Ahu Kocak & Amy Rugendyke AMC Group Schema Therapy in Prison
Presentation Overview Introduction AMC and Current offender specific programs at AMC Schema Therapy Schema Therapy for Forensic Populations Quiz Group Schema therapy at AMC Description of the therapeutic format Statistics & Feedback Future Directions & conclusion
The AMC - Alexander Maconochie Centre 430 Bed prison ; currently expanding to reach 539. 29 Female beds 2 Cell blocks 30 Special Care 5 Cottages 1 TRC cottage 10 bed suicide, 14 bed segregation unit Mixed classification, mixed security, remand and sentenced No transfers must deal head on with the long term and short term needs. Change behaviour can not change environment.
Current Offender Treatment Programs at AMC Cognitive Behaviour Therapy (CBT) is currently the principal method employed in offender treatment programs seeking to reduce recidivism. CBT is the core premise that dysfunctional beliefs and behaviours are cognitively mediated, and can be modified to bring about positive outcomes. For significant traumatic histories, or long-standing patterns of maladaptive behaviours, identifying and challenging those thoughts considered maladaptive, becomes increasingly difficult as they have little evidence to support the contrary. The benefits of standard CBT approaches for this chronic population can be argued as less effective. Focus on behaviours rather than overwhelming emotional states and it s aetiology.
Schema Therapy Integrative, unifying theory & treatment Used to treat complex presentations and need seeking traits and behaviors' Focus on core human needs Focus on childhood experiences and early adult relationships. Experiential methods added to Cognitive & Behavioural methods Therapeutic relationship used to meet needs and repair early relationship-representations (safe attachment offered).
Coping Modes Schema Therapy Schemas Modes Healthy Adult Demanding Parent Punitive Parent Parent Modes Child Modes Emotion Coping Modes Behaviour Compliant Surrender Conning Manipulator Parent Modes - Cognitive Vulnerable Child Emerging evidence is promising Happy Child Angry Child Impulsive Child Child Modes Enraged Child
Group Schema Therapy Common use with borderline personality disorder with impressive results Adapts the standard approaches to ensure full group participation. create a family dynamic which enables therapists to re-parent group members. Increases learning experiences through modelling and vicarious learning. Group format is a likely catalyst in the change process. The GST program randomised control trial (Farrell & Shaw) 100% retention rate 94% no longer met the diagnostic criteria for BPD. All improvements remained at a six-month follow-up.
Schema Therapy in forensic settings So What..? Bernstein and colleagues adapted the individual ST format for use with forensic patients, and in 2013 the therapy was approved in the United Kingdom for use in forensic hospitals. Explicitly links modes with criminal, violent, and addictive behaviours, and managing these forensic coping modes becomes the focus of treatment. Cognitive awareness strategies and experiential techniques can be developed to express anger in a constructive way, improve frustration tolerance, reduce impulsivity, and enhance reliance on more healthy forms of coping Bully and Attack: Uses threats, intimidation, aggression and coercion to get what they want. They directly harm other people in a controlled and strategic way emotionally, physically, sexually, verbally, or through antisocial or criminal acts. Predator: Focuses on eliminating a threat, rival, obstacle, or enemy in a cold, ruthless, and calculating manner. Suspicious Over Controller: Attempts to protect themselves from a perceived or real threat by focusing attention, ruminating, and exercising extreme control. A person in this mode is likely to be perceived by others as being extremely jealous and controlling. Conning Manipulator Mode: Will con, lie, or manipulate others in a manner designed to achieve a specific goal that benefits them and is likely to either victimize or hurt others. It is common for people to use this mode in order to escape punishment.
Schema Therapy in forensic settings And Why..? High rates of childhood abuse, Post-Traumatic Stress Disorder and personality disorder diagnosis. Offenders with personality disorders, particularly those with high psychopathic traits, are three times more likely to generally re-offend and four times more likely to re-offend with a violent crime. Offenders dealing with complex trauma histories are likely to suffer intense emotions and physiological reactions. Unsurprisingly, these highly reactive individuals with complex psychosocial histories present as challenging clients in therapy and in prison dynamics.
I need to do better, I hate myself when I realise I am in here. I think you sh*t, fat idiot, you can never do anything right..i have never done anything right So I smoke pot, so the pain is not so bad, you know.. I feel outraged..like when noone cares and I am ignored so I lose my sh*t so I [want to] hurt them, show them I am worth listening to, I dominate and get feared It makes me feel exposed, sad, scared even.. I don t talk, just shut down, usually stop going to the group Sometimes I just do what they want, like clean the whole pod, give my stuff away, its easier that way.. I feel like I can do what I want, noone can tell me otherwise, rules are stupid here I told him he can t treat me that way, im not like the other prisoner s, I can read for starters..he is obliged to give me an explanation sometimes I think it s not worth it. The bigger picture is its their job to do, and there Is no winning..i just want to do my time and get home..at the end of the day I am responsible for my actions Angry Child Undisciplined Child Happy Child Vulnerable Child Compliant Surrender Detached protector Detached self soother Self Aggrandizer Bully and Attack Conning/Manipulative Punitive Parent Healthy Adult
Group Schema Therapy at AMC : Mode Awareness and Management (MAaM) So far we have completed two groups, and commenced a third. Referral Criteria: disruptive need seeking/ problem behaviours, min. 8 months remaining on their sentence or remand period, and a willingness to integrate with detainees of a different security classification to themselves Exclusion Criteria: Evidence of an active psychotic disorder, possible autism spectrum disorder, and/or charges of child sex offenses
Pilot Group Schema Therapy at AMC : MAaM Manualised with clinician manuals and participant workbooks 2 facilitators psychologists trained in Schema 2 individual sessions screening and developmental history 20 group sessions, once per week 90-120 minutes each, with a 10 minute break 2 follow up sessions upon completion No external or monetary incentive
Group Schema Therapy at AMC : MAaM Identify needs and dominant maladaptive coping modes. focus is placed on understanding why maladaptive coping modes may have developed, and negative consequences of such modes. Goal: meet the need of connection and belonging, as evidence contrary to their schemas of defectiveness and abandonment Reparenting, empathetic confrontation of maladaptive attitudes and behaviours, limit setting, and unconditional positive regard. Focus on meeting the need of acceptance and encouraging intrinsic motivation for change.
1. Group cohesion Connectedness Understanding childhood needs Safety and connection Positive regard 2. Mode awareness Cognitive awareness Insight Motivation 1:1 session - rescripting 3. Mode management Behavioral Experiential Crime tracking 4. Mode change (introduced only) Behavior pattern breaking Values Goals Relapse prevention closure
Statistics and Feedback Statistics Low numbers mean no conclusions can be drawn from quantitative data but there is promising trends in descriptive and qualitative data. Drop out rate 0% (high motivation to engage) Psychometrics include pre and post :DASS, PANAS, TLV, Social Self Esteem, and Fear of intimacy all showing good results so far. Effect of program on behavior change, diagnostic criteria for Cluster B and Recidivism? Too soon to tell. However only 5% of completed participants have received internal disciplines post program (contraband related). Feedback Therapeutic community, other clinical and other programs staff high interest and good feedback Custodial Staff commenting on behavioural changes of detainees after program completion From detainees VERY POSITIVE FEEDBACK, high interest many self referrals
To the question: the best thing about this group is.. Informative and enjoyable Learning to stop and think of consequences Life skills We never had new teachers or participants, always the same so we could trust them Realising I am basically good and can better myself
To the question: The worst thing about group is... It ending The days I was sick and missed out There was nothing bad It finished It went for too long The homework
To the question: compared to other groups at AMC this group is... Its extraordinary and different It heaps better I haven't done others I get kicked out Is not just for parole its for me Was fantastic should be more like this
To the question: any other feedback? Best program The future prospects for this group are high I believe There could be more one on one sessions if possible I enjoyed every session If there is ever a part two I would sign up straight away Looking forward to putting it all into practise Please don't change this group! Ever! Thank you for my new life
Future Directions/Limitations Cost-benefit analysis Longitudinal analysis Recidivism Severity of offence/problem behaviour Community corrections Female detainees Generalizability Uniform Staff Training Refresher/Maintenance Modules Relationship between intervention and change of behaviour not yet statistically known
Conclusion The MAaM GST program has a strong therapeutic focus while also attempting to address criminogenic needs and maladaptive behavioural patterns. The program appears to have resulted in positive outcomes for detainees with complex presentations, personality disordered traits, and traumatic histories. Feedback from participants, other clinical staff and case management has also been positive.
Relationships matter: the currency for systemic change was trust, and trust comes through forming healthy working relationships. People, not programs, change people. Dr Bruce Perry Thank you for your efforts and support. Don't give up trying to get through the walls, and remember anything man made can be unmade Bill (participant)
References ACT Health. (2008). Adult corrections health services plan, 2008-2012. Canberra. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5: Amer Psychiatric Pub Incorporated. Arntz, A. (2008). Schema-focused therapy for borderline personality disorder: Effectiveness and cost-effectiveness, evidence from a multicenter trial. European Psychiatry, 23, Supplement 2(0), S65-S66. doi: http://dx.doi.org/10.1016/j.eurpsy.2008.01.238 Australian Institute of Criminology. (2014). Australian crime: Facts and figures 2013. Canberra: Australian Government. Retrieved from http://aic.gov.au/media_library/publications/facts/2013/facts13.pdf Bamelis, L. L., Evers, S. M., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of Schema Therapy for personality disorders. American Journal of Psychiatry, 171(3), 305-322. Bernstein, D. P., Arntz, A., & Vos, M. d. (2007). Schema focused therapy in forensic settings: Theoretical model and recommendations for best clinical practice. International Journal of Forensic Mental Health, 6(2), 169-183. Bernstein, D. P., Keulen-De Vos, M., Jonkers, P., de Jonge, E., & Arntz, A. (2012). Schema Therapy in Forensic Settings The Wiley-Blackwell Handbook of Schema Therapy (pp. 425-438): John Wiley & Sons, Ltd. Bernstein, D. P., & Nentjes, L. (2014). Schema therapy for forensic patients with personality disorders. Manual 3: "Program manual". Retrieved from http://www.kfz.nl/web/images/uploads/manual_3-_program_manual.pdf Bernstein, D. P., Nijman, H. L., Karos, K., Keulen-de Vos, M., de Vogel, V., & Lucker, T. P. (2012). Schema therapy for forensic patients with personality disorders: design and preliminary findings of a multicenter randomized clinical trial in the Netherlands. International Journal of Forensic Mental Health, 11(4), 312-324. Bryant, R. A. (2000). Cognitive behavioral therapy of violence-related posttraumatic stress disorder. Aggression and Violent Behavior, 5(1), 79-97. doi: http://dx.doi.org/10.1016/s1359-1789(98)00021-4 Ehlers, A., & Clark, D. Early psychological interventions for adult survivors of trauma: a review. Biological Psychiatry, 53(9), 817-826. doi: 10.1016/S0006-3223(02)01812-7 Farrell, J. M., Reiss, N., & Shaw, I. A. (2013). The schema therapy clinician's guide: A complete resource for building and delivering individual, group and integrated schema mode treatment programs. West Sussex, UK: John Wiley & Sons, Limited. Farrell, J. M., & Shaw, I. A. (1990). Emotional awareness training for borderline personality disorder patients: a treatment manual. Unpublished manuscript for NIH RO3, Indiana University School of Medicine, Indianapolis. Farrell, J. M., & Shaw, I. A. (2012). Group Schema Therapy for Borderline Personality Disorder: A Step-by-Step Treatment Manual with Patient Workbook: Wiley. Farrell, J. M., & Shaw, I. A. (2014, 21 June). Introduction to group schema therapy. Paper presented at the APS College of Clinical Psychologists Conference, Melbourne. Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: a randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317-328.
References Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. The lancet, 359(9306), 545-550. Gibson, L. E., Holt, J. C., Fondacaro, K. M., Tang, T. S., Powell, T. A., & Turbitt, E. L. (1999). An examination of antecedent traumas and psychiatric comorbidity among male inmates with PTSD. Journal of Traumatic Stress, 12(3), 473-484. Giesen-Bloo, J., van Dyck, R., Spinhoven, P., & et al. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63(6), 649-658. doi: 10.1001/archpsyc.63.6.649 Heckman, C. J., Cropsey, K. L., & Olds-Davis, T. (2007). Posttraumatic stress disorder treatment in correctional settings: A brief review of the empirical literature and suggestions for future research. Psychotherapy: Theory, Research, Practice, Training, 44(1), 46-53. doi: 10.1037/0033-3204.44.1.46 Hemphill, J. F., Hare, R. D., & Wong, S. (1998). Psychopathy and recidivism: A review. Legal and Criminological Psychology, 3(1), 139-170. doi: 10.1111/j.2044-8333.1998.tb00355.x Lobbestael, J., van Vreeswijk, M., & Arntz, A. (2007). Netherlands Journal of Psychology, 2007, number 3 Shedding light on schema modes: a clarification of the mode concept and its current research status. Netherlands journal of psychology, 63(3), 69-78. doi: 10.1007/BF03061068 NHS England. (2013). NHS standard contract for medium and low secure mental health services (adults). United Kindom. Simpson, S. G., Morrow, E., van Vreeswijk, M., & Reid, C. (2010). Group schema therapy for eating disorders: a pilot study. Frontiers in psychology, 1. Stevens, B., Farrell, J., Reiss, N., & Bradford, S. (2014). Schema Therapy Workbook (Forensic). Unpublished Manuscript. Timmerman, I. G. H., & Emmelkamp, P. M. G. (2005). The Effects of Cognitive-Behavioral Treatment for Forensic Inpatients. International Journal of Offender Therapy and Comparative Criminology, 49(5), 590-606. doi: 10.1177/0306624x05277661 Torgersen, S., Kringlen, E., & Cramer, V. (2001). The prevalence of personality disorders in a community sample. Archives of General Psychiatry, 58(6), 590-596. doi: 10.1001/archpsyc.58.6.590 Turner, M. G., Hartman, J. L., & Bishop, D. M. (2007). The effects of prenatal problems, family functioning, and neighborhood disadvantage in predicting life-course-persistent offending. Criminal Justice and Behavior, 34(10), 1241-1261. van Asselt, A. D., Dirksen, C. D., Arntz, A., Giesen-Bloo, J. H., Van Dyck, R., Spinhoven, P.,... Severens, J. L. (2008). Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. The British Journal of Psychiatry, 192(6), 450-457. van Vreeswijk, M., Broersen, J., & Nadort, M. (2012). The Wiley-Blackwell Handbook of Schema Therapy : Theory, Research and Practice (1 ed.). Hoboken: Wiley Retrieved from http://canberra.eblib.com.au/patron/fullrecord.aspx?p=879005 Young, J. E. (1990). Cognitive therapy for personality disorders: A Schema-focused approach. Sarasota, FL: Professional Resource.