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 Centre430 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).

Schema Therapy

Schemas

Modes

Child Modes – Emotion

Coping Modes –Behaviour

Parent Modes - Cognitive

Emerging evidence is promising

Punitive

Parent

Vulnerable

Child

Happy

Child

Angry

Child Impulsive

Child

Enraged

Child

Healthy Adult

Demanding

Parent

Compliant

Surrender

Conning

Manipulator

Paren

t Mod

es

Cop

ing M

od

es

Child Modes

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..Ihave 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 BehavioralExperientialCrime tracking 4. Mode change (introduced only)

Behavior pattern breakingValuesGoalsRelapse preventionclosure

Statistics and FeedbackStatistics

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).

FeedbackTherapeutic 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

Uniform Staff Training

Refresher/Maintenance Modules

Relationship between intervention and change of behaviour not yet statistically known

Generalizability

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)

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