 6. How much does it cost? £4700 currently, in total (not each year). 7. What are the requirements to apply? BPS-accredited undergraduate and Postgraduate qualification in Forensic Psychology, or BPS Stage 1 of the Diploma in Forensic Psychology and extensive experience of applied forensic psychology practice. 8. What does it mean for those who complete the course successfully? It means they are eligible to apply to the HCPC to practice as Forensic Psychologists in the UK. Our course is approved by the HCPC. Provided by Nic Bowes (Programme Director) There is also a new training programme which started in September 2013 at the University of Birmingham; the Doctorate in Forensic Clinical Psychology Practice. This four-year programme is unique course integrating forensic and clinical psychological practice at Doctoral level aimed at psychologists who wish to work in forensic and clinical settings. Please review the programme’s details on the University of Birmingham website for more information.

In conclusion, I wanted to draw all in-training members’ attention to the Trainee Forum. This is a forum which Stage 2 trainees can join to post questions and get advice and support with their training from other trainees. There are over 500 members, so there is a lot of experience and support on offer. All you need to do is send an email to [email protected] and look out for responses. Alternatively contact Sarah Senker (DFP In-training representative) on [email protected]


Also please keep a look out for training events on the DFP website under ‘Events’. Training events focussed towards in-training members are free and there are lots of other relevant and interesting BPS training events that are accessible for a small fee. Sarah Disspain DFP in Training Representative

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Pursuing a PhD in Forensic Psychology Dean Fido Background to the training route HE PhD route is designed for students with a keen interest in contemporary issues facing forensic psychology and associated populations. Unlike applied routes discussed within this article, the PhD option is a purely research-based approach. There are many routes for PhD candidate acceptance. Most important of these is the ability to formulate innovative, theory-driven research ideas, which have utility for application. Other prerequisites include a strong MSc or MRes degree in a related topic and evidence of well-written and presented research. Set PhD research placements are available, as are placements for researchers with independent research ideas.

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Reflections/experiences of the training route The PhD option is possibly the most obstacle-laden route for one wishing to become a practicing forensic psychologist. An individual taking up a PhD position will seek to become an expert in a distinct forensic issue via research-based investigation. Important to consider is that completion of a PhD does not grant permission to practice forensic psychology, it merely acts as a stepping-stone to the partition between lectureship, research, and forensic practice. Unlike training avenues, the PhD route does not guarantee that you will interact with forensic populations. Sampling will predominantly depend on your overall research aims, funding, and supervision team. Supervision teams containing forensic psychologists with access to other institutions may act as gatekeepers for forensic samples, and will encourage their use. During a PhD, 80 7

access to forensic samples will purely be research-based, foregoing the actual ‘working with’ offenders, which would be experienced in training routes. Whilst forensic issues can be researched in nonforensic samples (victims; aggression), allowing completion of one’s PhD, the lack of exposure to such populations may detriment the ability to obtain forensic-based work afterwards. For example, most trainee positions, and some taught courses, encourage at least six-month’s work experience with forensic samples prior to enrolment. At the expense of forensic-base work experience, PhD completers will be able to boast a range of skills including large project planning, theory-driven research formulation, and mass dissemination. It is not uncommon for individuals enrolled on PhD courses to attend two or three academic conferences a year, where they will be able to disseminate their research to a wide, multidisciplinary audience. Furthermore, as one’s PhD is essentially a series of inter-linked investigations, students are encouraged to forward these on for individual publication. It should be noted that trainees might also publish work, though their research opportunities are restricted to working hours, sample access, and the management of other duties. Following the completion of a PhD, the most common directions are post-doctorate research and further specialisation in ones’ area of interest, or taking up a lectureship role. The under- and post-graduate teaching of forensic psychology, at some institutions, may require additional forensic-based work experience, and in some instances, chartership. If one wanted to transfer their researchForensic Update 2014 Annual Compendium

based skills from their PhD to another forensic training route (such as stage II training), then their PhD may enable them to submit evidence for partial exemption from core role II (research) and further contribute to BPS chartership. However, one would still be required to enrol as a trainee and complete the other three core roles. This will incur the associated costs as previously documented. From a personal perspective as somebody who is coming to the end of their PhD, whilst I have been more than happy with my independent development both on a personal and academic level, the prospect of using this route as a means of entering the applied field of forensic psychology is daunting. Although my research makes me informed on key issues facing forensic psychology, I have foregone forensic work experience and the development of core competencies. Rightly so, these are important for BPS


chartership status, and so transference to applied forensic psychology would require an unknown number of years of further training. As somebody now competent to teach various aspects of psychology at graduate level, neglecting an income for further years of training is a commitment that would need to be carefully considered. In summary, the PhD route may be ideal for somebody who is interested in the investigation of certain issues surrounding forensic psychology and who has an interest in teaching and dissemination. On completion of a PhD, candidates can evidence a wealth of transferable skills, such as project planning, data analysis, and management, for other employment roles. Dean Fido PhD Doctoral Student, Nottingham Trent University.

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The Qualification in Forensic Psychology (Stage 2) – Getting it done John Hodge What is the Qualification trying to achieve? TRANGELY, despite the plethora of documents and writing about the Qualification, little attention has been given as to what are its aims, other than BPS Chartership and, more recently, a basis of Registration for the Health and Care Professions Council. The output, in terms of the nature of forensic psychology and forensic psychologists has been largely neglected. Recently, Hodge (2013) has suggested that the competences and Core Roles required for the Qualification, map very well on to the role and requirements of Scientist Practitioners. This is consistent with a broader view that all psychology professions work within this general framework (Lane & Corrie, 2006) The concept of Scientist Practitioner was initially developed by American clinical psychologists at a conference in Boulder, Colorado, in an attempt to develop their professional identity in 1949. This concept was quickly adopted by British clinical psychologists and has formed the basis of training in clinical psychology in this country. The essential elements of the Scientist Practitioner model are (Wikipedia): G Delivering psychological assessment and psychological intervention procedures in accordance with scientifically-based protocols – [CR1] G Accessing and integrating scientific findings to inform services – [MSc, CR2] G Framing and testing hypotheses that inform decisions – [CR1, CR2]

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Building and maintaining effective teamwork with other professionals that supports the delivery of scientistpractitioner contributions – [CR1, CR3] G Research-based training and support to other professions in the delivery of psychological services – [CR4] G Contributing to practice-based research and development to improve the quality and effectiveness of the psychological aspects of service provision – [MSc, CR2] As illustrated, these map closely with the competency development required by the Qualification. It is the research and developmental elements built into this model which clearly distinguish psychology practitioners from other professions.

The development of the Qualification process The Qualification began as the BPS Diploma in Forensic Psychology and had two stages. Stage 1 was originally achieved by an in-house set of examinations together with the submission of a piece of postgraduatelevel research; or alternatively by acquiring an MSc from an accredited postgraduate course. The Stage 1 in-house examination route closed two years ago, leaving the forensic MSc as effectively the entry-level qualification into Stage 2. Stage 2 was developed by the BPS to address the absence of any clear professional training route for forensic psychologists and in the lack of any clear source of funding to encourage universities to develop training (e.g. similar to that of clinical psychologists which is funded by the NHS). Stage 2 was


conceived as a set of 20 competences, encapsulated within four Core Roles, which are meant to be developed and demonstrated during the course of the trainee’s work. It was originally intended that Stage 2 should be achieved within two to three years. The 20 competences have stood the test of time, and are identical now to their original conception, although their descriptions are currently being brought up to date. They are also reflected in the key roles required for academic forensic psychology courses. However, how the competences were to be achieved was less clear, as was the means of their assessment. These matters have focused the attention of the Qualification Board (previously the Board of Examiners) over the past 10 years. This has largely been done through a series of (not always popular) amendments to the Candidate Handbook, which has also had to remain consistent with the overarching Regulations which govern all BPS postgraduate training and qualifications. This period of time has seen the introduction of reflection into Practice Diaries; the development of a set of assessment guidelines; the concept of a summary Exemplar Report; and the more recent introduction of Training Plans and Competence Logbooks. All of these introductions have not been easy for trainees (or indeed for their supervisors, who have had to learn to work within the new structures alongside their trainees). It is important to understand that the BPS Stage 2 process is a form of apprenticeship training (Collins, 2005) – learning ‘on the job’. This is very different from an academic course. The advantages are – eventually – a very thorough acquisition of skills. The disadvantages lie in the lack of structure for learning normally provided by academic courses. If you wish to get through Stage 2 quickly, you, and your Supervisor, must create structures to promote your learning, using the tools provided by the Candidate Handbook, Training Plans, Exemplar Plans and Competency Logbooks.


Before you begin, you need to understand the nature of competency assessment. This requires that you must not only demonstrate the knowledge required by academic assessment, but over and above this demonstrate your skill in the use of that knowledge and associated processes. This requires the repetition, reflection and practice of each skill or competency, as will usually be evidenced in your Practice Diary and in the developing quality of your work output.

How to get through Stage 2 quickly At the time of writing the average time to complete Stage 2 is 5.8 years. This, however, includes the many candidates who interrupt their training – for example, for maternity leave – plus a number who registered for both Stages 1 and 2. It is possible to complete Stage 2 in two to three years, and some candidates are now achieving this. The key to doing so is to get organised from the start and to recognise that all aspects of the work you do can help to develop and demonstrate competences. The Training Plan is the first step to organising your training. The Training Plan is intended to provide focus to help you to develop and demonstrate a subset of the competences each three-month period and it is reviewed and renewed on a quarterly basis. To start with, the competences will most likely be those required by your current operational workload, and the initial competences in the Core Roles. It is very important here not to focus just on one Core Role, but to make use of the opportunity provided by the Breadth of Experience Rule which allows you to use the same project or experience to demonstrate competences in two different Core Roles. An example of this could be that if you are demonstrating your skill in conducting risk assessment (or indeed interventions) in CR1, then the outputs of these assessments (or interventions) can be communicated in CR3 to evidence competences 3.2 (paper reports); 3.4 (oral presentations) and 3.5 (responding to queries). You can identify

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similar links between these and other Core Roles to significantly reduce the overall work required to demonstrate the competences. Your quarterly Training Plan can also help to focus your entries in your Practice Diary, by largely confining these to the competences in the current plan. Your Practice Diary should always be reflective (i.e. demonstrate your psychological thinking by explaining how you have used research and theory to determine your practice) and also contain the evidence of the repetition and practice needed to develop your skills. Running alongside the Training Plans should be your Competency Logbooks, which should be taken to each three-monthly training review to enable your Supervisor to (briefly!) comment on your progress on each of the competences you are currently working on. As you demonstrate the competences to his or her satisfaction in each exemplar, you can support this view with a few selected Practice Diary references and other evidence and comments. This way your Competency Logbook will gradually fill as you demonstrate the different competences. Once a competency has been demonstrated, there is little real need to revisit it with further comments, unless you wish to add more and better evidence later for assessment purposes. This way the Competency Logbooks act as true logbooks and provide a record of your passage through the competences, and a developmental history to support your Exemplar Report. The gaps in the Competency Logbooks will also help you to develop your later Training Plans. Exemplar Reports are meant to be (like apprenticeship pieces) the best examples of your work, to eventually be put forward for

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assessment. It is likely, therefore, that Exemplar Reports made in the earlier stages of your training will require amendment or even to be completely changed, as your practitioner skills develop. Always remember that if your current plans don’t allow you to demonstrate your best work, they should be changed. When it comes to assessment, your Exemplar Report should pull all the evidence of your competence across the full Core Role together and make a business case for your competence in that Exemplar/Core Role. This is essentially a CR3 task and is not dissimilar to writing a risk assessment or end of intervention report.

In conclusion Stage 2 of the Qualification in Forensic Psychology is capable of being achieved in a much shorter time than is currently the average. However, to do this requires both the trainee and Supervisor to make best use of the tools available to organise an optimal learning experience. John Hodge Registrar and Chief Supervisor

References Collins, A. (2005). Cognitive Apprenticeship. In R.K. Sawyer, The Cambridge Handbook of the Learning Sciences. Cambridge: Cambridge University Press. http://ebooks.cambridge.org/chapter.jsf?bid= CBO9780511816833&cid= CBO9780511816833A011 Hodge, J.E. (2013). The Qualification in Forensic Psychology: Rationale and training model. Division of Forensic Psychology Conference, Belfast. Lane, D. & Corrie, C. (2006). The Modern Scientist Practitioner. London: Routledge. Wikipedia. The Scientist Practitioner Model.



Assessment in the Forensic Qualification Dr Julie Harrower TOOK ON THE POST of Chief Assessor for the BPS Forensic Qualification in April 2013, having taken part in the original establishment of this award many years ago. I have held various Board roles in the past, including Chief Examiner and Chair, and in relation to assessment I have many years experience as an academic in terms of setting assessment, and ensuring quality assurance in relation to the outcomes of those assessments. The role of the Chief Assessor is to monitor the assessment process in order to ensure equity, fairness and transparency. There are clearly agreed procedures in relation to the assessment process for the Qualification with a number of quality checks en route from receipt of the candidate’s portfolio to the conclusion. Two Assessors separately assess each submission in relation to each of the four Core Roles. The Lead Assessor for each Core Role then considers their conclusions in order to produce a single agreed assessment decision. This can be Competence Demonstrated; or Conditional Pass which requires minor amendment and resubmission; or Competence Not Yet Demonstrated which requires a more detailed resubmission. Where there is any doubt or disagreement the candidate may be invited to a viva voce where two independent Assessors ask the candidate for clarification in relation to any omissions or unclear evidence in order to enable the candidate to demonstrate their competence. The assessment process refers to the time from when the assessors receive a candidate’s portfolio until the conclusion of the viva voce examination if this has been deemed necessary. During this process the Chief Assessor will provide advice/guidance to assessors on their

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decision-making, in particular whether or not to invite a candidate to viva voce, and identifying which units of competence need to be examined at viva voce. Assessors will, more often than not, be clear about their decisions in these areas, so the input of the Chief Assessor can simply be a reassurance that the appropriate decision has been made. The Chief Assessor attends the viva voce and produces the notes of the meeting as well as the final report. As all viva voce examinations are recorded, the Chief Assessor will listen to the recordings of the viva voce examinations and will read the candidates’ portfolios, producing a report for both Assessors to consider and provide feedback before the final report is agreed. This facilitates discussions with the assessors about the assessment outcomes and other members of the Forensic Psychology Qualifications Board (FPQB) when the assessors’ recommendations about the assessment outcomes for candidates are being considered. Less commonly, assessors will have difficulty making a decision (for example, when they are unsure if the work submitted by the candidate meets the standard required, or where there is disagreement among the assessors about the outcome of the assessment). In these cases the Chief Assessor will facilitate discussion and agreement between the assessors on an appropriate outcome for the candidate. Where agreement between assessors cannot be reached, the Chief Assessor will make a final decision (although this has never needed to happen in my experience). The Chief Assessor will also provide training sessions for assessors as requested or required, and there is an annual Assessors Conference. These sessions are devised to ensure that assessors are kept updated about 85

any changes to the Qualification and are an opportunity to discuss the benchmarks that are used in the assessment process to facilitate some consistency among assessors in terms of the application of standards and quality assurance. The Chief Assessor is a member of the FPQB and contributes to the general business of the FPQB. This includes, for example, discussions about applications from people who wish to become assessors for the Qualification, about the organisation of viva voce examinations, about modifications to the Qualification, and about preparation of internal validation reports and external visits from organisations such as the Health and Care Professions Council. Additionally, the Chief Assessor may contribute, in collaboration with the Registrar and Chief Supervisor, to external FPQB activities such as workshops or presentations to groups of students who are considering enrolling for the Qualification, or who have already enrolled on the Qualification. This allows us to provide an overview of the Qualification and to deal directly with any queries. However, the Registrar, Chief Supervisor, or the Society’s Qualifications Officer deal with all queries from candidates and supervisors. In this way the process of supervision is completely separated from the process of assessment, which enables candidates to discuss issues with the Chief Supervisor/ Registrar independently.

Recent assessment themes The time taken to complete the Qualification is reducing and it is of note that the External Examiner has commented on a significant improvement in quality across performance on all four Core Roles in the last three years. However. the FPQB remains keen to address concerns that the assessment process for core role exemplars has become unduly complex. Accordingly there is a concerted effort underway to clarify what is required to demonstrate competence on the core roles, to ensure competencies are 86 8

assessed on a more holistic basis and to provide more intelligible feedback. The Chief Assessor runs an annual workshop for assessors at which the four Lead Assessors present evidence on the key themes and issues relating to their particular Core Role. Recent outcomes and actions have included: G An ongoing project by the Lead Assessors to clarify the descriptors for the competencies required for each core role and what is needed to evidence competency. G Improved consistency in feedback given to candidates. G The drafting of a Handbook and further training opportunities for Assessors. G Workshops on Core Role 2 for candidates, with consideration for further workshops for the other Core Roles. The 2014 workshop identified further needs for: G Training sessions for Assessors, to include standardisation exercises to improve consistency across assessors. G A simplified set of processes. G More feedback about the process from the candidates. Specific points noted about candidate submissions are outlined below. Core Role 1: Conducting psychological applications and interventions Strengths G An improved use of theory to underpin the assessments and interventions. G Good choices of exemplar projects. G Greater attention to ethical issues and to anonymity. G Evidence of good practice in working with other professional colleagues. Weaknesses Not providing enough evidence of the candidates’ own contribution from a forensic psychology perspective. G Not providing enough signposting, or clear explanation of how the evidence provided clearly demonstrates the competency. G


Further requirements G More evidence of better planning and use of the relevant literature. G Recognition that evaluation is an integral component of assessment and intervention work and must be factored into the initial planning. Core Role 2: Research This core role shows the highest variability in quality of submissions, but there has been a significant improvement, particularly in the use of the research report format. Decider issues include: G Is an organisational need met? G Is there a critical literature review and does it justifies the research question? G Is the hypothesis or research question clearly stated? G Is the method sufficiently well described to be understandable and replicable? G Are reliable and valid measures used? G Does the analysis follow the research report format? G Is the dissemination appropriate for nontechnical stakeholders as well as psychologists? G Is the data collection ethical?

Core Role 3: Communicating psychological knowledge and advice to other professionals G Candidate submissions have become much better organised. G Clarification is required about the submission of supplementary evidence. G More links should be made between literature and practice. G Need for more demonstration of how the work contributes to policy. G Need for more evaluation. G Need to ensure that psychological evidence is provided. Core Role 4: Training other professionals in psychological skills and knowledge Good practice includes: G More use of TNA methodology and report to explain, structure and plan the work, and including elements such as project risk assessment and the obtaining of agreement from others. G Evidence-based aims and objectives, noting the significance to the wider work environment. Planning which considers relevant factors affecting the design of the training and its transferability. G Demonstrate clearly how training was implemented, taking into account issues of resourcing. G Planning and implementing appropriate assessment systems, G Structured evaluation review and report, designed and reviewed with agreement of others and showing both strengths and areas for improvement. Dr Julie Harrower Chief Assessor


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The BPS Chartership vs. HCPC Training Route: A Supervisor’s perspective Cerys Miles BECAME a qualified forensic psychologist via the BPS chartership route in 2008, at a time when very few trainees were successfully completing this qualification. I found the process challenging and at times demotivating, and experienced the common frustration of initially ‘failing’ Core Roles on the basis of what were unclear criteria and overly critical feedback. It was only through the support of my supervisor and colleagues who were going through the process alongside me that I remained focused and achieved my goal, albeit later than I had initially anticipated. I went on to use my own experiences in my subsequent supervision of trainees through the BPS chartership route. I have found that the process seems to have slowly become clearer over time and I have been able to support my trainees accordingly. This has been reflected in the trainees I have supervised passing Core Roles on the first and second submissions at a much higher rate than was the case when I was a trainee, a trend I believe has been observed nationally. Nevertheless, there continue to be challenges associated with supervising trainees on the BPS route towards chartership. One of these is the frustration relating to inconsistencies in the feedback provided by the assessors of submitted Core Roles. This is exacerbated by the ‘anonymous’ nature of the feedback and the lack of opportunity to discuss this with the assessors involved. It can feel as if you have no ‘say’ as a supervisor in terms of assessing the competence of trainees whose forensic psychological skills I observe on a daily basis. I have also found the timescales associated with having to wait

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for feedback from the BPS on a Core Role submission difficult to manage and this can lead to uncertainty and a loss of momentum when supporting a trainee in planning their on-going work for chartership. As a supervisor of BPS trainees I have (for a fee) joined the Register of Applied Psychology Practice Supervisors (RAPPS). Whilst this is apparently intended to identify those with ‘special expertise’ as a supervisor, according to the BPS website, the register is open to all psychologists with chartered membership. This leads me to question the need for a separate RAPPS, when the BPS provides a ‘List of Chartered Members’ as well as a ‘Directory of Chartered Psychologists’ for those who wish to offer their services to the public. More recently I have had the experience of supervising trainees through an HCPC practitioner programme route. It has taken me time to become accustomed to the differences between this and BPS chartership, for example, becoming familiar with the ‘standards of proficiency’ against which trainees are assessed, rather than the Core Role criteria. However, I have been well supported in developing my understanding of the programme requirements by the university where the programme is run, for example, through training and feedback events. The flexibility of the programme, particularly in terms of how standards of proficiency can be demonstrated, is especially helpful and far less restrictive than the distinct BPS Core Role model. I have also found the dual supervisor approach adopted on the programme on which trainees I supervise are enrolled (whereby each

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trainee is assigned both an academic and clinical supervisor) invaluable in providing support to trainees. Frequent supervision is closely linked to the submission of work throughout the programme, and timely feedback ensures that progress is maintained. In my experience the HCPC route is far more empowering for both supervisors and trainees, in that it is the supervisors (in close collaboration with the trainee) who ultimately assess whether the trainee meets the required standards of proficiency in order to register as a practitioner psychologist with the HCPC. While there is both an internal and external moderation process to supplement this, I feel that I have much more of a meaningful influence in terms of determining a trainee’s competence, when compared to supervising trainees on the BPS chartership route. I have also found that trainees on the HCPC route are more easily able to maintain motivation and commitment to this programme compared to BPS trainees, who understandably can find the process disempowering. This appears to be linked to the clear requirements for qualification as well as the hands-on support provided to trainees by the affiliated university. HCPC trainees, for example, are provided (at least on the programme on which I have trainees registered) with compulsory workshops that specifically link in with the work required for the training programme (including reflective reports and case studies). While BPS trainees are able to attend national CPD events, these are often held in locations that are difficult for trainees to reach and/or are not necessarily clearly linked to Core Role criteria.


When I first became involved in the supervision of HCPC trainees, concern was expressed amongst the profession that this would be seen as an ‘easy’ route towards qualification and thus produce registered forensic psychologists who were not of an equal standard to BPS chartered forensic psychologists. In my personal experience, this is absolutely not the case and I am confident that the trainees I have been involved in supervising, who have just finished the HCPC training process and achieved registration, will be excellent practitioners, indistinguishable from chartered forensic psychologists. Indeed, to access a place on an HCPC training programme in the first place, trainees undergo a rigorous assessment process, which provides a useful means of gauging suitability and readiness for the route. They also (like BPS chartered forensic psychologists) have the opportunity to follow up their qualification with a doctorate, an excellent means of achieving continued professional development post qualification. It is important to add that there is nothing ‘easy’ about the HCPC route. Both supervisors and trainees have to work hard to develop and demonstrate competency, and a considerable level of commitment is required. Rather, the HCPC route, in my experience as a supervisor on one of the available programmes, is a more clearly structured and supportive process for all involved. Dr Cerys Miles CPsychol DFP Ordinary Committee Member. Affiliations: Forensic Psychological Services, Public Sector Prisons, NOMS Wales Cardiff Metropolitan University.

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Issue 115 – July 2014 91

Notes from the Chair Dee Anand 94 Division of Forensic Psychology Annual Awards Special Section commemorating the centenary of the First World War 98 Applied psychology in the Armed Forces: Current provision Professor Jamie Hacker Hughes 100 The Dstl and the role of the psychologist Fiona Butcher 104 Uniformed clinical psychology in the British Army Captain Duncan Precious 107 Effects of military operational tour on perceptions of mental illness and offending Kathleen Roberts 114 Military reserve service and post-tour work adjustment: Exploring lived experiences to inform applied practice Kevin Wilson-Smith & Elizabeth A. Bates 120 One intervention for ex-service personnel in custody: The Veterans group at HMP Grendon Simon Bonnett, Geraldine Ackerman & M.T. Articles 126 A proactive approach to engaging difficult to reach inpatients: A service evaluation Katherine Crosby, Katie Downsworth, Katie Gilchrist & Kristy O’Hare 132 Using Cognitive Analytic Therapy within a forensic setting: An overarching relational model Jenny Marshall, Kate Freshwater & Steve Potter 138 Following up the outcomes of a CBT-based substance misuse intervention for men in a secure psychiatric setting Faye Baker, Rachel Harwood, Michael Adams, Caroline Baker & Clive Long 145 The effectiveness of the Addressing Substance Related Offending-Secure (ASRO-S) treatment programme in a secure forensic hospital setting: A service evaluation Katie Downsworth & Eric Jones

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Notes from the Chair Dee Anand S WE ALL KNOW, crime was invented by Jack the Ripper and flourished until Sherlock Holmes apprehended him shortly after The Great Fire of London. Unfortunately, this didn’t stop paedophiles running rampant across fields and through our streets hunting children with large nets while Members of Parliament and the BBC covered for them. We also know that poor people use legal aid instead of getting jobs, only mental people commit sex crimes and if you’re not a love rat you’re a psycho. I agree – this is probably a strange way to begin my very first ‘Notes from the Chair’ but I hope this is making a point and I hope it is a point which will become central to the function of the Division during my time as Chair. Before I get to that, however, I must issue our gratitude to my predecessor, Ian Gargan. Ian has steered the Division over the past two years with professionalism, dedication and efficiency. He has made the Division a sharper, more professional organisation with a tenacious grasp of the internationalisation agenda and a calm and measured approach to some difficult challenges during our time. On behalf of the Committee, all of our members and colleagues from other Divisions where Ian has promoted crossdivisional working I would like to thank him and assure him that I intend to continue his good works as best I can. Ian is taking up a role as Chair of the Professional Practice Board from November and it is great news for forensic psychology – and indeed a testament to his good works – that one of ‘our own’ is assuming such a senior position within the British Psychological Society (BPS).

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DFP Conference 2014 These notes are written shortly after a very successful conference in Glasgow. Our thanks must go to Kerry Wood, Priscilla Chauhan and Claire Bainbridge for their considerable efforts in arranging such an inspiring and enjoyable event. For those of you fortunate enough to attend, you will no doubt have enjoyed the keynotes from John Livesley, Alison Liebling, Jo Clarke and Lawrence Jones. There was a theme running through these keynotes which echoed the necessity to take care of one’s own resilience as a practitioner and to appreciate the impact of a number of factors on well-being, risk, resilience and the understanding of behaviour as a developmental process. We were also fortunate to benefit from an invited workshop by Adrian Needs and Lawrence Jones, invited symposia from Nicola Graham-Kevan looking at intimate partner violence, Catherine HaniltonGiachristis looking at Child Abuse in the digital age, and other symposia including Susan Cooper discussing working with complex women offenders, Liz Gilchrist convening a symposium on understanding family violence, and Simon Duff convening a symposium discussing working with difficult to engage clients. This was a wide-ranging, educating and stimulating conference fabulously organised and had the added bonus of a session with two well-known crime writers – Christopher Brookmyre and Denise Mina – reading from their works and discussing their approach to writing. The Senior Award was well deserved and presented to Jackie Bates-Gaston and the Junior Award to Jamie Walton. This was overall a fantastic event with excellent feedback and if you have not yet attended a DFP Conference I would strongly urge you to attend next year – I will discuss confirmed speakers and keynotes in a 91

subsequent ‘Notes’ but rest assured it promises to be another great event. Next year, the conference will be in Manchester and it will be suitable for psychologists and other professions so do have a look at the speakers and harangue your employers to support your attendance!

My View As some of you will have seen from my conference notes, I have come from a background of 15 years working in Forensic Mental Health, programme design and delivery, assessment and Expert Witness work in Independent Practice. For the past seven years I have also worked part-time running MSc courses in Forensic Psychology and I am current Chair of the DFP Training Committee. I also sit on the Expert Witness Advisory Group of the BPS and it is this rather eclectic mix of experience which has informed my motivation for the progression of the discipline. I was a member of the Bradley Committee Steering Group and I sit on the Low Secure Services Clinical Reference Group for NHS England. For me, Forensic Psychology needs to hold its head high and our recent Conference is a clear example of why. During my time as Chair of the DFP I hope to encourage practitioners and academics in the field to work closely together to promote and shout loudly about the dynamic, integrative and uniquely focused discipline that is forensic psychology. We are not consigned to a unidimensional measure of understanding risk but rather the tripartite model of understanding risk of harm, deteriorating mental health and recidivism and fully considering the impact of one on the other and the interaction between these dimensions is central and identifying for forensic psychology. We should all be in a position to robustly define and defend who we are and what we do in the face of greater challenges – those that are judicial, political, financial and professional. I believe in Chartership as the central component to promoting standards and the professionalism of forensic psychology. 692

Of course, it is also essential to work with our regulatory body but it is important to remember that the BPS is still the only body delivering a qualification at stage 2 and I think it is necessary for us at times to become better at promoting this, both as individuals and as a profession. I believe it is also essential to understand the aspects of forensic psychology driven by understanding core psychological principles and that we should consider ourselves psychologists first, before considering ourselves as experts or specialists in forensic psychology. This will allow us to grow dynamically as a profession with a clear understanding of the range of skills we have and help us to identify areas in which we can ethically develop ourselves and best utilise our skill base. I have worked closely with the training committee and the Partnership and Accreditation Committee to redraw the standards of proficiency which will follow from stage 1 to stage 2 and it is through these levels of educational development and understanding that we can best equip the next generation of forensic psychologists to follow examples we can set in forging forensic psychology in the UK and hopefully with transferable skills abroad.

Mythbusting and Going Forward Of course, my opening to these ‘Notes’ was a somewhat light-hearted look at the presentation of some of the issues which directly impact our profession and indeed our ability to do our jobs efficiently. The serious point, however, is that misconceptions about offending behaviour and indeed offenders can have the potency to create a whirlwind of public opinion which can influence sometimes knee-jerk reactions from the media and politicians as well as impacting our own conscience and ability to carry out our daily work. It is important for us as individuals, citizens and professionals, in my view to challenge myths about such things, but also as a profession and a Division to take issue with some of these and have a direct influence on such reporting and possibly more importantly, to have an audible, pragmatic, Forensic Update 2014 Annual Compendium

informed and professional voice in the right places. We have a tremendous amount of expertise within the Division and within the Committee and I hope over the next two years we can develop and progress into a sharper, more focused Division whose members are aware their voices are being heard, where the profile of forensic psychology is raised and the focus always remains on the highest professional standards. We have already set up a DFP Policy Working Group as a sub-group within the committee which has galvanised members within that group with some innovative and useful suggestions for taking this agenda forward. This is a group which will meet regularly, has a specific remit and is sharply focused on utilising our understanding of best practice, knowledge and transferable skills, ethics and the wider agenda with the aim of situating forensic psychology as integral to that agenda. There is much work continuing on your behalf through members of the committee giving up their time voluntarily and in my next notes, I will say more about the structure of the committee and members on the committee, the commitment to development of professional standards linked in to HCPC Standards of Proficiency and the development within the BPS stage 2 qualification route which has improved significantly in recent times. It is true that we face challenging times. It is true that we must be responsive, alert and flexible in our reaction. However, it is also my view that we should not be alarmed or threatened by change. Rather we should attempt to influence that change where necessary but also retain pride and confidence in our own skills to adapt and evolve our profession with the highest focus on professional standards. It may be the case that we cannot prevent the public from


believing that all sex offenders should be named, shamed and dealt with by amateur surgery, that prisoners should never be released from prison but that prisons should be nowhere near anybody’s house, that those with a substance misuse problem are as bad as any criminal and we are only kept safe by Fake Sheikhs and redtops. But we can take responsibility for furthering knowledge and responsible practice, educating where necessary and developing the profession.

What can you do? I would encourage all of you to communicate with us and with me. I would encourage all of you to persuade those who are not yet members of the Division to take up membership and create their own value for the Division. We want to hear from you and we want the voice that goes out to be representative of our members and we would like to hear from you to that end. I would encourage all trainees to make contact with their ‘in-training’ members of the committee. I would encourage all of you to initiate and engage with discussions on the fp-prac forum ([email protected]). I am a member and I want to see and be a part of discussions on issues you feel are affecting forensic psychology. And lastly, I would encourage all of you to go forward in your work with pride and knowledge that your Division is supportive of your ability to carry out your work to the highest standards and is working actively to promote this. I look forward to working for you and to hearing from you. Dee Anand Chair – DFP Chair – DFP Training Committee Email: [email protected]

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Division of Forensic Psychology Annual Awards Division of Forensic Psychology Annual Awards The Division of Forensic Psychology made two awards this year, presented at the annual conference. The Junior Award in Forensic Psychology is reserved for a full or in-training member of the DFP at the start of their career who has produced work of outstanding quality and innovation. The Senior Award for Distinguished Contributions to Professional Practice in Forensic Psychology is reserved for a practitioner of forensic psychology who is full member of the DFP. With thanks to Alpha Hospitals for sponsoring the Senior Award.

Junior Award in Forensic Psychology The DFP Junior Award was presented to Dr Jamie Walton. Jamie was nominated by Dr Simon Duff and Dr James Millington. Dr Jamie Walton works at HMP Wymott in Preston (a Category C trainer prison) where he is the SOTP Treatment Manager. Jamie is a recent graduate (December 2013) from the University of Nottingham’s forensic doctorate programme who has demonstrated that he has the potential to make a genuine contribution to the research base in forensic psychology. To date his systematic review, concerned with the efficacy of sex offender treatment, has been accepted for publication (Walton & Chou, in press), his critique of the ‘sex with children’ scale has been submitted (Walton, Chou & Duff, (submitted), and his major research is in preparation for journal submission. His major research focused on an important theme for all of us working with sex offenders namely, how do offenders who consider themselves untreatable and unchangeable because of their underlying sexual preference for children, understand how they will cope once released from custody. No one has previously considered this area which speaks to the very heart of understanding risk and need from the perspective of the individuals who may reoffend, a perspective that is too often overlooked. His work allowed Jamie to consider his findings in relation to Ward’s Good Lives 94

model and identify that for these men a Good Lives approach contradicts their ability to achieve relatedness through sexual expression. As such we may need to rethink how we aim to support these individuals once they are back in the community. As Jamie states, ‘if sexual preference is more stable than dynamic then a sequence of research efforts is required to determine what could constitute desirable treatment goals for offenders with sexual preferences for children. It is possible perhaps that the more manifested and predominant the preference for children is, the more adapted the treatment goal may need to be and the less likely that it could be achieved through time-bound therapy. For those who desire sexual expression but are incapable or unwilling to work toward sexual relationships with adults, clinicians may need to think particularly intuitively about what treatment goals are appropriate and achievable.’ These three academic products, from two years of study, are testament enough to the dedication and quality of work that mark Jamie out as recipient for the Junior Award. He has performed work that is recognised within the community of forensic psychologists to be of a high standard and he is examining areas that are novel and important. However, it is not simply an individual’s products that identify them as having the potential to make an important contribution to their profession. It is the process too. Jamie took practical, important questions and crafted them into an empirical design, patiently Forensic Update 2014 Annual Compendium

examined potential methods with which to explore his questions, and carefully developed a procedure that was appropriate to gather his data and supportive of his research participants, who were a vulnerable group of individuals. His approach throughout was clinically informed, participant-centred, yet academically rigorous, attributes that identify him as an individual who could continue to make important contributions to our understanding and our work with vulnerable and risky people in society.

References Walton, J.S. & Chou, S. (in press). The effectiveness of psychological treatment for reducing recidivism in child molesters: A systematic review of randomised and non-randomised studies. Trauma Violence & Abuse. Walton, J., Chou, S., & Duff, S.C. (submitted). The Sex with Children Scale: A brief discussion about theoretical basis, validity and reliability.

Senior Award for Distinguished Contributions to Professional Practice in Forensic Psychology The DFP Senior Award for Distinguished Contributions to Professional Practice in Forensic Psychology was awarded to Dr Jackie Bates-Gaston. Jackie was nominated by Nic Bowes. Dr Jackie Bates-Gaston has been Chief Psychologist and Head of Psychology in the Northern Ireland Prison Service (NIPS) for 22 years, during which time she has developed and delivered psychological services for both staff and prisoners. Prior to this she had been a Senior Lecturer in Psychology at the University of Ulster. She is also a Chartered Forensic Psychologist and was Honorary Professor in Applied Psychology at the University of Heriot Watt, Edinburgh for 10 years. Jackie’s achievements span the period of ‘the troubles’ and have continued into the transition to peacebuilding under the new government established in Northern Ireland. Jackie has a professional understanding of the human issues in forensic settings which was invaluable, particularly when Forensic Psychology in the NIPS had peculiar security and professional challenges. One of her first tasks in post was dealing with the aftermath of a bomb explosion in Belfast Gaol. Her response of effective compassion and psychological advice led to the development of a post-incident care service to both prisoners and staff. She Forensic Update 2014 Annual Compendium F

pioneered a staff and families support system, in the aftermath of serious incidents, which in the early 1990s were all too frequent and incredibly challenging. This pioneering work included interventions for trauma, post-incident care and return to work strategies, which Jackie shared with other emergency services in Northern Ireland. While Forensic Psychology within the NIPS was very different from that in prisons in the rest of the UK, Jackie realised that the service needed to respond to changing times 95

and that organisational cultural change was necessary. She introduced and designed assessment centres for the selection and recruitment of new officers and Governors, which also ensured equality of opportunity. She was instrumental in changing the inherently ‘macho’ culture of the NIPS so that the benefits of psychological support and expertise was accepted, valued and sought out by staff at all levels. Within a year of being appointed Jackie had identified the essential psychological needs of staff and prisoners and with generous support from colleagues in the Home Office, had the NIPS staff trained in the delivery of Sex Offending Programmes and Thinking Skills which were just being introduced into England and Wales at that time. Her capacity to form strong and lasting professional partnerships with leading forensic psychologists and key agencies such as NOMS, has been one of her key strengths as Head of Psychology in the NIPS. This facet helped lay important foundations for the development of offender services in a small jurisdiction. Jackie’s experience in working with politically motivated offenders in Northern Ireland has provided her with unique expertise in working with ‘terror’ offending in the early 1990s. Her professionalism, understanding and sensitivity provided a strong platform for her to intervene, work collaboratively and inform forward moving policies in the evolving political process in Northern Ireland. This has enabled her to work in a sensitive, modest and task orientated way, sharing goals rather than focussing on differences and offering guidance, consultancy and support to those facing similar issues today. Her range of qualifications and breadth of experience offer inspiration on working collaboratively, respectfully and holistically. Her reputation in forensic psychology is recognised both nationally and internationally. She has been invited to share ideas, experience and skills in working with offenders and staff with prison authorities in 96 1

Russia, Norway, Singapore and China. Through her research on Prison Officer stress and her relationship with Heriot Watt, she was invited by the Chinese government to discuss the contributions of forensic psychology to imprisonment and improvements in their regimes and became one of the first Western psychologists to visit an ultra modern Beijing prison. Jackie sits on the Parole Board in England and Wales and works in partnership with the Health and Care Professions Council to ensure that professional forensic psychology standards are represented. In her 42 years as an enthusiastic and committed British Psychological Society (BPS) member Jackie has served on many BPS committees including: the Northern Ireland Branch; the National DFP; the Professional Affairs Board; Council, member and Chair of the Occupational Section; the Standing Committee on Equal Opportunities; the working group on Expert Witness Guidance; the DFP Board of Assessors; the DFP Training Committee; and is the current Chair of the NIDFP. She has contributed to many consultation papers published by the Division. In 1991, Jackie was the only psychologist working in the NIPS. The NIPS now has almost 40 psychology posts, which is a tribute to the work Jackie has put in to promote the discipline and application of forensic psychology. Under her guidance, the NIPS Psychology Services now delivers a complete suite of interventions and programmes which enable offenders to address not only their offending, but the multiplicity of complex and deep rooted personal issues which lead to those behaviours. Jackie adheres to the research evidence which clearly indicates that programmes, services and interventions, are more effective in reducing re-offending if attention is paid to the quality of delivery. She continually ensures that staff from all disciplines and grades, who are involved in psychological interventions, gain access to the highest quality training and development. Jackie Forensic Update 2014 Annual Compendium

consistently gives professional support and supervision to the development of psychology staff and it is to her credit that twelve of those she has supported have gained professional Forensic Chartership. She strives to bring out the best in others through her energy, high standards and her ability to secure the resources needed to deliver forensic psychology services.


Jackie’s personality means that her motivation is focused on enabling change to improve things for others, rather than for personal gain or glory. Her humility and integrity has won her strong professional support and allies in the UK and Ireland where she has been pivotal in the development and recognition of the importance of forensic psychology within criminal justice.

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Special Section

Applied psychology in the Armed Forces: Current provision Professor Jamie Hacker Hughes Summary of a symposium presented at this year’s British Psychological Society Annual Conference. N THE YEAR in which the British Psychological Society (BPS) commemorates the beginning of what was thought to be the war that would end all wars, and in which 16 million died and 21 million were wounded, the BPS is preparing to mark a century of military psychology. In 1915, Dr, later Lt Col, Charles Myers joined the Royal Army Medical Corps and as the Consultant Psychologist to the BEF (British Expeditionary Force) supervised the psychological treatment of thousands of soldiers in Casualty Clearing Stations (CCS) and NYDN (Not yet diagnosed neurological) units on the French coast. Myers was the first to describe the term ‘shell shock’, although he did not himself invent the term, and his book of his wartime experiences, Shell Shock in France, was later published in in 1940. Charles Myers was to become the first President of the BPS. Meanwhile, Myers’ Cambridge colleague, W.H.R. Rivers, also joined the RAMC to work at the Craiglockart Hospital in Edinburgh with, among others, Wilfred Owen and Siegfried Sassoon, as described by the novelist Pat Barker in her Regeneration Trilogy. In World War Two, in which 60 to 70 million died and six million more were injured, psychologists again came to the fore. All three branches of the Armed Services, the Admiralty, the War Office and the Air Ministry, employed psychologists, in uniform and as civilians, who were mainly involved in personnel selection and training. Some also worked as experimental psychologists, notably for the Air Ministry.

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Following the war, psychologists became a recognised class of their own in the Civil Service and it was through the work of psychologists like Charles Raven, Monte Shapiro and Hans Eysenck, many in military – or former military – hospitals, that today’s profession of clinical psychology was born. Psychologists have continued to work within, and alongside, the military ever since, both in the UK and around the world. There is an International Military Testing Association, International Military Mental Health Conferences, a Handbook of Military Psychology and even an International Military Mental Health Running Club! This invited symposium – Applied psychology in the Armed Forces: Current Provision – explored the ways in which the discipline of psychology is employed by applied psychologists in the service of the UK’s Armed Forces. The symposium was chaired by Professor Jamie Hacker Hughes, CPsychol FBPsS, former Head of Clinical Psychology and Defence Consultant Advisor in Psychology at the MoD, Director of the Veterans and Families Institute at Anglia Ruskin University and President Elect of the BPS who also acted as discussant. The other speakers in the symposium were Fiona Butcher, CPsychol, Senior Researcher at the Defence Scientific and Technology Laboratories (Dstl), who demonstrated the full spectrum of research and other activities in which a wide range of applied psychologists are engaged within Defence, Dr Rachel

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Norris, CPsychol, Head of Defence Clinical Psychology and Defence Consultant Advisor on Clinical Psychology, who explained the roles that the clinical, counselling, forensic, health and neuro psychologists and addiction specialists within Defence health care play in supporting good physical and mental health across our Armed Forces, Dr Gail Walker-Smith, CPsychol AFBPs, the Ministry of Defence’s Head of Profession for Occupational Psychology, who talked about the roles that the MoD’s many occupational psychologists play in the Royal Navy, the Army, the Royal Air Force and the Ministry of Defence and, finally, Capt. Duncan Precious, RAMC, the British Army’s first regular uniformed clinical psychologist, who talked about the role of uniformed clinical psychologists in the Army.

This symposium presented the range of activities in which today’s military psychologists, and psychologists working within Defence, are engaged in as we prepare to mark 100 years of military and Defence psychology. You can find out more about the roles of a psychologist in the Dstl and in the Army in the following articles by Fiona Butcher and Capt. Duncan Precious.

Correspondence Professor Jamie Hacker Hughes Director, Veterans and Families Institute, Anglia Ruskin University. Email: [email protected]

BRITISH CEMETARY IN FLANDERS FIELDS


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Special Section

The Dstl and the role of the psychologist Fiona Butcher The following article aims to explain the Dstl and how psychologists work within the organisation. This is illustrated by describing a particular research challenge that has been faced by the Ministry of Defence (MoD) in the last couple of years.

What is the Dstl?

How do psychologists work in Dstl?

HE Defence Science Technology Laboratory (Dstl) is part of the MoD and its purpose is to maximise the impact of science and technology for UK defence and security. The role of the Dstl’s scientists and analysts is to act as trusted advisors in order to: G Supply sensitive and specialist science and technology services for the MoD and wider government. G Provide and facilitate expert advice, analysis and assurance to aid decisionmaking and to support the MoD and wider government to be an intelligent customer. G Lead the formulation, design and delivery of a coherent and integrated MoD science and technology programme using industrial, academic and government resources. G Manage and exploit knowledge across the wider defence and security community and understand science and technology risks and opportunities through horizon scanning. G Act as a trusted interface between the MoD, wider Government, the private sector, academia and allies to support military co-operation, capability delivery, diplomacy and economic policy. (This includes the Dstl’s role in international research co-operation activities). G Champion and develop science and technology skills across the MoD, including managing the career of the MoD scientists.

There are approximately 50 psychologists in the Dstl that draw upon recognised areas of psychology such as neuro, cognitive, social and behavioural psychology and include psychologists from professional groups such as Forensic, Occupational and Health Psychology. The human sciences related research delivered by the the Dstl benefits from a broad and vibrant external academic and commercial supply chain which Dstl psychologists harness to deliver the research. Within the organisation, the the Dstl psychologists work in an inter-disciplinary, problem-focussed way working as part of multi-discipline applied research teams, with other Dstl personnel who are from a broad range of science, technology and analysis disciplines. Beyond a few sensitive and specialist capabilities retained within government, a Dstl psychologist’s role primarily focuses on enabling the MoD and wider government to access the science base by translating customer needs into science and technology issues that can be addressed in collaboration with academia and industry .

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What kind of research challenges does a Dstl psychologist address? The research challenges that Dstl psychologists address are complex ‘messy’ real world problems that require investigation from a number of different perspectives; which is why Dstl takes a multi-discipline research approach; in order to provide research outputs that can be readily applied Forensic Update 2014 Annual Compendium

in the operational environment as well as inform future defence and security strategy and policy. An example of a recent challenge is what has been described as the threat from insiders. Since the end of the Cold War the role of the UK Armed Forces has evolved into an increasing number of peace keeping and peace enforcement operations, where UK personnel are embedded as part of coalition forces within the host nation’s population. These operations require increased levels of interaction with local populations and forces. In the recent past the Insider Threat (sometimes referred to as ‘Green-on-Blue’), has been at times a real threat for UK Forces operating in Afghanistan. The term ‘Insider Attack’ is used when a member of the Afghan National Security Forces attacks members of the International Security and Assistance Force, of which the UK is a part. There are a number of possible causes for these attacks, such as a perceived cultural clash; or insurgent infiltration; or coercion of a member of the Afghan National Security Forces. The research undertaken aims to contribute not only to current operations but also provide knowledge of how to counter Insider Attacks in future operations. Dstl psychologists have carried out in-house applied research using data collected by operational analysts deployed in Afghanistan, as well as partnering with commercial and academic suppliers, in order to address the following four research challenges:

Challenge 1 – Improving the effects of influence: ‘How can people be dissuaded from undertaking Insider Attacks, both before and during an incident?’ Previous work has identified the need to prevent Insider Attacks through the identification of underlying causes, rather than just ‘symptom spotting’. This will have implications for the design of effective training and Forensic Update 2014 Annual Compendium F

exercises. There is also a need for UK Forces to understand their Afghan National Security Forces counterparts more effectively and it has been recognised that the human and social sciences have great potential to contribute to operations, education and training in this area. A key aspect of the research is to increase understanding of how to dissuade people from engaging in Insider Attacks. This moves beyond ‘symptom spotting’, to identifying the underlying causes. Methods of reducing the chances of a situation escalating, and hence reducing the probability of an Insider Attack, are crucial. If a situation does escalate, troops require an understanding of how to dissuade at that crucial point, and how to respond if they are unable to dissuade – including all available options. It should be noted that Insider Attack situations are likely to develop quickly, and communications between those involved are often slowed by language barriers. To address this challenge, one of the activities the Dstl undertook was in-house research to gain a better understanding of how the Afghan National Security Forces and British Forces that are working together perceive each other. Findings from this research have been used to enhance training and current working practices. In addition, a review of extant commercial training courses has been carried out in order to identify potential training improvements.

Challenge 2 – Improving the identification of intent: ‘How can intent to undertake Insider Attacks be detected and used to reduce the probability of their occurrence?’ For many years, researchers have investigated the potential existence of particular behavioural indicators to detect suspicious intent. Published research has indicated that both novice and expert human observers are capable of detecting both criminal intent and deliberate deception at accuracy rates above chance performance. 101

The ability to notice, and ask about, changes in behaviour could help identify people who are more or less likely to be involved in an Insider Attack. This could be achieved by being aware of what is ‘normal’ through engagement with individuals, groups and their peers. The objective is not to list behavioural indicators, but is to ensure a greater understanding of those we engage with. Understanding the people, the environment (context) and ourselves (our ability to develop rapport and empathy) is critical to the success of current and future operations, regardless of the individual’s role. There can also be significant differences in behavioural cues across cultures, which is especially relevant to this research challenge. To support our understanding in this area the Dstl commissioned some academic research to investigate whether particular types of events could be potential motivators and predictors of Insider Attacks. In conjunction with this research, Dstl psychologists and Operational Research analysts conducted a longitudinal analysis of past incidents to establish whether there were any trends or themes that could be identified.

Challenge 3 – Improving the effectiveness of training: ‘How can UK training be further improved to enable our forces to be more aware of developing Insider Attacks, and take effective action to eliminate or minimise their effects before, during or after an incident?’ Effective preparation of UK Forces is needed to lessen the likelihood of an Insider Attack. One approach to mitigate this threat involves the training of ‘soft’ skills, such as: G observation skills; G human behaviour understanding; G cultural understanding; G communication and de-escalation skills. These are provided to personnel prior to deployment, to enhance their ability to cope with a number of complex situations.

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The wide range of factors and motivations that may lead an individual or group to conduct an Insider Attack makes it difficult to identify specific threat cues that personnel should look out for. However, developing ‘soft’ skills will aid personnel in reducing cultural misunderstandings, identifying suspicious behaviour and activity, and deescalating situations when they occur. Work in this area has included undertaking training needs analysis for specific roles as well as assessing existing commercial training that could potentially supplement pre-deployment training provided to military personnel. In addition, the Dstl has commissioned ‘proof of concept’ projects with commercial suppliers who develop interactive training technologies. Our behavioural scientists including psychologists act as technical partners and work with the suppliers to assist them in understanding the requirements, as well as providing technical assurance on the outputs for the military end users.

Challenge 4 – Improving force protection: ‘How can science and technology be used to detect an impending Insider Attack, or mitigate the effects of an Insider Attack before, during or after it has occurred? Making use of the understanding of human behaviours could lead to technological support tools that could assist with the detection of an impending Insider Attack, over both the longer or shorter terms, and the deescalation of a developing incident. For this particular challenge, behavioural scientists including psychologists have advised on the socio-cultural factors that need to be taken into consideration when reviewing a range of potential technology options. For example, we would need to minimise the potential of alienation between the Afghan National Security Forces and the International Security and Assistance Force, especially if the technology options prevent access or increase segregation.


In summary….

Correspondence

Dstl psychologists work on a range of applied research and analysis projects, addressing challenges that are often complex and ‘messy’. In addressing these challenges the Dstl takes a multi-discipline, problem focussed approach, working with a range of science, technology and analysis disciplines, both within the Dstl and with commercial and academic suppliers.

Fiona Butcher, CPsychol CSci AFBPsS Principal Psychologist, Dstl, Porton Down, Salisbury, Wiltshire, SP4 0JQ.

Fielding Johnson Building, University of Leicester. Built as a lunatic asylum and during World War I was used as 5th Northern General Hospital. The University’s motto ‘Ut Vitam Habeant’ means ‘So that they may have life’. Representing the sacrifice of all those who served and died in the Great War, the motto holds a double meaning, with education also giving life to all who studied here. Forensic Update 2014 Annual Compendium F

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Special Section

Uniformed clinical psychology in the British Army Captain Duncan Precious The Army is only as good as its soldiers so mental well-being is as essential as physical fitness. As a military clinical psychologist your aim is to reduce psychological distress, enhance and promote psychological well-being by the systematic application of knowledge derived from psychological theory and research. It’s your job to provide professional psychological assessment and treatment to those who need it as part of a military multidisciplinary mental health team both in the UK and overseas. Clinical psychologists are more than psychological therapists: you will use your research competence to critically evaluate research publications and when required design and carry out applied research and audit. Your specialist clinical skills and experience will give you the edge when supporting your mental health colleagues and others through provision of clinical supervision and training. N JULY 2012 the British Army opened its doors to clinical psychologists becoming commissioned officers. I have the privilege of becoming the first commissioned clinical psychologist in the British Army and at present remain the only uniformed clinical psychologist across the whole of the UK military. I have been invited to share my personal reflections of the role and my time in the post so far.

I

Becoming a uniformed clinical psychologist The recruitment process was long and uncertain. The first stage was attendance at a two-day acquaint visit at the Army Medical Headquarters Camberley, in which I was given a full briefing and first introduced to the infamous Army Personal Fitness Test. I then travelled down to Westbury to complete the Army Officer Selection Board (AOSB). This was a three-day formal selection course, a requirement for any potential Army Officer. The AOSB tested me in every way imaginable and took me completely out of my comfort zone. It highlighted my strengths and weaknesses in a way I have never quite experienced before. Indeed, one of the main objectives was to evaluate my 104 1

ability to cope under pressure, which it certainly did. Several months later I then attended the Army Interview Board (AIB). This was a more familiar interview process involving a number of senior officers from different strands of the British Army. Following successful interview I was then offered a commission as a Captain after successful completion of the Professionally Qualified Officer’s Course at the Royal Military Academy, Sandhurst (RMAS). This was an 11-week course that equates in essence to the final term of Regular Army Officer Training. It taught me military skills, tactics and strategy, military history, leadership and command responsibilities and tested my physical fitness and mental resilience throughout. I then spent a month at Defence Medical Services Training Group, Keogh (DMSTG) to complete my Entry Officers Course which was a specialised medical training course. It took me in total 12 months from sending in my application form to stepping into my first day in post.

Role During my first year in a busy Department of Community Mental Health at Catterick Garrison, my main effort has been getting up Forensic Update 2014 Annual Compendium

to speed clinically. To put it in perspective, if we were to use a stepped care model then we cover primary care right up to step five (specialist/inpatient services). Therefore, the variety of work is immense. Moreover, due to a number of different factors, for example, the demands of military service, the constant moving around of personnel and some of the barriers to help-seeking, the constant challenge of engaging and keeping people in therapy is a critical task. Another main component of my role has been the preventative piece and I have sought opportunities wherever possible to promote mental health education and training. One positive area has been the development of mental resilience training within the military and this is an area I am exploring further with research.

Personal reflections I have been asked by many clinical psychologists ‘What are you first, a psychologist or army officer?’ I reply ‘both’. Indeed, I have found it possible to step in and out of the roles in different situations – to effectively wear two hats. In the words of George Kelly I have not felt as though I have been slot rattling between two polar opposites. During my military training I had to step out of the role of being a clinical psychologist as first and foremost I was being assessed on my potential to be an Army Officer. However, I was able to retain a sense of autonomy and competence by using skills that I have developed as a psychologist, such as problem solving, reflexivity, flexibility of thinking, interpersonal skills and relationship building. I also utilised many of the psychological skills I teach in therapy in order to cope with the stress, pressure and demand of training. In contrast, in my clinical role, I am first and foremost a clinical psychologist and where possible leave the military etiquette at my door. I imagine that inside my therapy room it works like most therapy rooms up and down the country. In a similar way I have also been able to apply the leadership and personal skills I developed in my officer Forensic Update 2014 Annual Compendium F

training to enhance my role as a psychologist. It has not been all plain sailing and there have been some ethical dilemmas to negotiate, in terms of confidentiality and the occupational requirement. However, it has been possible to resolve these through supervision, consultation with my military colleagues and personal reflection. Of course, I am not blind to the fact that on operations the potential ethical dilemmas are likely to increase significantly as I will be more firmly placed in my Officer role and there will be far less black and white and a whole lot more grey. One of my other main reflections has been the extent to which the military identity has influenced my thinking, behaviour and emotions. Wearing a uniform has meaning. There are no two ways about it. Once you put it on you become part of something, part of an organisation’s ethos, history, culture and way of life. There is a very strong identity associated with being in the military and during my time in phase 1 and 2 training I definitely internalised the military culture and set of standards and values that so strongly underpins it. Perhaps, due to the fact that I am a psychologist, but also because I remain in a unique role, I have reflected a lot on the influence of culture and organisational and individual identity within the military. Indeed, having worked as both a MoD civilian trainee clinical psychologist and uniformed clinical psychologist I feel that being in uniform has given me greater insight into the military mind-set, culture and identity and has enhanced my clinical work considerably.

Highs Militarily speaking, one of the most rewarding experiences was the time I spent at RMAS. I have fond memories of this and made some lifelong friends. It held true to everything I had heard and read about this prestigious and impressive institution. It lives and breathes history, tradition, pride and excellence. Since then, my proudest moment has been to pass the prestigious 105

pre-parachute selection course, an extremely arduous and physically demanding course that is the pre-requisite to completing parachute training, to enable me to serve alongside the elite Parachute Regiment.

Lows The low point was the amount of time I spent away from home in my first year of training. In 2013 I was away for over five months of the year. My wife was pregnant, also looking after our two daughters and working full-time. She had it much harder than I did at Sandhurst and this gave me a massive insight into what military personnel have to contend with on operations. I had not really experienced such a profound sense of homesickness before and I am not sure I could ever get used to being away from home for this long. Trying to focus and concentrate whilst always in the back of my mind thinking about what was happening at home and how my wife was coping was a difficult experience. Then ringing home and finding out when things were going wrong and feeling completely helpless in being able to do anything about it, made it seem as though I was shirking my responsibilities as a husband and father.

Uniformed clinical psychology around the globe Most NATO countries have regular or reserve uniformed clinical psychologists in at least one branch of their Armed Services (Army, Navy, Air Force). In relation to our closest English-speaking allies, the United States Military and Australian Defence Force have well-established psychology corps. The US have uniformed clinical psychologists across all three of their Armed Services. The influence of the uniformed clinical psychologist reaches more than just a clinical role as they are deeply embedded within their chain of command. They also have unique occupa-

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tional roles, completing psychological screening measures and assessing personality, intelligence, aptitude and mental wellbeing in order to select personnel for highly specialised roles. This highlights the potential for the profession and how we have a long way to go to develop uniformed psychology in the UK military.

Future focus It is a time of unprecedented change within UK defence with the significant reduction in the size of the Armed Forces. Inevitably change creates a degree of uncertainty, particularly when it comes to the longevity and sustainability of new roles such as uniformed clinical psychology. Nevertheless, the priority for me remains. That is to try to make a difference to the lives of the people that walk through my door and on a wider level establish and demonstrate the utility of uniformed clinical psychologists and the unique role we can take on both in the firm base and on operations.

In summary The last two years have been packed full of variety and challenge. I am incredibly proud to be applying my trade in support of our brave service men and women, and to have experienced the opportunity to be part of something very exciting and historic for my profession. We are actively recruiting more uniformed clinical psychologists and I can honestly say, in terms of the variety, challenge and opportunities that I have so far experienced, it is an incomparable setting to work in.

Correspondence Captain Duncan Precious Clinical Psychologist, Royal Army Medical Corps (RAMC).


Special Section

Effects of military operational tour on perceptions of mental illness and offending Kathleen Roberts Purpose: To further understanding of attitudes towards mental illness and perceived likelihood of crime for soldiers returning from military duty. Method: An attitudinal survey was undertaken and analysed to compare attitudes towards mental illness and crime using data gathered from military and non-military personnel. Results: Statistical analyses demonstrated significant differences in attitudes held by military and non-military personnel with regard to the causes of mental illness and the need for support services, and the likelihoods of soldiers being affected by mental illness and offending following military duty. Conclusion: Whilst some significant differences in attitudes were found, overall the results suggest there to be little or no effect of military occupation or operational tour experience on attitudes towards mental illness and offending.

HERE IS A CONSIDERABLE AMOUNT OF EVIDENCE to suggest that UK soldiers returning from operational tours of duty are at an increased risk of developing mental health issues; most notably, post-traumatic stress disorder (Iversen et al., 2008). Research has also indicated that an increasing number of military personnel have a presence within the Criminal Justice System, often as a result of acts of violence or aggression (Treadwell, 2010). It has been estimated that approximately 3.5 per cent (2820) of persons in prison are ex-military (Howard League for Penal Reform, 2009), although others have estimated this number to be higher, at around 9.1 per cent, or 118 from their sample of 1191 taken from a pilot study carried out at HMP Dartmouth (NAPO, 2008). Such research argues that there are possible links between the mental health of a returning solider and their offending behaviours. For example, the symptoms and consequences of disorders such as PTSD, depression, anxiety and alcohol abuse, which

T


have been found to be common after deployment (Hotpf et al., 2006), may incidentally lead to anti-social behaviours such as anger outbursts, increased risk-taking behaviours and exaggerated stress interpretations of events. Little is known, however, about the current attitudes of soldiers towards mental illness and offending, and the research reported here was undertaken in order to determine possible reasons for soldiers not seeking help. Comparisons were made between views held by military soldiers, both with and without operational tour experience, comparable to those held by a civilian sample. Additionally, age, education, rank, number of tours, number of trauma-related symptoms, and resiliency levels were investigated as a further aim of the research was to suggest where effective interventions might be implemented to deter military personnel from becoming involved in the Criminal Justice System.

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Method Design A between group design was used to test attitudinal differences between soldiers with operational tour experience, soldiers without operational tour experience, and a civilian sample. Sample A total of 100 participants (62 males; 38 females) aged between 18 and 74 years (M=32.47; SD=13.81) were used for the study. The sample consisted of 50 army soldiers (34 with operational tour experience, and 16 without experience), recruited at an army barracks in North Yorkshire, and 50 civilian participants from the community. Measures Attitudinal data was gathered using the ‘Attitudes to Mental Illness Questionnaire’ (AMIQ), as used in a 2011 survey report regarding public attitudes towards mental illness (NHS Information Centre for Health and Social Care, 2011); and the ‘Trauma Screening Questionnaire’ (TSQ), developed by Brewin, Rose, Andrews, Green, Tata, McEvedy et al. (2002), which was completed by soldiers who had experience of operational tour. The AMIQ is a 27-item measure comprising four subscales (‘Fear and Exclusion’, ‘Understanding and Tolerance’, ‘Integration and Community’, and ‘Causes and Need for Services’) and has a possible score range of 27 to 135. The TSQ is a 10-item unidimensional measure of PTSD, with a possible score range of 0 to 10. ‘Likelihood Scales’ were developed to examine participants’ perceptions of the likelihoods of various events, such as maintaining their current position in the army if they suffer a mental illness, and the likelihood of operational tour causing a soldier to commit a criminal offence. This scale has a possible score range of 0 to 100. The ConnorDavidson Resilience Scale (CD-RISC), developed by Connor and Davidson (2003) was used to measure levels of resiliency, and has a score range of 0 to 100. 108 2

Procedure Fully informed consents were gained prior to taking part in the study and all data was anonymised. Full debriefs including details of support were provided for each participant after completion of the measures. All measures were completed by volunteers in individual testing sessions, and data was collected by and returned to the researcher only. Due to the different sample populations being used, there were two different questionnaire booklets; one for civilian participants, and one for military participants, with three or four questionnaires included, respectively. Each participant was also asked to complete a short demographic survey prior to taking part, including questions regarding their age, gender and highest certified educational level. Military participants were also asked to provide their rank, whether they had ever been on an operational tour of duty, and if so, how many they had experienced. Analysis Responses to the four quantitative measures were analysed using MANOVA. In order to examine the primary aim of the study, Bonferroni post hoc tests were conducted on significant results from the AMIQ and the Likelihood Scales.

Results Attitudes to mental illness and offending Statistical analysis from responses to the AMIQ indicated that there was a difference in attitudes to mental illness between the three participant groups. The mean and standard deviations of scores indicated that the civilian group scored more positively on all four subscales of the survey than either of the military groups. However, Bonferroni post hoc tests demonstrated that only statistically significant differences were apparent on the subscale measuring Causes and Need for Services. This difference was found to be between the civilian group (M=12.56; SD=1.81) and both of the military samples, suggesting that the civilian sample had Forensic Update 2014 Annual Compendium

significantly more positive attitudes than either of the military groups (With operational tour experience M=10.41, SD=2.43; Without operational tour experience M=9.81, SD=2.14). No statistically significant between-group differences were noted for the other AMIQ subscales. A significant difference was also indicated on the attitudes expressed on the Likelihood Scales. Bonferroni post hoc tests showed this significance to be only between the civilian sample and those with operational experience, and specifically, regarding attitudes towards the likelihood of a soldier suffering a mental illness and committing an offence, and the likelihood of a soldier keeping their job if they suffer a mental illness. This difference is shown in Table 1 below. Age, education and rank Further MANOVA tests found there to be no significant effect of age or educational level on responses to the AMIQ or the Likelihood Scales. Rank was also found not to have a significant effect on responses within either of the military samples.

Number of tours and PTSD symptoms Additionally, no significant between group effects of the number of tours or the number of symptoms of trauma, as measured by the TSQ, were found on either the AMIQ or the Likelihood Scales. Resilience The ranges of scores on the CD-RISC varied for each participant group: those with operational experience ranged between 35 and 93 (M=69.82, SD=12.36); those without operational experience ranged in scores between 35 and 88 (M=66.87, SD=14.54); and the civilian sample ranged between 38 and 94 (M=67.88, SD=11.89). Those without operational tour experience tended to have lower resilience scores overall. However, a MANOVA test found there to be no statistically significant effect of resilience on attitudes to mental illness or on the Likelihood Scale items.

Table 1: Perceived Likelihood scores for: (i) soldiers suffering a mental illness and committing an offence; (ii) soldiers keeping their job if they suffer a mental illness. With Operational Tour Experience

Without Operational Tour Experience

M

SD

M

SD

M

SD

How likely do you think it is that a soldier suffering mental illness will commit a criminal offence?

39.01

21.03

49.02

29.87

57.21

26.94

How likely do you think it is for a soldier to keep their job if they suffer from a mental illness?

53.12

29.40

36.64

32.45

26.21

23.71


Civilian

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Discussion Results from MANOVA tests demonstrated there to be a significant difference on the Causes and Need for Services subscale of the Attitudes to Mental Illness Questionnaire (AMIQ) between the civilian and military samples. Specifically, the civilian group had more positive attitudes towards mental illness. Based on the age ranges of the sample from the present study, it may be argued that these findings are supportive of those reported in the original Attitudes to Mental Illness 2011 Survey report (NHS Information Centre for Health and Social Care, 2011). For instance, for this subscale it was reported that older participants had more positive opinions regarding the causes of mental illness and whether there are sufficient services available to such individuals. Within the present study, the civilian sample was, on average, older than either of the military samples, thus indicating similarity with the previous findings. However, it must be noted, that when age was examined individually for an effect, no significant results were found in this study. As a result, it may be hypothesised that other factors affected the civilian participants’ more positive attitudes. For example, factors such as previous experiences, media influence and education may be considered. Although, due to there being limited, if any, previous research examining attitude differences between these two populations, any conclusions drawn must be noted to be speculative and preliminary. Further, the item on the Likelihood Scale regarding the perceived likelihood of a soldier who is suffering a mental illness committing a criminal offence, and the question of whether a solider is likely to keep their job in the Army if they suffer a mental illness, were both found to differ significantly between the civilian group and the military participants with operational tour experience. Specifically, it is evident that the civilian sample perceived the likelihood of a soldier who is suffering a mental illness committing an offence as higher than the likelihoods expressed by those with military 2110

operational tour experience. Whereas, with regard to whether a solider is likely to keep their job if they suffer a mental illness, those with operational tour experience rated it as more likely than the civilian group. When considering these findings it may be suggested that the effect of previous media reports need to be examined with regard to the effect on civilian participant responses. For example, previous research has found that the media predominantly reports mental illness with negative associations, often with dangerousness and criminality (Coverdale, Nairn & Claasen, 2002). Wahl (2003) also reported findings of mental illness being consistently associated with dangerousness within media reports, additionally commenting on the negative impact which this may have on public attitudes towards those who suffer from such disorders. It may be suggested that this link which continues to be made between mental illness and potential criminality may encourage persons to believe that one suffering from a mental disorder is at increased risk of committing an offence. With reference to the findings regarding the likelihood of a soldier keeping their job in the Army if they suffer a mental illness, a study reported by Iversen et al. (2005) found that nearly 30 per cent of the participants within their sample had suffered from mental health issues whilst still serving in the forces, with the majority seeking help from military support services. This would indicate that despite experiencing adverse psychological effects, some individuals are still willing and able to remain in their military occupation. With regard to the findings of the present study, it may be suggested that, although many of those who had experience of operational tour reported some symptoms of trauma, the fact that they are still members of the Army, despite these issues, may have influenced their responses to this question. Further, it was found that there were no significant differences between the attitudes held by soldiers with operational tour expeForensic Update 2014 Annual Compendium

rience and those without the experience on any of the attitude scales used. This may indicate that there were no significant effects of the experience of operational tour on attitudes to mental illness or offending within the sample of military participants. In addition to the primary findings of the research, statistical analyses found there to be no significant effects of age, education, rank, number of tours, trauma-related symptoms or resilience levels, on attitudes expressed by any of the sample groups. These findings may be suggested to be in contrast to previous research findings. For example, previous investigations examining the effect of education on attitudes to mental illness and the Criminal Justice System found that higher educational attainment often led to more positive attitudes (Lambert, Baker & Ventura, 2008; Rabkin, 1974). A possible cause for this contradiction may be the result of the varied sample that was obtained within the present study. In order to further test the hypothesis of education affecting attitudes, it may be necessary for participant groups to be selected with less variation of educational attainment levels, to allow for greater comparisons to be made. Additionally, no significant effect of the number of tours was found, thus supporting findings reported by Fear et al. (2010). However, previous indications suggest that the more traumas one experiences, the higher their chances of developing some form of mental illness (Scott, 2007). This, therefore, suggests that, whether there is in fact a relationship between the number of operational tours one experiences and their chances of developing a mental health issue, the increased experience may not have an impact upon their general attitudes towards mental illness and offending. Based on the conceptualisation that resilience refers to a person’s ability to adapt to changing situations (Hoge, Austen & Pollack, 2007), a suggestion may be made that with higher resilience comes a higher level of acceptance and tolerance towards people with mental illness, for example. Forensic Update 2014 Annual Compendium F

However, the present study found there to be no significant effect of resilience on one’s attitudes, suggesting that individual resiliency levels did not impact upon their reported attitudes. Limitations The use of the self-report measures utilised within the study may provide a source of critique for the methodology implemented. For example; there may have been perceived stigma surrounding the issues addressed. This could have led to service personnel in particular not wishing to be accurate in divulging emotional issues they experienced or attitudes they held. They may have, therefore, been influenced to provide more socially desirable answers. This may have been particularly prevalent when completing the AMIQ and TSQ scales. However, it may be argued that the advantages to using such methods also need to be considered. For example, Barker, Pistrang and Elliott (2002) noted that, by using self-report measures in research, access to unobservable information is possible, such as personal attitudes, as in the case of the present study. The authors also noted that issues of socially desirable answers may be effectively addressed in future studies with the use of specific social desirability scales (Barker, Pistrang & Elliott, 2002), for example, the Social Desirability Scale (Crowne & Marlowe, 1960). A further limitation of the study methodology can be made regarding there being no measure to determine whether any person within the civilian sample had any previous experience of the military. It may be considered that such a factor could affect individual’s attitudes, and thus the results, and may be a consideration for future research.

Conclusions The present study suggested that there was a difference between civilian participants and both military groups with regard to attitudes towards the causes of mental illness and the need for services. It was also found that civilians considered the likelihood of a 111

solider with a mental illness committing an offence as higher than the military population with operational tour experience. However, military personnel with operational experience perceived the likelihood of a soldier with a mental illness keeping their job in the Army as higher than the perception of the civilian group. It is also noted that there are no significant differences in the attitudes held by soldiers with and without operational tour experience, suggesting there is little impact of the experience on attitudes. Finally, no variables, such as age; education; rank; numbers of tours; trauma-related symptoms; or resilience had significant effect on attitudes within the present sample.

From such findings, it may, therefore, be concluded that, whilst opinions specific to causes of mental illness and need for services differ between the groups, there are relatively few significant differences between military and civilian participants with regard to attitudes towards mental illness and offending. This may suggest that there were little or no effects of military occupation or operational tour experience on personal attitudes.

Correspondence Kathleen Roberts, MSc MBPsS University of York. Supervised by Dr Jane Clarbour. Email: [email protected]

Broughton War Memorial, North Lincolnshire. 112 2


References Barker, C., Pistrang, N. & Elliott, R. (2002). Research methods in clinical psychology (2nd ed.). West Sussex: John Wiley & Sons, Ltd. Brewin, C.R., Rose, S., Andrews, B., Green, J., Tata, P., McEvedy, C., Turner, S. & Foa, E.B. (2002). Brief screening instrument for post-traumatic stress disorder. The British Journal of Psychiatry, 181, 158–162. Connor, K.M. & Davidson, J.R.T. (2003). Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18, 76–82. Coverdale, J., Nairn, R. & Claasen, D. (2002). Depictions of mental illness in print media: A prospective national sample. Australian and New Zealand Journal of Psychiatry, 36(5), 697–700. Crowne, D.P. & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24(4), 349–354. Fear, N.T., Jones, M., Murphy, D., Hull, L., Clversen, A., Coker, B. et al. (2010). What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK Armed Forces? A cohort study. The Lancet, 375, 1783–1797. Hoge, E.A., Austin, E.D. & Pollack, M.H. (2007). Resilience: Research evidence and conceptual considerations for post-traumatic stress disorder. Depression and Anxiety, 24(2), 139–152. Hotpf, M., Hull, L., Fear, N.T., Browne, T., Horn, O., Iversen, A. et al. (2006). The health of UK military personnel who deployed to the 2003 Iraq War: A cohort study. The Lancet, 367, 1731–1741. Howard League for Penal Reform (2009). Report of the inquiry into former armed service personnel in prison. Retrieved 1 May 2012, from: http://www.howardleague.org/fileadmin/ howard_league/user/pdf/Veterans_inquiry/ Military_inquiry_final_report


Iversen, A., Dyson, C., Smith, N., Greenberg, N., Walwyn, R., Unwin, C. et al. (2005). ‘Goodbye and good luck’: The mental health needs and treatment experiences of British ex-service personnel. British Journal of Psychiatry, 186, 480–486. Iversen, A.C., Fear, N.T., Ehlers, A., Hacker Hughes, J., Hull, L., Earnshaw, M. et al. (2008). Risk factors for post-traumatic stress disorder among UK armed forces personnel. Psychological Medicine, 38, 511–522. Lambert, E.G., Baker, D.N. & Ventura, L. (2008). A preliminary study of views toward the mentally ill and the criminal justice system: A survey of college students. Journal of Criminology and Criminal Justice Research and Education, 2, 1–9. NAPO (2008). Ex-armed forces personnel and the criminal justice system. Briefing paper. Retrieved 31 March 2012, from: www.napo.org.uk/templates/ asset-relay.cfm?frmAssetFileID=317 NHS Information Centre for Health and Social Care (2011). Attitudes to mental illness – 2011 survey report. Retrieved 31 March 2012, from: http://www.ic.nhs.uk/webfiles/publications/ mental%20health/mental%20health%20act/ Mental_illness_report.pdf Rabkin, J. (1974). Public attitudes toward mental illness: A review of the literature. Schizophrenia Bulletin, 10, 9–33. Scott, S.T. (2007). Multiple traumatic experiences and the development of post-traumatic stress disorder. Journal of Interpersonal Violence, 22(7), 932–938. Treadwell, J. (2010). Counterblast: More than causalities of war? Ex-military personnel in the criminal justice system. The Howard Journal of Criminal Justice, 49, 73–77. Wahl, O.F. (2003). News media portrayal of mental illness: Implications for public policy. American Behavioural Scientist, 46(12), 1594–1600.

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Special Section

Military reserve service and post-tour work adjustment: Exploring lived experiences to inform applied practice Kevin Wilson-Smith & Elizabeth A. Bates Introduction CCORDING TO Wolpert (2000), for military personnel, the military role has greater importance than the individual role. Standard military exit for soldiers brings with it the process of role transition and, therefore, potential problems caused by ‘a change in position, a change in behaviour, or the interaction of the two’ (p.108). There are numerous role transition theories; most models aim to explain the process by which an individual responds to changes to themselves or their environment. For example, Nicholson (1984) suggests that work role transition can be seen as a cycle in a staged process: (1) Psychological and physical preparation (experiences of anticipation prior to the change, including fear, feelings of unreadiness and unrealistic expectations); (2) The encounter stage (first days of the new role, emphasising the role of defensive coping); (3) Adjustment (exploration of the new role at their own pace to reduce the risk of person-job misfit); and (4) Stabilisation (achievement of a person-role fit). Nicholson suggests that each of the stages has pitfalls and remedies (Bruce, 1991); strategies such as realistic job previews (Wanous, 1980) and systematic self-appraisals (Herriot, 1984) have been successful in overcoming issues at the stabilisation stage. The application of the cycle of transition is evident within the context of military service. Wolpert (2000) suggests the main concerns with military exit in relation to role transition are: a loss of status/responsibility, financial needing to work, competing with

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younger people, civilian employers not understanding military service, not having strong civilian roots or role identifications and finally a change in the family dynamics. This significant transition period may need a period of re-socialisation with some military skills translating to civilian roles (Wolpert, 2000), although Higate (2000) argues that the cultural habit of the military may in fact lead to ‘negative capital’ in context to transferable skills. Post-tour work readjustment Work adjustment can be described as the relationship between an individual and an organisation, having theoretical underpinnings in the theory of work adjustment proposed by Dawis, England and Lofquist (1968). The theory implies that achieving equilibrium between an individual’s work personality and their work environment has the purpose of achieving a balance between satisfaction and ‘satisfactoriness’ (Saxberg, 1984, p.757). Research has suggested that work adjustment for Reservist soldiers is a difficult process (e.g. Howard, 1980) with many firsthand accounts outlining concerns in relation to the challenges involved in the transition from deployment back to civilian job roles (Myers, 2003). Harvey (1982) found that often a lack of work readjustment led to reduced productivity and morale, which as a consequence can lead to the issue of reservists leaving their civilian job role within the first 12 months (Black & Forensic Update 2014 Annual Compendium

Stephens, 1989). This reinforces the idea that tenure is a good predictor of work readjustment (Dawis, et al., 1968). Other factors used to assess an individual’s level of successful work readjustment include a general sense of job satisfaction (including co-workers, supervisors and pay; Feldman & Thompson, 1993), psychological well-being (Feldman & Thompson, 1993) and also levels of work productivity (Black, Gregersen & Mendenhall, 1992). In order to aid the process of work readjustment, organisations should offer support in pre-deployment and at the point at which the solider returns back to their civilian job. The aim of this study was to explore the lived experiences of Reservists’ readjustment to civilian employment. Although originally designed to investigate non-clinical readjustment concerns, this paper highlights themes identified within a homogenous sample that may inform the understanding of Reservists’ experience for clinical and forensic practitioners.

Method Semi-structured interviews were conducted and analysed using interpretative phenomenological analysis (IPA; Smith, 2008). IPA involves a detailed exploration of how people make sense of their social and personal world; it places emphasis on the meanings that people hold about their experiences, events and social world. IPA offers a dynamic research process and is attentive to

the participants’ subjective reports rather than objective accounts. The research follows a double hermeneutic approach as the researcher brings their own conception to the analysis (Smith, 2008).

Qualitative design and sample Setting and sample Ten Reservist soldiers participated in semistructured interviews (six males; four females). The sample was drawn from the Reservist community with the following inclusion criteria: (1) recent completion of a tour of duty; (2) currently returned to civilian employment; (3) not medically discharged; and (4) no current health concerns (physical or mental). Participants were recruited from across the UK via social media forums. Interviews were recorded with consent and lasted around 90 minutes. Interview schedule Questions were developed in line with recommendations made by Smith, Flowers and Larkin (2009) and consisted of 10 semistructured questions across the categories of identity, transition and support/coping strategies. Analytic procedure A step-by-step approach for IPA was conducted (see Table 1) for each transcript and a master table of themes was created. As outlined by Lyons and Coyle (2007), the following steps were adhered to:

Table 1: Overview of step-by-step approach. Step

Procedure

Step 1 Step 2 Step 3 Step 4 Step 5

Researcher familiarises themselves with text Themes are identified Themes are placed into clusters Production of a summary table Integration


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Respondent validity was strengthened by providing participants with the opportunity to read the summation of themes identified within each interview to ascertain if the data still holds true. The analysis began with reading and rereading the transcript in order to produce notes on the concepts and language used by the participants in line with double hermeneutics, producing an account of how the researcher thinks the participant is thinking of their lived experiences of returning from operation tour back to civilian employment. Once a comprehensive set of notes were produced for each participant, the notes were analysed for emergent themes across the range of transcripts. Following the identification of the emergent themes, subordinate themes were explored.

Concluding comments The overarching themes identified in the results section provide a glimpse into the lived experience of Reservist soldiers. Although the authors are aware that the idiographic nature of phenomenology focuses on the interpretation of hermeneutic accounts and is, therefore, less concerned with generalisation, it is hoped that the aforementioned themes may be used to facilitate a discussion with presenting Reservists.

Correspondence Kevin Wilson-Smith & Elizabeth A. Bates University of Cumbria. Email: [email protected]

Findings The thematic framework for the analysis revealed three superordinate themes: (1) Variations in the Sense of Self Identity; (2) The Process of Transition; and (3) Processes Involved in Civilian Role Readjustment. A number of subordinate themes/ clusters were also identified within each superordinate theme and have been presented below (Table 2) before in-depth analysis.

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Table 2: Thematic framework. Superordinate theme 1: Variations in sense of self-identity Participants appear to experience a varying sense of multiple role identities when describing their lived experiences of having careers in both civilian and military life. The theme appears to have two clear clusters, self-perception of role identity and the impact of others perceptions on how they see themselves. The concept of duel self in context to Reservist service is reinforced by Sucharov (2005) who comments ‘Reservists during their stint of duty are temporarily not themselves but people placed in… circumstances that in themselves may allow (or demand) a certain type of behaviour’ (p.36).

Cluster 1.1 Self-perception

‘I think it’s a bit like being two different people, and only the people who ya with, like the lads you know what I mean, know who you are and your workmates think they know who you are. I kind of see it as being two separate people.’

Cluster 1.2 Perception of others

‘I mean, aye (yes) the way in which they (work colleagues) see you and everyone has an opinion on Afghan and going over. I always think what if they saw me in my uniform you know… how..if they like thought think he must be a right vicious bastard to do that stuff and I don’t want to go drinking with him… but I don’t talk about it or ever wear my greens (uniform) in civvie street, I get dressed at the detachment.’

Superordinate theme 2: The process of transition Participants describe the transition from being on active duty as a process of readjustment, with a focus on familiar experiences, people and process acting as the catalyst in attaining a self in equilibrium between the individual and the different organisation expectations, similar to the model of work adjustment described by Dawis et al. (1968). The process of transition clustered into three main subordinate themes including a period of transitional disequilibrium, the process of grieving the loss of a soldier identity and finally the process of ‘waiting’/anticipation to return to military service.

Cluster 2.1 Transitional disequilibrium

‘It always takes a wee while to find your feet, you know… you don’t know whether you a coming or a going for the first few months. You wake up thinking shit I’m late for parade and then realise it’s Sunday and you don’t work like or it’s the weekend so you are off. It’s like getting used to being a civvie again and flitting from one job to the next all the time, running around like a blue arsed fly but you know… do you know what I mean?’

Cluster 2.2 The process of grieving the loss of ‘soldier’ identity

‘You have to remember that aint in charge. You go from being a leader to a follower and it aint easy, it pisses me off that I could do it better you know, like the way they (managers) talk to you and tell you how to do stuff, it’s never clear and it pisses me off.’ Continued overleaf


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Table 2: Thematic framework (continued). ‘It’s like you haven’t really left, I think of it as though I am still there, in my head like. I chat to the lads and that and when we meet we talk about what we did and army talk and that and never really talk about civvie jobs.’

Cluster 2.3 The process of ‘waiting’ and anticipation to return to uniformed service

It’s a weird feeling really, cos, you know it’s strange because you get the feeling like you are constantly waiting to get called up, waiting to go back you know and that’s a, well it’s a nice feeling. It’s like you don’t actually ever leave but just go on holiday, and you have to work on holiday for money but actually it’s not your proper job and you’re waiting to start work again.’

Superordinate theme 3: Processes involved in civilian role readjustment The final theme summarises the participants lived experience of readjusting to returning to their civilian job role. The theme consists of four main clusters including aspects of emotional readjustment, behavioural adaptations, linguistic adaptations and finally the process of reinterpretation of their civilian job role in context to its moral worth.

Cluster 3.1 Emotional readjustment and a sense of separation from the collective

‘It’s like you know them so well and you don’t know your work mates like that. It’s a difference bond you have lost and you are so used to seeing them every day. You watch each other’s backs you know what I mean and they would do anything for you, but not work mates, they’d stab you in the back, it’s not like the lads you serve with, nothing beats that.’

Cluster 3.2 Behavioural adaptations

‘I even had to think about how I walked like a squaddie… you know people at work say God you walk fast like you are pacing or something.’

Cluster 3.3 Linguistic adaptations

‘I have to remember not to swear cos you can say whatever the fuck you want in uniform with your mates [laughs] not in front of officers though or if you do you say with all due respect sir fuck off [laugh]. Civvie managers think it’s unprofessional but it’s just words init so I have to remember not to swear so much.’

Cluster 3.4 Re-evaluation of jobs moral worth

‘You feel like you are changing the world, you know making a difference, you don’t feel you are making one bit of difference packing boxes you know, you just do it to pay the bills don’t ya. It aint gonna get you a medal is it?’

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References Black, J.S & Stephens, G.K. (1989). The influence of the spouse on American expatriate adjustment and intent to stay in Pacific Rim overseas assignments. Journal of Management, 15(4), 529–544. Black, J.S. Gregersen, H.B. & Mendenhall, M. (1992). Global assignments: Successfully expatriating and repatriating international managers. San Francisco: Jossey-Bass. Bruce, R.A. (1991). The career transition cycle: Antecedents and consequences of career events (NPRDC-TR-91-8). San Diego, CA: Navy Personnel Research and Development Center. Dawis, R.V., Lofquist, L.H. & Weiss, D. J. (1968). A theory of work adjustment (revision). Minnesota Studies in Vocational Rehabilitation (No. XXIII), 1–14. Minneapolis: University of Minnesota, Industrial Relations Center. Feldman, D. & Thompson, H. (1993). Expatriates, repatriates and domestic geographic relocation: An empirical investigation of adjustment to new job assignments. Journal of International Business Studies, 24(3), 507–529. Harvey, M.C. (1982). The other side of foreign assignments: Dealing with the repatriation dilemma. Columbia Journal of World Business, Spring, 53–59. Herriot, P. (1984). Down from the Ivory Tower. Graduates and their jobs. Chichester: Wiley. Higate, P. (2000a). Tough bodies and rough sleeping: Embodying homelessness amongst ex-servicemen. Housing Theory and Society, 17, 97–108.


Howard, C. (1980). The returning overseas executive: Culture shock in reverse. Human Resource Management, 13(2), 22–26. Lyons, E. & Coyle, A. (2007). Analysing qualitative data in psychology. London: Sage. Myers, S.L. (2003). Returning from Iraq war not so simple for soldiers. The New York Times, 12 September. Nicholson, N. (1984). A theory of work role transitions. Administrative Science Quarterly, 29, 172–191. Saxberg, B.O. (1984). Review of the book: A psychological theory of work adjustment. Personnel Psychology, 37(4), 756–758. Smith, J.A. (2008). Qualitative psychology: A practical guide to research methods (2nd ed.). Los Angeles, London, New Delhi, Singapore: Sage. Smith, J.A., Flowers, P. & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method, research. London: Sage. Sucharov, M.M. (2005). The international self. New York: State University of New York Press. Wanous, J.P. (1980). Organisational entry: Recruitment, selection and socialisation of newcomers. Reading, MA: Addison-Wesley. Wolpert, D.S. (2000). In J.A. Martin, L.N. Rosen & L. R. Sparacino (Eds.), Military retirement and the transition to civilian life. The military family. London: Praeger.

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Special Section

One intervention for ex-service personnel in custody: The Veterans group at HMP Grendon Simon Bonnett, Geraldine Akerman & M.T. T HAS RECENTLY BEEN REPORTED (Treadwell, 2010) that former service personnel are disproportionately represented at every stage of the criminal justice system one of the growing occupation groups in prison. Treadwell highlighted the lack of research into the connection (if any) of having served in the forces and offending. MacManus and Wesseley (2011) cited the National Association of Probation Officers (NAPO, 2008) report which estimated that 9.1 per cent of English and Welsh prisoners have served in the armed forces. These figures relied on self-report and were not always verified. The Defence Analytical Services Agency of the Ministry of Defence estimated a figure of 3.5 per cent using a more robust method of linking prison data with Ministry of Defence personnel records. Treadwell stated that Home Office research suggested between 4 per cent and 6 per cent of those in custody had served time in the armed forces, whereas research undertaken in HMP Dartmoor found that 16.75 per cent had done so. The NAPO report highlighted how the majority of offences committed were of a violent nature. MacManus and Wesseley (2011) described the level of anxiety reported in the media of the problems that those returning from war and leaving the forces may face. For instance, lack of accommodation, employment, relationship difficulties, and drug and or alcohol misuse. MacManus et al. (2013) undertook a study into those who had served in Iraq and Afghanistan and committed violent offences and found that

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having served a role in combat increased the risk of violence. Please visit http://www.kcl.ac.uk/kcmhr/pubdb/ for access to a comprehensive range of research relating to the armed forces. Some, but by no means all of those who have left the armed services could be diagnosed with post-traumatic stress disorder (PTSD), which is a response to a traumatic stressor and involves re-experiencing, avoidance, and hyperarousal by noises, smells and so forth. The diagnosis of posttraumatic stress disorder was added to the Diagnostic and Statistical Manual (3rd ed.) in 1980 (DSM-III: American Psychiatric Association, 1980). The criteria includes various traumabased syndromes for instance, traumatic neurosis, fright neurosis, concentration camp syndrome, war sailor syndrome, rape trauma syndrome, battered women’s syndrome, Vietnam veterans syndrome, shell shock, and abused child syndrome. Busuttil (2010) reported that between 1 per cent and 8 per cent of serving personnel are diagnosed with PTSD, but highlighted the problem of having this recognised after discharge, as delayed onset PTSD. Busuttil discussed the problems associated with assessing the scope of the problem with those who are discharged, given that to count as ex-service personnel an individual need only have served one day in the forces; Thus, there could be many who are included in this group who have not experienced that which those at the other extreme, those who have served in active combat have undergone. Forensic Update 2014 Annual Compendium

It is also noted that some of the reasons veterans joined the services may make this group more vulnerable to later problems. Klein, Alexander and Busuttil (2012) described possible vulnerabilities, such as having experienced childhood adversity, but noted that this may be a protective factor, as those having such experiences may have developed robust coping strategies. NAPO (2008) examined the case histories of exservice personnel in custody and found that the majority of the ex-soldiers were suffering from post-traumatic stress disorder (PTSD) at some stage and that very few had received any counselling or support at any time after discharge. Klein, Alexander and Busuttil (2012) state that this study and the later study (NAPO, 2009) had been flawed in that it relied on self-report. More recently, Bray et al. (2013) undertook what they described as the first comprehensive review of all regular veterans in the criminal justice system, reported that ex-service personnel were not over represented in custody in England and Wales, (with a figure of 3.5 per cent) but acknowledged that they did not include Reservists. They explained that data was not available for Reservists, or accessible for those in Northern Ireland or Scotland. Treadwell (2010) referred to this as the ‘hidden wound’ – an injury that is little talked about because of the stigma attached to soldiers suffering psychological problems (p.76). Steenkamp and Litz (2012) describe the co-morbid affects effects of serving in the theatre of war, for instance mental and physical illness, physical illness, a negative impact on relationships and employment and a poorer quality of life. They review the treatment available to the veterans and highlight that there are a number of barriers to being able to access care, for instance the inability to travel to the venue in which it is provided, the impact on employment or family life, and the expectation that they should not need help. They concluded that evidencebased therapy was most effective as treatment for PTSD. Treadwell (2010) poignantly highlighted how at one time the service Forensic Update 2014 Annual Compendium F

personnel are hailed as heroes, but those who go on to offend are then spurned. Thought needs to be given as to how those leaving the forces can be helped to make the transition, and what support can be given to those who have been willing to give up their life in the service of their country.

The therapeutic community as treatment As noted above, there seems to be growing evidence that there are an increasing number of ex-servicemen in prison whose offences can be related to a change in behaviour, partially or fully due to their experiences in the armed forces and particularly those who have experienced trauma on the battlefield. This is nothing new (Jones, 1946, 1952; Jones & Wesseley, 2005; Nash, Silva & Litz, 2009) as the Therapeutic Community (TC) method grew out of Mill Hill psychiatric hospital and was developed further by Wilfred Bion and John Rickman at Northfield psychiatric military hospital, where wounded soldiers from World War II were showing signs of combat fatigue, or shell shock. Staff working with these men recognised the need for an environment in which they could recover from the distress they were exhibiting. It was recognised that while they needed care, they were autonomous and still had self-agency, and so this was integrated into the treatment. Maxwell Jones developed the TC philosophy and explained the research he was undertaking and found that the men responded well to group discussion and ‘Social Learning’ evolved (see Jones, 1952, 1968; Stevens, 2010; Whiteley, 2004). Siegmund Foulkes and Harold Bridger helped to apply group analysis and TC principles, and included regular meetings discussing how to run the community in a democratic manner, along with social events. In 1946 Tom Main was appointed as Hospital Director and evolved the treatment to include psychoanalysis and psychiatry to help those in treatment to resolve interpersonal conflict. Rapoport (1960) described his view of the ‘Community as doctor’ and 121

eveloped the model further by adding the core principles of a therapeutic community; G Democratisation – that is ensuring that each member has an equal say in how the community runs, having open channels of communication, and transparency in decision-making. G Communalism – which is learning to recognise that what each individual considered to be a unique problem or symptom, can in fact be shared by others. This principle helps residents to make links with others as they disclose their struggles when others can share their experience of similar issues and thus provide coping strategies and hope that things will improve. G Permissiveness – This involves the ability to tolerate behaviour and communication that would generally be sanctioned. This enables such behaviour, thoughts or attitudes (conscious and unconscious) to be discussed and its function to be understood, resulting in the development of more pro-social alternatives. Permissiveness encourages the resident to behave as they would generally, in order to receive feedback as to how this behaviour is experienced by others and resolve interpersonal difficulties. G Reality confrontation – this is being able to explain to others, and (importantly being able to hear), how a residents behaviour, views and management of emotions impacts on others. For instance, if a resident is irresponsible, or not taking responsibility for their actions, this is open for analysis by the group and community and how it impacts on others is discussed. Many residents will state that such feedback has not been given to them in the past, or if it has it has not been heeded. Yalom (1980) spoke of the mirror being held up to the resident, and describes how residents find it difficult to see themselves as others do. Later, Haigh (1999) and Genders and Player ( 995) spoke of the need for attachment to

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the community and the importance of joining and leaving the community appropriately. This is a quality many ex-service personnel value, as they report feeling unprepared for the loss of the forces structure, the camaraderie and sense of belonging. They value the structure, and predictability of a TC, while having the safe, contained space to examine and explore their difficulties. Throughout the journey of therapy the resident will know that they will leave as some point, they will hear stories of others who have done so successfully (as well as those who have struggled), and can make plans as to how they will cope in the various situations they are likely to encounter. Importantly, they will be able to detach in a planned manner and with a sense of themselves as an autonomous individual. In line with the Good Lives model (Akerman, 2011; Ward & Gannon, 2006; Ward & Stewart, 2003) much thought is given to what goals had been sought through joining the forces and how this can be achieved in another way. Some work is already being done by various establishments around the country (Lee & Jones, 2007) focussing particularly on resettlement, drugs and alcohol needs for ex-service personnel. Support ranges from financial help, housing, employment, all provided by ex-servicemen’s charities such as the Royal British Legion and Soldiers Sailors Air Force Association (SSAFA). It also provides information on the Ex-Servicemen’s Mental Welfare Society, more commonly known as Combat Stress. Combat Stress provides a dedicated prison’s in-reach representative who will support (as much as possible) the veteran through the justice system and into custody and can diagnose mental health problems with the individual. They also provide residential services for those in need of treatment in the community and can suggest further referral to one of these once the veteran has been discharged. However, it has limited resources and manpower to sustain the required level of support to veterans serving longer sentences.


The Veterans group at HMP Grendon Many prison officers are also ex-service personnel and so recognised the need for support for their former comrades-in-arms. As the research began to understand the numbers of people involved, initiatives developed in various establishments to offer support. Initially a group of ex-service personnel met in Grendon and spoke of how their needs could be met in addition to the support already provided through the groups. They identified the need for an outlet where they could discuss their experiences with others who may understand them more. They expressed their concerns that by discussing their experiences they would be breaching the security of their regiments, which they still held dear. They were assured that even though they had signed the Official Secrets Act, they could safely discuss the impact their experiences had on them. Primarily, the Grendon Veterans meet on a quarterly basis and will either discuss issues currently being faced in their therapeutic groups or will offer support to fellow exservicemen who are struggling, either with their problems relating to their index offence or how to connect and make links with other group members. The group generally offer support without commenting too much on therapy, as the core of the work is done in their groups. The group also take part in charity events, currently they are doing a sponsored run/cycle/row of a distance which is equivalent to travelling from Grendon to Afghanistan, and this is to raise funds for the ‘Star and Garter’ charity. They also raised funds for the Lee Rigby fund, which helped them to offer support to a fallen comrade and develop their self-esteem. Members of the Grendon Veterans group have spoken of how some aspects of the core work carried out in the therapy groups, can sometimes be misunderstood, this is due to non military personal not being able to make links. This as you can imagine can be frustrating for some men, as they find it difficult to express emotion regularly on a day-toForensic Update 2014 Annual Compendium F

day basis, having been trained not to. Some of the men will express this during our meetings. The group will try to guide, and persuade individuals to try other ways of expressing what or how they are feeling. Lt Col (Ret) Tom Ridgeway who represents the services charities – Royal British Legion (RBL) and SSAFA (Soldiers Sailors Air Force Association) – is welcomed in to the establishment, along with other military guests and will advise and offer emotional in addition to available financial support on behalf of the charities. Tom has a very long history with helping veterans which stems back many years. His support has helped many soldiers over the years and this continues across the country with other representatives of the charities. We finish this article with a few words from a former member of the Veterans group who has progressively moved on from Grendon. My name is M.T.; I served with the 1st Battalion the Devon and Dorset Regiment. I served for four-and-a-half years before having a mental breakdown when my marriage ended. Since attending the Veterans group they have helped me realise that I should be, and have the right to feel proud about my service. Another difficulty I had, I always felt misunderstood, my blind loyalty no one seemed to understand. The Veterans group understood this and understood me instantly the first time since leaving the forces. When I first attended the Veterans group I felt guarded and unsure of speaking out about my self. It was against what soldiers do ‘asking for help’, then one day I felt the camaraderie-ship you only get around service men and women. This helped me to feel at ease and open for the first time since leaving the Army. I feel proud of my service, my confidence has grown because they understood me, they got it… Because of this, I have now been in contact with members of my regiment for the first time since 1989. My previous Officer Commanding also visits regularly, and has offered with help and advice for the future. Because of the Veterans group I feel proud be a ‘Veteran’, 123

without the group I would still be feeling ashamed and embarrassed, my journey would still have many miles to go…

The Authors Simon Bonnett (Prison Officer). Geraldine Akerman (Forensic Psychologist. M.T. (Service User).

Conclusion This paper described the Veterans group at HMP Grendon, which began out of an identified need for those who have served in the armed forces to speak about their experiences with those who may be in the position to understand them. So far, due to the informal nature of the meetings there has been no research into the impact it has on those involved. This may be considered in the future.

Correspondence Geraldine Akerman Email: [email protected]

War Memorial Gateway, The Meadows, Nottingham. 124 3


References Akerman, G. (2011). Offence paralleling behaviour and the custodial good life at HMP Grendon. Forensic Update, 104, 20–25. American Psychiatric Association (APA) (1980). The Diagnostic Statistical Manual of Mental Disorders (3rd ed.). Washington, DC: APA. Bray, I., O’Malley, P., Ashcroft, S., Adedeji, L. & Spriggs, A. (2013). Ex-military personnel in the Criminal Justice System: A cross-sectional study. The Howard Journal, 52, 516–525. Busuttil, W. (2010). Combat-related stress. In D. Conrad & A.K. White (Eds.), Promoting men’s mental health. UK: Radcliffe Publishing. Genders, E. & Player, E. (1995). Grendon: A study of a therapeutic prison. Oxford: Clarendon Press. Haigh, R. (1999). The quintessence of a therapeutic community: Five universal qualities. In P. Campling & R. Haigh (Eds.), Therapeutic communities: Past, present and future (pp.246–257). London: Jessica Kingsley. Jones, M. (1946). Rehabilitation of forces neurosis patients to civilian life. British Medical Journal, 1, 533–535. Jones, M. (1952). Social psychiatry: A study of therapeutic communities: A new treatment method in psychiatry. New York: Basic Books. Jones, M. (1968). Social psychiatry in practice: The idea of the therapeutic community. Harmondsworth: Penguin. Jones E. & Wessely S. (2005). Shell shock to PTSD. Military psychiatry from 1900 to the Gulf War. East Sussex: Psychology Press. Klein, S., Alexander, D.A. & Busuttil, W. (2012). Scoping review: A needs-based assessment and epidemiological community-based survey of ex-service personnel and their families in Scotland. Robert Gordon University. http://scotland.gov.uk/Resource/0041/ 00417172.pdf Lee, H. & Jones, E. (2007). War and health; Lessons from the Gulf War. Chichester: Wiley. MacManus, D., Dean, K., Jones, M.,Rona, R.R., Greenberg, N., Hull, L., Fahy, T., Wesselley, S. & Fear, N. (2013). Violent offending by UK military personnel deployed to Iraq and Afghanistan: A data linkage cohort study. The Lancet, 381, 907–17 MacManus, D. & Wesseley, S. (2011). British Medical Journal, 342, 1–2. Main, T. (1946). The hospital as a therapeutic intervention. Bulletin of the Menninger Clinic, 10, 66–68. (Reprinted in 1996 in Therapeutic Communities: The International Journal for Therapeutic and Supportive Organisations, 17, 77–80).


NAPO (2008). Ex-armed forces personnel in the Criminal Justice System. London: National Association of Probation Officers [online]. Assessed 17 April 2014, from: http://www.napo.org.uk/publications/ Briefings.cfm NAPO (2009). Armed forces in the Criminal Justice System. London: National Association of Probation Officers [online]. Assessed 17 April 2014, from: http://www.napo.org.uk/publications/ Briefings.cfm Nash, W.P., Silva, C. & Litz, B. (2009). The historic origins of military and veteran mental health stigma and the stress injury model as a means to reduce it. Psychiatric Annals, 39, 789–795. Rappoport, R. (1960). Community as doctor: New perspectives on a therapeutic community. London: Tavistock. Steenkamp, M.M. & Litz, B.T. (2013). Psychotherapy for military-related post-traumatic stress disorder: Review of the evidence. Clinical Psychology Review, 33, 45–53. Taylor, J., Parkes, T., Haw, S. & Jepson, R. (2012). Military veterans with mental health problems: A protocol for a systematic review to identify whether they have an additional risk of contact with criminal justice systems compared with other veterans groups. Systematic Reviews, 1, 1–53. http://www.systematicreviewsjournal.com/ content/1/1/53 Treadwell, J. (2010). Counterblast: More than casualties of war?: Ex-military personnel in the Criminal Justice System. The Howard Journal of Criminal Justice, 49, 73–77. Stevens, A. (2010). Introducing forensic democratic therapeutic communites. In R. Shuker & E. Sullivan (Eds.), Grendon and the emergence of forensic therapeutic communities in research and practice (pp.7–24). UK: Wiley-Blackwell. Ward, T. & Gannon, T. (2006). Rehabilitation, etiology, and self-regulation. The Good Lives model of rehabilitation for sexual offenders. Aggression and Violent Behaviour, 11, 77–94. Ward, T. & Stewart, C.A. (2003). Criminogenic needs and human needs: A theoretical model. Psychology, Crime and Law, 9, 125–143. Whiteley, S. (2004). The evolution of the therapeutic community. Psychiatric Quarterly, 75, 233–248. Yalom, I. (1980). Existential psychotherapy. New York: Basic Books.

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Article

A proactive approach to engaging difficult to reach inpatients: A service evaluation Katherine Crosby, Katie Downsworth, Katie Gilchrist & Kristy O’Hare Purpose: In December 2012 a ward-based programme which applied proactive engagement strategies tailored to the individual needs of forensic inpatients was implemented in a low/medium secure forensic setting. This evaluation demonstrates a link between this approach and an increase in formal psychological therapy uptake and improvement in patient experience. Background: Research has shown that many forensic inpatients are unmotivated and resistant to engage with interventions (Prochaska &Levesque, 2002). Typically, psychological therapy is designed for those who are motivated to change and can, therefore, exclude many service users. Method/Key points: Data from 128 patients was analysed using a mixed method approach. A within subjects design used a paired samples t-test to determine whether there was a significant difference between the number of patients engaging in psychological therapy pre- and post-implementation. A correlation ascertained whether a relationship between engagement in ward-based activities and the increase in uptake of formal psychological therapy was apparent. A thematic analysis identified six key concepts relating to patient experience. Conclusions: The ward-based activities appear to have had a significant impact upon the uptake of formal psychological therapies. The overall feedback from patients highlighted six key themes: social interaction; new skills; improving mental well-being; enjoyment and opportunity; therapeutic alliance; and autonomy. These findings support existing research which emphasises the need for proactive approaches to patient engagement with psychology services. BSERVATIONS in forensic mental health services indicate that many forensic service users appear unmotivated and resistant to psychological therapy. Such service users can spend long periods of time in hospital without engaging in any meaningful rehabilitation work. Research exists which challenges traditional treatment models and their effectiveness with such service users (Prochaska & Levesque, 2006). Prochaska and Levesque (2002) discuss how most traditional treatment programmes are not designed for such individuals and therefore not able to meet their needs. They discuss how action-oriented approaches such as cognitive behavioural therapy (CBT) are designed for people in the preparation stage of the change cycle. They argue for a move away from passive reactive approaches in

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which professionals wait for service users to seek support before acting; to a proactive approach to treatment recruitment. Research has found that change is a process that unfolds over time and goes through a series of stages: precontemplation, contemplation, preparation, action, maintenance and termination (Levesque, Gelles & Velicer, 2000; McConnaughy et al., 1983, 1989). The service users described above who may be considered unmotivated and resistant to treatment can be seen to be in the precontemplation stage of the cycle. Many service users get stuck in this stage for years. The costs to individuals, their families and the wider community highlight how important it is to motivate and engage such offenders to participate in appropriate treatment programmes. Forensic Update 2014 Annual Compendium

In June 2012 the Forensic Mental Health Department in a low/medium secure hospital carried out an internal review of psychology input. This review was congruent with the research above and found that the level of psychology input was greatest for acute wards with longer stay patients demonstrating a reluctance to engage in therapy. This review also found that the treatment programmes offered tended to be groupbased, manualised, structured and exclusively available for those assessed and considered to be suitable, that is, in the preparation or action stage of change. Subsequently, in December 2012 the Department embarked on a ward-based programme which aimed to offer a stagematched intervention applying proactive recruitment methods which took into account an individuals’ readiness to change (Jinks, McMurran & Huband, 2012). The current service evaluation aimed to demonstrate a link between this novel approach to engaging patients with an increase in formal psychological uptake and an improvement in patient experience.

Method Participants One-hundred-and-fifty-three service users within a secure forensic service were offered ward based psychologically informed activities. The age range of participants was 19 to 81 years and the group consisted of both male and female service users. For the purpose of the service evaluation a decision was taken to omit those service users who were residing on assessment wards (N=25) as the primary focus of these wards was to determine level of psychological need and appropriate psychological pathway rather than to deliver therapeutic interventions. Consequently data from 128 patients was available for the purpose of the evaluation: 56 medium secure and 72 low secure service users. Twenty-six were female and 102 were male.


Ward-based programme The ward-based programme was delivered by a team of five Higher Assistant Psychologists who spent between one to two hours per week with the service users on each ward. Examples of session content include: low intensity psycho-educational sessions focused upon anxiety; mindfulness techniques; group activities/games; cognitive stimulation exercises, for example, discussion of newspaper articles; identity and selfesteem building craft sessions and voice hearing discussion groups. The sessions differed across the levels of security, chronicity of mental health and gender. All sessions, however, focused upon building rapport with a view to aiding the potential for therapeutic alliance. Measures Psychological records were used to determine the number of interventions that each participant engaged in pre and post the implementation of ward-based sessions. Pre-ward-based sessions was defined as the time period December 2011 to December 2012. Post-ward-based sessions was defined as December 2012 to December 2013. A within subjects design was used and a paired sample t-test was conducted to determine if there was a significant difference in the number of patients on each ward engaging in psychological therapy pre- and post-implementation. Engagement in ward-based sessions was subjectively determined by the Higher Assistant Psychologist delivering the session. A scatter graph was used to determine whether a linear relationship existed between the increase in uptake of therapy and the number of patients who engaged in ward based sessions. A Pearson’s correlation ascertained whether a significant correlation was present. In order to give context and depth to quantitative findings, service users were asked to give their views of the ward based activities. A theoretical thematic analysis based on the model proposed by Braun and 127

Clark (2006) was carried out in order to identify any emerging themes relating to patient experience and well-being.

Results Statistical analysis Examination of the raw data showed that the number of people engaged in formal psychological therapy post-implementation of the ward-based activities had doubled from 37 to 74. A paired sample t-test demonstrated that the number of people on each ward engaged in psychological therapies increased significantly post-implementation of the wardbased activities: (t=–4.772, df=9, p11-)032&$4-,,>'30=G$ $

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Forensic Update Newsletter of the Division of Forensic Psychology Guidelines for Contributors We welcome contributions in various formats including: reviews, research (completed or in progress) and commentaries on any aspect of forensic psychology or related fields. It is usually possible to publish contributions more quickly than refereed journals. However, this will be somewhat dependent on the amount of material the Editorial Team receives. Articles will be edited by the Editorial Team. Forensic Update is published quarterly in January, April, July and October. Copy should be with the Editors at least three months prior to proposed publication date. The Editors cannot guarantee that a submission will appear in the following edition after it has been accepted. Please contact the Editors if you would like to discuss ideas for papers or guidance for submissions. Audience: Please write your article at a level suitable for an intelligent reader with a basic knowledge of forensic psychology. Please try to avoid assuming detailed specialist knowledge. Please keep statistics to a minimum. Psychologists in Training: Trainees need to ensure that their supervisor is aware of their interest in submitting material to Forensic Update. The work needs to have been supervised before it is submitted. The Editors would also advise that material be co-authored and countersigned. Style: We aim to publish articles that are accessible and, therefore, would encourage you to write in a lively and easily readable style. Length: Articles should ideally be between 1500 and 2000 words. Shorter or longer articles may be published subject to discussion with the Editors as we don’t want to impinge on a paper’s quality by being too fussy about the word limits. References: These should be kept to a minimum wherever possible and should be presented in the following format: Milgram, S. (1974). Obedience to authority. New York: Harper & Row. Kennerley, H. (1996). Cognitive therapy of dissociative symptoms associated with trauma. British Journal of Clinical Psychology, 35, 3325–3340. Footnote: At the end of your article, please include your name and where you work, contact details and word count. For example, Ann Other is with the Nowhere Institute [email protected] 2515 words Copyright: Copyright of material published in Forensic Update is retained by the British Psychological Society. However, authors may reprint their own articles without permission. Authors will be required to complete a copyright form before their article goes to press. Presentation: It is essential that authors proofread their work for grammatical or spelling errors and send a final copy without tracked changes. It can take significantly longer to review articles if this is not carried out thoroughly. Tables or figures should be attached as separate Word or Excel files. Authors need to be mindful that this publication is in black-and-white, so please do not send us anything in colour. Further guidance on presentation can be obtained from the Style Guide published by the British Psychological Society. It can be downloaded free of charge from the Society’s website.

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