A retrospective evaluation of a therapeutic community for mentally disordered offenders

This paper reports a retrospective evaluation of a therapeutic community (TC) for mentally disordered offenders in a regional secure unit (RSU). All 85 patients who had passed through the TC since it opened in 1987 were eligible for the study.
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  Full Terms & Conditions of access and use can be found at Download by:  [University of Nottingham] Date:  31 May 2016, At: 12:34 The Journal of Forensic Psychiatry ISSN: 0958-5184 (Print) 1469-9478 (Online) Journal homepage: A retrospective evaluation of a therapeuticcommunity for mentally disordered offenders Mary Mcmurran , Vincent Egan & Shahla Ahmadi To cite this article:  Mary Mcmurran , Vincent Egan & Shahla Ahmadi (1998) A retrospectiveevaluation of a therapeutic community for mentally disordered offenders, The Journal of Forensic Psychiatry, 9:1, 103-113, DOI: 10.1080/09585189808402181 To link to this article: Published online: 04 Jan 2008.Submit your article to this journal Article views: 64View related articles Citing articles: 6 View citing articles  A retrospective evaluation of a therapeutic community for mentally disordered offenders MARY McMURRAN, VINCENT EGAN and SHAHLA AHMADI ABSTRACT This paper reports a retrospective evaluation of a therapeutic community (TC) for mentally disordered offenders in a regional secure unit (RSU). zyxwvut ll 85 patients who had passed through the TC since it opened in 1987 were eligible for the study. Information on 81 patients was available in clinical records, providing a descriptive profile of the population. Information on recidivism was collected from the Home Office Offenders Index for 53 patients, providing information on effectiveness of the TC in terms of its impact on crime. Those for whom post-discharge crime information was collected were split into assessment and treatment groups, and short- and long-stay groups. All patients significantly reduced their offending after discharge as compared with pre-admission levels. There was no significant difference between the assessment and treatment groups, or between short- and long-stay groups. Whilst there was a significant overall reduction in offending, this cannot be attributed to the TC programme. Programme design, selection criteria and pre-admission assessment all require further attention to optimize the effectiveness of group treatment for mentally disordered offenders. Keywords: therapeutic community, mentally disordered offenders Therapeutic communities (TCs) are based on the premise that some people experience problems because they cannot relate to the society in which they live, and are designed to amend this difficulty. The four central tenets of TCs are: (I) democratic decision-making, with diminution of the staff-patient The Journal of Forensic Psychiatry Vol9 No 1 May 1998 103-1 13 zyx   outledge 1998 ISSN 0958-5184    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   N  o   t   t   i  n  g   h  a  m   ]  a   t   1   2  :   3   4   3   1   M  a  y   2   0   1   6  134 TOURNAL OF FORENSIC PSYCHIATRY Vol. 9 No. zy   divide; zyxwvuts 2) communalism, in that there is shared responsibility for the practi- calities of running the community; (3) reality confrontation, where residents’ behaviours are challenged in respect of their appropriateness and impact on others; and (4) permissiveness, in that mistakes are tolerated as part of the learning process (Rapoport, 1960). Whilst the general social milieu is intended to be therapeutic, group meetings form the core process of the TC. These meetings variously discuss the business of the community and address residents’ problems in group therapy. The TC approach has been used with offenders in hospital and prison settings. A follow-up of personality disordered people referred to the Henderson Hospital between September 1969 and February 1971 compared 194 admissions with 51 who were not admitted (Copas zyx t al., 1984). A high proportion of both groups had previous convictions and previous hospital admissions, and success was defined as having neither further convictions nor further hospital admissions at follow-up. At 3 years the success rate was 41 for those admitted compared with 23 for those not admitted, and at 5 years the success rates were 36 and 19 respectively. Success rates increased with length of stay in the hospital, with those who stayed 9 months or more achieving a success rate of 71 after 3 years. Those with one criminal conviction did better than those with more than one conviction, who in turn did better than those with none. Those classified as ‘extrapunitive neurotic’ were likely to fail, whereas those classified ‘neurotic’, ‘intropunitive psychopath’ and ‘psychopath’ were more likely to succeed. Cullen (1994; 1997), reporting on follow-up studies of former inmates of Grendon prison, notes that reconviction rates are not significantly different from those of comparable prisoners serving similar sentences but that those who stayed longer in therapy did better than those who left early. Specific- ally, half of those who left before 18 months were reconvicted within 2 years compared with 19 of those who stayed for 19 months or more. Wexler (1997) notes that, in the United States, TCs are the treatment of choice for prisoners with substance abuse histories. Wexler, Falkin and Lipton (1990) compared prisoners in four treatment options: a TC; a milieu drug treatment programme; counselling; and a no treatment control group. At 35 to 40 months after discharge, the percentage of rearrests was lowest for the TC group (26.9 ) and highest for the no treatment group (40.9 ), with those for the milieu group and the counselling group falling between the two. The length of time to rearrest increased with the length of time spent on the TC. A replication of this study has shown similarly successful results, with an added component of an aftercare TC further improving outcome (Wexler, 1997). The problems faced by individuals are rarely dis- crete; for example, offenders accepted for substance abuse treatment pro- grammes have a high incidence of personality disorders, as well as other    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   N  o   t   t   i  n  g   h  a  m   ]  a   t   1   2  :   3   4   3   1   M  a  y   2   0   1   6  A THERAPEUTIC COMMUNITY 105 psychological and psychiatric problems, suggesting that co-morbidity needs to be addressed in treatment (Hiller zyxwv t zyxwv l., 1996). Whilst TCs appear to work for some personality disordered offenders, there is evidence that ‘psychopaths’ actually deteriorate after treatment. In this research context, psychopathy is defined by a high score on Hare’s Revised Psychopathy Checklist (PCL-R; Hare, 1991). Rice, Harris and Cormier (1992) carried out a retrospective evaluation of a TC in a maximum- security institution for mentally disordered offenders. The treated group, who spent at least 2 years in the TC, were matched with an assessment-only group in terms of age, offence and criminal history. Any reconviction, revo- cation of parole, or return to the maximum-security institution was con- sidered a treatment failure at follow-up, which was at a mean of 10.5 years after discharge. Although the programme showed a modest overall success rate in that only 57 of the treated group failed as compared with 68 of the comparison group, ‘psychopaths’ (i.e. those who scored 25 or more on the PCL-R), when analysed separately, produced some worrying results. Failure rates were 89 and 81 for treated and non-treated ‘psychopaths’ respectively, and 78 and 55 for the two groups when violent crimes only were studied. That is, ‘psychopaths’ treated in a TC showed higher rates of general recidivism and violent recidivism as compared with a non-treated group; treatment in a TC made ‘psychopaths’ worse. Ogloff, Wong and Greenwood (1990) studied men in a TC programme in a forensic psychiatric hospital. Hare’s Psychopathy Checklist scores were used to designate patients psychopathic (score 27 or over), mixed (score 18-26), and non-psychopathic (score 17 or less). The psychopathic group stayed in the TC for a significantly shorter time, showed less motivation and improved less than the other two groups. The effectiveness of TCs in reducing reconviction in offender populations is, therefore, equivocal. Arnold Lodge, the regional secure unit (RSU) of the East Midlands Centre for Forensic Mental Health, has been operating a TC for personality disordered offenders since 1987. Cairngorm Ward is one of five wards within Arnold Lodge, a 55-bedded medium secure unit for the assessment and treatment of patients suffering from mental illness or per- sonality disorder. Cairngorm Ward houses eight patients and operates as a TC primarily for personality disordered offenders. A total of eight residents is small for a TC (e.g. the Henderson houses 29 in total) and is more akin to one small therapy group within a total TC. Cairngorm Ward residents, however, associate with patients from other wards within the unit. Whilst democracy is limited within a secure setting, the TC is run along traditional lines. Typical daily events are ‘community meetings’ where the business of the community is discussed, ‘talking groups’ to address personal and inter- personal problems, ‘review meetings’ that cover the events of the day, and ‘crisis meetings’ called by residents when problems require immediate    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   N  o   t   t   i  n  g   h  a  m   ]  a   t   1   2  :   3   4   3   1   M  a  y   2   0   1   6  106 JOURNAL OF FORENSIC PSYCHIATRY Vol. 9 No. 1 attention. Individual goal-setting sessions, group expressive therapies, edu- cation, work skills and leisure activities are also part of the TC programme. There have been no outcome studies on Arnold Lodge’s TC since its incep- tion zyxwvu   years ago and, as with any service, it is imperative to collect follow- up data to see i the service provided is working to the benefit of the client group. A retrospective evaluation of all patients who had been admitted to the TC up to 1996 was conducted. METHOD Since the opening of Cairngorm Ward in January 1987, 85 patients were identified as having been treated there. Information was collected for 81 of these patients. Medical files on 3 of the patients could not be traced, and 1 patient was excluded from the study because of minimal information on his case being recorded. Information about these patients was gathered from clinical notes and included demographic data, criminal history, psychiatric history, substance use, family history of criminality, family history of psy- chiatric problems, details of the index offence, admission and discharge infor- mation. This provided a descriptive profile of all patients accepted on to Cairngorm Ward for assessment or treatment. Information about offending before admission and after discharge was collected from the Home Office Offenders’ Index, a large database holding all recorded convictions since 1963. Information was available for only 53 patients, 65.4 of the sample. At the time of the study I1 patients were still resident on the unit (2 still in the TC and 9 on other wards within the unit), and the remaining 17 (21.0 ) did not appear on the index. Although, according to the Index User’s Guide (Home Office, 1996), the aim is to match at least 95 of any sample with a record on the index, we were informed that for in the region of 20 of files to be missing is not uncommon. Analysis of offence data provided infor- mation on effectiveness of the TC in terms of its impact on crime. RE zyxw   U LTS Population profile The mean age of the patients was 26.9 years (SD zyx   6.41). There were 56 (69.1 ) patients who were male, and 25 (30.9 ) who were female. Of the 81 patients, 68 were white (84 ), 9 were of mixed race (11.1 ) and 1 was African-Caribbean (1.2 ); information on ethnicity was missing for 3 patients (3.7 ). Information on the prevalence of risk factors for crimi- nality identified in cross-sectional and longitudinal studies (Andrews and    D  o  w  n   l  o  a   d  e   d   b  y   [   U  n   i  v  e  r  s   i   t  y  o   f   N  o   t   t   i  n  g   h  a  m   ]  a   t   1   2  :   3   4   3   1   M  a  y   2   0   1   6
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