Engaging the LD Offender Im talking today about a therapeutic - - PDF document

Engaging the LD Offender

I’m talking today about a therapeutic community for offenders who have committed serious offences and have a learning difficulty/disability. To avoid having to say learning difficulty/disability every time I hope you’ll forgive me if I use the acronym LD. According to Pearce and Haigh the roots of therapeutic communities can be traced back to the Middle Ages with a community set up at the shrine of St Dymphna at Geel in Flanders. They say that this was probably a community for people with LD. However, I would like to suggest that the founding father of therapeutic communities was actually Pachomius in fourth century Egypt. Pachomius was living the life of a hermit and was widely known for his holiness, groups of young men came to him wishing to learn about the way to holiness. Initially, Pachomius tried to show them how they should behave, waiting on them and caring for them in the hope that they would copy his example, unsurprisingly to modern day readers, they did not. In response Pachomius came up with the first set

• f community rules, and, I think therefore, can lay claim to being the founder of

therapeutic communities even if what he was trying to set up was monastic

• communities. Pachomius’ work was carried on by St Benedict whose rule is still widely

read today. Anyone interested in therapeutic communities may find it worth exploring this short and simple text. Should you wish to look at this issue further there is a conference on April 20th titled “Concepts of Community” which is set up to use the comparison between monastic communities and therapeutic communities, to help us understand what we want in a well-functioning community. To move a little closer to the present day in 1796 The Retreat hospital opened in York founded on the basis of what was called “moral treatment”, the basis of this was to treat insane people as closely to how so called “normal” people were treated as was possible. On the other side of the Atlantic a fairly well known community was set up by Quakers in Pennsylvania in 1817, working to a similar model. This early phase of TC’s was relatively short lived however as physical treatments for mental difficulties and psycho-analysis gained ground. However, the need to find ways to treat those traumatised by the Second World War resulted in work at Northfield Military Hospital and Mill Hill Hospital which gave this way of working considerable emphasis, and revitalised the whole therapeutic community idea, with the phrase “Therapeutic Community” first being used in 1946. The therapeutic community with which I am concerned is at HMP Grendon which is a Category B prison with a roll of approximately 220. The prison has six wings and each wing is run as a therapeutic community, which makes us very lucky. Wings B, C, and D, are mainstream wings, A wing is for those who have committed sexual

• ffences, G Wing is an assessment community, and F Wing where I’m the clinical

lead, is for those with LD. All communities have community meetings on Mondays and Fridays and, except G Wing, small therapy groups on Tuesday, Wednesday, and Thursday. A new arrival stays on G Wing for between 3 – 6 months. If they pass their assessment and choose to stay a resident is then allocated to a wing where he will become a member of the community and, if he can stay engaged with the therapy, usually live for a minimum of 18 months or three years on F Wing. On F Wing we also accept residents direct from other establishments and carry out our own assessments, which take four months.

The resident is expected to abide by the wing constitution, this varies slightly from wing to wing but core elements are the “No sex, drugs or violence” rule and the Four Pillars of the community; Democracy, Community Living, Tolerance and Reality Confrontation. Residents are also expected to keep matters confidential to their wing. Residents are

• pen to challenge by their peers and staff and are expected to challenge in their

turn in an appropriate manner. At the end of the assessment period a meeting is held in which staff will discuss with the resident their progress and set them a series of treatment targets. Progress on these targets is assessed every eight months on F Wing and targets may be altered

• r removed if felt to be no longer appropriate.

While in the prison residents are expected to have a job or be in education; they are also expected to have a “rep job” which is an unpaid job which gives something back to the community. Rep jobs vary in responsibility and trust from watering the wing’s plants to being the Chairman of the wing. Off wing jobs also can involve highly trusted positions such as Prison Equality Mentor. Any man wishing to take up a post needs to get backing from his group and then the community as a whole. The discussion about this usually covers such issues as how it will further his therapeutic work, what challenges there are for him and how he will manage the challenges. Most aspects of a resident’s life are open to discussion by the resident’s therapy group or the community. There is provision for rule breaking and the hope is that such behaviour can be thought about and understood by the community to help the resident in question to make changes. A serious breach of the rules may result in a commitment vote; a discussion by the whole community as to a resident’s commitment to therapy, which can result in the resident being asked to take part in certain sanctions, or being asked to leave the community. All this is the same as the other wings. In individual therapy the relationship with the therapist is the agent of change, in Group Analysis it is the relationship with the therapy group; in a therapeutic community it is the relationship with the whole community which is the agent of

• change. This allows a resilience which would not otherwise be possible and the

addressing of issues rooted in profound disturbance. The TC+ units sprang out of the lack of facilities for offenders with LD to progress, they are a relatively recent innovation the oldest, the community at HMP Dovegate having opened at the beginning of 2013 and the unit at HMP Gartree opening a couple of months later. F Wing at HMP Grendon is fairly late to the party having

• pened in April 2014.

I’ve mentioned the ways that TC+ is similar to the mainstream communities; however, there are some important differences. Firstly is the issue of numbers, experience has shown that residents with a lower IQ can find it difficult to get involved in discussions in larger communities and tend to fail to engage in the therapeutic process in larger groups. Accordingly the wing has a roll of 20 as compared to 40 – 45 residents for wings for those with a higher IQ. This is also reflected in the size of our therapy groups with members being six or seven to a group as opposed to approximately nine on the other wings. In contrast we have a much higher staff to resident ratio, something approaching one to one when we are fully staffed. The next issue is time. It is usually accepted that people with LD tend to have a shorter attention span than those with a higher IQ. Accordingly our therapy groups meet for 40 minutes have a 15 minute break and then meet for a further 45

• minutes. This, as so much with the TC+ project, has advantages and disadvantages.

Some of our residents tell us that they feel they would be unable to take part without that break; others see it as a badge of shame and say that it gets in the way, interrupting important work at a crucial moment. In my opinion both are correct, as so much in therapy we have to work with what is and use it as a basis for learning. Again in contrast to the other wings our groups are structured. On the mainstream wings their therapy groups are open and any resident can bring any issue to any group session; a process of negotiation and a group decision takes place if there are competing bids for time. Whilst some of this is still true for TC+, there are significant differences. The first is that all our therapy groups have a focus, Tuesday is a reflection group, Wednesday focuses on relationships and Thursday is a themed group, which has a clear structure and usually tasks. These are run in blocks of approximately sixteen weeks and are what I want to put most attention to; I will return to them later. We have a much wider range of resources all wings have an Art Therapist and Psychodramatist, but in addition to this we also have a Music Therapist, an Occupational Therapist, and a nurse. These make an important contribution and in the case of Occupational Therapy have been considerable help in developing an holistic approach to the needs and difficulties of our client group. All of this makes for a pretty full timetable and I think raises an important issue. Have we in our attempts to make therapy more accessible to the LD Offender overloaded a client group who need more space? This really is the theme of this presentation. When I first thought of writing this I was much more coming from the position of telling you how well we had done in opening therapy up to this difficult to reach client group, but I am aware that in psychotherapy every time you add something you lose something, and I think it is important to think about what we might have lost and is it worth the price. I’ve been working on TC+ for a little under two years, when I joined the unit I was uncomfortable about the Thursday structured sessions, however I came to feel that they had an important place for a client group that have historically found it difficult to engage with psycho-therapy. I think at this point it might be helpful to look at the work of Valerie Sinason. Her book “Mental Handicap and the Human Condition” is invaluable in my opinion and probably the benchmark for anyone wanting to engage in psychotherapy with this client group. In particular there are two concepts which we have incorporated into

• ur understanding, the first of these is Secondary Handicap. For those of you who

have not previously come across this term, it signifies the way in which someone with LD tries to hide their difficulty and in so doing actually handicaps themselves further. The other idea we see a lot of is what Valerie terms “The handicapped smile” this is the inane smile that I am very familiar with from my days in LD organisations in the

• utside community. Valerie says that this is rooted in the understanding that almost

no-one wants to hear about the pain and suffering of living with a learning difficulty. The handicapped smile is not something that we see very much of on F Wing, but what it represents is still there and shows up in other ways. Tuesday to Thursday we start the day with a fifteen minute feelings check, just a space for everyone to go round and say how they are feeling and managing, many people just say they’re fine regardless of what’s been going on, and almost all finish off their contribution with the phrase “Looking forward to groups”. Bearing in mind the tendency of our residents to hide the reality of what they are living with I felt we might need to adapt

• ur Thursday sessions somewhat.

Show we are interested The sessions we had been running were based on standard Offender Behaviour Programmes which we had expanded and re-worded to make them suitable for our residents, but I felt that we needed something which would much more address the tendency to keep the pain hidden, and show our residents we wanted to know about their suffering. In addition it had started to become clear that many of our residents had a real difficulty in understanding the parallels between the things that had happened in their lives and the things they had done; in effect what had led them to offend. In my opinion this is a key area for any reduction in risk. We therefore started to write our own programmes beginning by looking at this link. We put together a block which we called “From being hurt to hurting others” In assembling the components of the block we tried to keep in mind a child’s widening experience and so we started in the home then looked at the street, school etc. We also asked

• ur residents to access these components a great deal through drawing. I think our

residents thought that we were using drawing materials because of their LD, but in fact my feelings is that doing things this way allows us to get to feelings and thoughts that are more difficult to see if we stay with the purely verbal. The outline for the block is on the handouts, although inevitably it got changed to meet circumstances. As you can see we started by asking the residents to draw a picture of their home. This in itself needed some preparation for two reasons, firstly was the fact that we had a number of men on the wing who came out in a cold sweat if asked to do anything that involved a sheet of paper. We therefore discussed this individually and

• n the community meetings before the block began, not everyone was

comfortable but we had an agreement to give it a go, with the proviso that I would give them at least 24 hours notice of any activity we expected them to take part in. The second issue, of course, was the simple question “Where is my childhood home?” more than one of the men on my wing had had more homes than their age before they were into double figures, we therefore needed to discuss with staff and residents what this simple question meant; we settled on “Whatever springs to mind when someone asks the question”. Even with all this preparation we still had difficulties and the Thursday of the first session of the block one man couldn’t make it into his group. He came to one of the clinical staff full of anxiety because he felt he did not know what we were asking. The member of staff talked with him for a little while and pointed out that he had told her all the information he needed to make the drawing, she walked him back to his group and sat him next to the facilitator who by chance was the art therapist for the wing, who completed the drawing to the residents instructions. The drawings clearly brought up powerful feelings some couldn’t complete them one or two destroyed them before they could be shown to the group. Most however were able to complete the task and start to use the drawing to tell the rest of the group something of their past. However, we learned an important lesson “Allow more time” Everything always took longer to explore than we had expected. I think this was less to do with the residents needing more time because of their LD and more to do with my expectations that they wouldn’t really engage fully with the real meaning of the task i.e. to start to pick up the pain of their backgrounds and so wanting to fill up the programme in case of this. You will see we scheduled some sessions with case studies. The point of this was to give the residents practice in joining up cause and effect starting with other people’s lives which might have less emotional impact. Some of these we drew from people we had worked with in the past and some I drew from literature. Again in this I made some mistakes, failing to take into account the feelings our residents had

about being seen as children. I had used the example of Voldemort, from the Harry Potter stories, who, from his history, is clearly a very good example of someone who having been completely uncared for as a baby and child has failed to develop any sense of empathy or compassion. Unfortunately, we didn’t get as far as this, since the majority of the residents saw this as childish and insulting and wouldn’t look at it. On the same basis we also did a session on defences drawing all the time on the residents own experiences to try and build an understanding that would make it easier to make use of the therapy. The drawing session titled “Our Street” proved to be quite productive, perhaps this was made easier by the residents having had some experience of what was being asked of them. I think it was also made easier by it moving slightly away from family with the conflict of being mistreated by those you love and the difficulty of talking about this. Whatever the reason a number of men were able to make use of this session and it showed a very interesting view of their lives. One man’s drawing showed the local prison at the centre of the community, he was also able to talk about the extreme catholic/protestant segregation that went on in his part of Glasgow, with different buses and different times in all the shops. A number of men were able to start to talk about the prejudice they had suffered as a result of their LD. DM’s drawing I’ll focus on one drawing in particular which seemed a good example it shows the yard in front of a group of garages where this resident used to hang out with his “Friends” the word balloons have things like “Backward”, “Die” and other names he used to get called. This resident went on to talk about some of the mistreatment he received at the hands of this group of lads including being tied to a tree and pissed

• n. His offence is directly related to this. One morning he was asleep on his friend’s

bed and awoke to find his head on fire they had used an aerosol and a lighter to set fire to his hat; half an hour later he had stabbed his friend and killed him. Incidentally the picture shows his dog Jess whom he says was his only real friend. Another picture showed the idyllic cul de sac in which this resident had spent his early life until his father had shot his mother’s lover interestingly the address of the place where the shooting occurred with a brief record of the events is inserted into the cul-de-sac in the shape of a penis; this resident is serving an IPP sentence for

• rape. I’m not quite sure what that means yet if anything, but I keep it in mind. I’m not

sure if we completely achieved our aim for this block which was to open up for reflection the links between their mistreatment and their offending, but I think we may have made a beginning and therapy is always a work in progress. The next block was called “Living with a learning difficulty”, and it followed on from the previous block in that “From being hurt to hurting others” made it clear that for many of the residents their offending was closely linked to their LD, also this was an area that was still difficult for the residents to talk about. When I had first come onto the wing it was like a shameful secret that no-one mentioned. Since this was the whole reason for the existence of the wing I felt this couldn’t continue, quite apart from the basic framework of a TC that everything must be available to be talked

• about. There was another interesting learning point for us in this. We asked the

community to choose a group of residents to form a Focus Group to think about what they might want to include in this block. The Focus Group met a couple of times and came up with some good ideas and suggestions about how we might

deliver them. However, they came up with one idea that we had not thought about at all. They wanted to know about their various learning difficulties and the details of their IQ scores. As a staff group we were quite concerned about this we thought they would probably use the scores to set up some kind of league table on the wing. As a result we tried all sorts of ways to present the information about their various strengths and weaknesses without actually giving them the scores. Eventually we had to admit that none of these were going to work and we gave them the information that they wanted. They said thank you very much that explains why so and so does this in the group and got on with using the information in a supportive and responsible manner. It was a humbling experience and a valuable learning point. This block stirred up a lot of feelings however due to the insistence on looking at this difficult issue. Again we adopted an incremental approach, moving from when they first felt they were not as intelligent as others or were diagnosed as LD. Through the various experiences that shaped their attitudes. As you can see we scheduled a session on Internalised oppression, as it turned out staffing considerations meant that we had to do this session as a whole wing rather than as the three therapy groups. This session was given particular meaning by the fact that we had had an incident

• n the exercise yard shortly before the session where two residents had squared up

to each other after one had come out swinging his cell key on his lanyard and the

• ther had reacted strongly to this. The point that gave interest to the session was

that the insults used were “Mong” and Retard”. I think this block had a very clear effect however, and I think we definitely reached some of our goals. About the time

• f the end of the block we our Peer Review, it was interesting and moving to see

how openly the residents talked about the issues attached to having an LD. I was pleased to see that the reviewers noticed this and commented on it. However, in Valerie Sinason’s terms we have taken away the possibility of the handicapped smile and that has meant that the wing now has a different feel, more edgy. It’s more alive, but rather uncomfortable. I feel that there have been a lot of gains on the wing because of the two blocks I have described, but as I mentioned I am concerned about the cost. This is a client group which is notoriously disempowered, who are used to having things done to them, in constructing this programme have we repeated that? I am not entirely sure and I’d be interested in your thoughts.