The Assessment and Treatment Issues That Arise When Managing Violent People - Essay Example

The assessment and treatment issues that arise when managing violent people Introduction It is often said that the human brain is one of the last frontiers of exploration still left unfinished. The mind which is a part and parcel of the brain is a complex and sensitive state of being. It can be influenced by many factors starting from early childhood. So many emotions control the mind varying from love, hate, jealousy, caring, and so on, all of which are determined by the environment to which they are exposed. One factor that is disturbing to the individual and the society is the propensity for violence in its myriad manifestations. It is an undeniable fact that violence exists in practically all societies of the world. Even though most people in the society have been exposed to violence mostly through media, and occasionally in person, not everyone react in the same vein. But certain people are more vulnerable and they react in such way that can be harmful to others and sometimes even to the person who indulges in violence. In most cases, they are referred to as psychiatric cases which require intervention and treatment from qualified personnel along with support and help from other sections of the society. The growing complexity of the society, lack of caring and isolation have resulted in many people not being able to react logically, resulting in them being labeled as violent. The society and the government in most advanced societies have recognized this fact and the need to assess and treat such people in the hope that their behavior can be managed to a certain extent. Many people who become unreasonably violent often end up in the custody of law or institutions that cater to treatment of such people. This paper is a review of assessment and treatment that arise in the management of violent people, especially those who are already convicted and are in prison. In the process, it will evaluate various factors like risk, rehabilitation, recidivism, prediction of behavior, and effectives of treatment and rehabilitation. Concept of violence The concept of violence can be relative to a large extent among different societies and even within sections of a society. But a commonly accepted meaning would be an act that harms other people either physically or mentally. Violence can be intrapersonal and interpersonal. The former refers to doing harm to the self in ways like hurting oneself or trying to commit suicide. The latter which has more consequences refers to harm done by a person to others. But actual acts of violence are directly related to the mental health of an individual according to Daniel J Flannery. His book Violence and mental health in everyday life, states that “the first step towards understanding violence and its impact on mental health is to be able to accurately describe what it is and how and individual comes to act in and aggressive, violent way towards others” (Flannery, 2005, p. 8). What the author wants to say is that though almost everyone is exposed to violence in some form or the other (as mentioned earlier), it affects the mental health more seriously in some individuals due to various reasons. If the resulting mental health and acts of violence become so severe that individuals cannot cope with daily life, then it becomes a serious issue where that individual may require medical attention which includes various aspects like assessment of risk, treatment, management and rehabilitation. The next section will deal with violent individuals in a prison setting and the functions of a psychologist to help people manage their mental health in such a setting. A prison psychologist’s functions Management of mental health in a prison setting is more complicated in the sense that the patient is isolated from the society and his or her own immediate circle of family and friends. Fagan and Ax quoting Corsini, purport that psychologists who assist prisoners must have the capability and skill to “enter into good rapport with the widest variety of individuals, in the age group from 16 to 80, negroes and whites, mental ages 6 to 20, former annual incomes nothing to a million dollars” (Fagan & Ax, 2002, p. 30). What is important about this observation was that it was made way back in 1945, sometime after the concept of psychology being used in prison became accepted. Hence the help of psychologists in bettering the lives of prisoners has a long precedence of nearly sixty years. In 1946, the journal ‘The American Psychologist’ published an article by Dr Carroll L Shartle mentioning the duties expected to be performed by a prison psychologist. Dr Shartle mentions five primarily duties which are quite similar to the ones accepted today. They are interpreting the mental state of prisoners, interviewing and preparing reports of individual prisoners, assessing whether the prisoner is ready for parole, rehabilitation, and conducting research and reporting the findings in the field of penal psychology. These observations are strikingly similar to the accepted practices about the role of psychologists in prisons even today which includes assessment, treatment, rehabilitation, research, and mental health (Grieve). Assessment There are many reasons or dimensions to assessing the mental state of troubled and violent prone inmates in prisons. One primary reason is to classify the patient and to recommend the apt treatment. Another reason is to assess whether the patient inmate is ready for parole if so how to go about it. Assessment is also necessary to understand the level of antisocial behavior that may manifest itself in the patent in the event of a parole or otherwise. It is also done to assess the level of risk and dangerousness of the prisoner (patient) to other inmates and members of the society in case he or she is let out on parole. Risk and violence is differentiated in the following manner by Dr Hart, where the former is “hazard or threat that is incompletely understood and therefore that can be forecast only with uncertainty” (Hart). Risk assessment is complex and is indicative of the probable violence that an inmate may indulge in the future. It is also contextual in the sense that violence may be triggered on some event or happening taking place. It is also dynamic because causes that may lead to risk becoming a reality depends on factors like situations, information, and other hazards. Violence on the other hand is a physical manifestation of the possible risks or may even take the form an entirely new set of behaviors. The National Offender Management Service of the UK has classified risk of violence from individuals into four categories under the heading ‘offender profile’. Level one is low risk requiring minimum intervention and requires very low level of monitoring. The danger of violent acts increases as the category goes up to level four. Inmates who are classified at level four pose a high risk to society, and required the highest level of skill in intervention and monitoring which includes resource allocation in terms of money and manpower. They also tend to be repeat offenders and requires inter agency (security) cooperation for effective monitoring (National Standards for the Management of offenders, 2007, p. 6). Treatment Once a potential risk of behavior and chances of violence is assessed, the next obvious step is prescribing a treatment for the patient inmate. During the 1970s some authorities in the field had an inclination to use a pathological approach where suppression rather than a cure (solution) was intended. The idea might have been that the end result is to stop violent behavior and to reduce risk of injury to others, and hence suppression was enough for this purpose. But later studies have shown that this only has a prosthetic effect on the mind of the patient: “Although many studies report effective suppression of targeted challenging behavior (e.g. by extinction), interventions based on a pathological approach can be described as ‘prosthetic’, and there are well-established problems with generalization across settings, long-term maintenance and symptom substitution” (Xeniditis, Russell & Murphy 2001). Other approaches that aimed going deeper into the root of the problem such as cognitive and behavioral therapy became more favored. Behavioral modification: One of the ways in which favorable behavior can be obtained is the use of behavioral modification therapy. It simply refers to a situation whereby a patient provided with a reinforcement of positive behavior and denial of the same for undesired behavior. The origins of such a therapy probably started during the 1970s. The book “Violence of incarceration’ quotes Dr James McConnell as follows; “I believe the day has come when we can combine sensory deprivation with drugs, hypnosis, and astute manipulation of reward and punishment to gain almost absolute control over an individual’s behavior” (Scraton, Scraton, & McCulloch, 2008, P. 41).But is appears that behavior can be controlled through modification and manipulation. Negative behavior is followed by depravation of something that is favored by the patient. In that sense, he or she is coerced into behaving in an intended way. The above mentioned book states that studies have shown to create other stresses in patients in the use of behavior manipulation. On the other hand, providing reinforcements of rewards is a more positive approach since it appreciates good behavior and not just punishes bad behavior. In prisons, denying a positive reinforcement is commonly used, for example, assigning an inmate to solitary confinement for a few days. Positive reinforcement can be in the form of allowing special privileges like more freedom and even parole in case of extended good behavior. Psychodynamic intervention: This approach is a more complicated and deeper approach when compared to the earlier mode of intervention as the following definition illustrates: “Psychodynamic intervention involves careful attention to the therapist-client relationship with thoughtfully timed interpretations of transference and resistance. It draws from three major theoretical perspectives: ego psychology, object relations, and self psychology” (Corcoran & Walsh, 2006, P. 460). This approach needs close interaction between patient and therapist which is quite difficult in a prison setting. One reason is the concept of countertransference which is an essential part of psychodynamic therapy (Doctor, 2004). This essentially means that the therapist also becomes a patient in the process: “The two complex human beings are interacting in the course of psychotherapy are mutually influencing one another all the time and are evoking a variety of feeling towards one another” (Gabbard, 2004, p. 132). With too few therapists taking care of a relatively larger number of patients, this process may not be practical in prisons. Moreover, such therapists are bound to be government employees or those who have the time and inclination to indulge in social work. So, psychodynamic therapy may be effective, but not very practical in controlling violent behavior in a prison setting. Cognitive behavioral therapy (CBT): Cognitive behavioral therapy is often considered to be the best approach in treating post traumatic stress disorder (PTSD). The National Centre for PTSD managed by the United States Department of Veteran Affairs states that cognitive behavioral therapy treatments include the following approaches which includes cognitive therapy mentioned above. Exposure therapy is an approach where patients are allowed to recall their traumatic experience in detail more than once so that so that the arousal and distress resulting from such unpleasant memories can be reduced in a gradual way. Another approach is “Cognitive therapy, which focuses on helping patients identify their trauma-related negative beliefs (e.g., guilt or distrust of others) and change them to reduce distress” (National Center for PSTD Fact Sheet). The third approach is stress-inoculation training whereby patients are taught relaxation techniques which includes breathing exercises, relaxation of muscles and self talk. Rehabilitation Rehabilitation with regard to criminals is defined as “the result of any planned intervention that reduces an offender’s further criminal activity, whether that reduction is mediated by personality, behavior, abilities, attitudes, values, or other factors” (Martin, Sechrest & Redner, 1981, p. 8). Hence a successful rehabilitation should result in the criminal not acting in a manner that is harmful to others in any manner. But successful rehabilitation involves more than just psychological intervention. Studies show that people who leave prison need to obtain some form of employment, accommodation, and also a certain level of acceptance by the society and family members. Unless this is available, chances of resorting to previous behavior and getting convicted (recidivism) is high. A high percentage of those who go to prison have low qualification and chances of getting even basic employment is low. All these factors are seen as problematic in effective rehabilitation. Recidivism One way of monitoring the efficacy of treatment with regard to controlling of violent behaviour is the rate or recidivism. Figures in the UK show a high rate according to a report by the Committee on Public Accounts. “Recent figures suggest that 58 per cent of prisoners are reconvicted within two years of being released…..”. (House of Commons-Public Accounts- Fifty Third Report 2002). The report adds that most re-offenders are those who serve small sentences rather than those who serve longer or life sentences. Convictions for violence need not necessarily get long sentences unless it is habitual. Hence the same percentage as mentioned above can be attributed to violent re-offences also. Moreover, therapy and other programs intended to help inmates are intended for long term serving prisoners. This indicates that short term convicts do not get the benefit of such programs. Nothing works debate As mentioned earlier, the concept of prison psychology became a topic of relevance during the 1970s. Pathological rather than psychological interventions were in vogue at that time. Even some level of the latter did not reflect in any major change in prison and after prison behavior during those periods. This could have been the cause of the discouragement felt by many experts on the field which led to the oft quoted “nothing works” philosophy with regard to prison reforms. The debate was presumably started with an article by Robert Martinson in 1974. But advances in psychology that gave precedence to behavioral and cognitive approaches rather than pathological ones have since brought about a change to ‘nothing works’. Since then “there has been a proliferation of cognitive programs designed to address offending behavior based upon more careful matching of programs to offender needs, careful implementation of programs, and monitoring of their delivery, and backed up by aftercare and relapse prevention schemes” (Shoham, Beck & Kett, 2007, p. 66). The next section shows that the concept of ‘nothing works’ has changed to ‘some things work’ even though the expected results are far from satisfactory. Efficacy of treatment on controlling behavior and reducing recidivism A study by Friendship et al of 670 offenders who had undergone CBT as against 1801 who had not been subject to any treatment showed that the former had lower levels of recidivism. Freeman referring to another study by Craissati et al also agrees on the efficacy of this approach in reducing recidivism. The researcher had made a comparative study of four therapies namely CBT, dialectical behavior therapy, forensic psychoanalytic therapy, association with therapeutic communities and they “conclude that the evidence base is strongest for the first of these categories which covers programs used in prisons and the community” (Freeman & Power, 2007). In effect CBT has proved to be effective in treatment of patients in the community as well as in special settings like prisons. Friendship et al studies show that recidivism was reduced by nearly 14% after successful therapy. Other studies also prove that the success rate ranges from 10 to 14 percent making CBT the most effective in managing violent behavior as well as in bringing down the rate of recidivism. The ‘nothing works debate’ appears to have been a premature assessment of management of violent behavior especially with regard to prison reforms. There has definitely been a change especially after implementation of more humane methods like positive behavioral modification, psychodynamic intervention, and CBT. An overall view of effective management of violent behavior It is not easy to effectively control behavior with just intervention through psychological approaches. It requires input and cooperation from many areas. A sound conceptual model for intervention has to be implemented. Previous research tends to favor a cognitive behavioral approach. But this apart, acceptance by the society and family, an opportunity to make a living through gainful employment, a place to stay where there is no harassment, and training in social skills that is required to live in a society is also essential. Conclusion Management of violence even in societal settings is complex and requires a lot or resources. At least, the cost of treatment can in many cases be covered by individual families or thorough some form of insurance. But once a person has been indicted and jailed for violence, new parameters are involved other than plain treatment or intervention. Once convicted, the person tends to become labeled as a criminal. There has been progress with regard to the efficacy of psychological approaches and is found to be much better for the patient when compared with pathological treatment. Lack of qualified personnel and increase in the number of convictions are problems that have to be looked into for effective treatment and management of violent behavior with regard to direct intervention. other factors (as mentioned above) like occupation, and acceptance are also crucial factors that contribute to the success of management of violent behavior. In short it needs an all round input from therapist to family to society for effective management of such behaviors. References Corcoran, J and Walsh, J. (2006). Clinical assessment and diagnosis in social work practice. Oxford University Press: US. Doctor, Ronald. (2004). Psychodynamic lessons in risk assessment and management. Advances in Psychiatric Treatment, 10: 267-276. Retrieved May 6, 2009, from The Royal College of Psychiatrists: http://apt.rcpsych.org/cgi/content/full/10/4/267#BION-1957 Fagan, T.J and Ax, Robert Kirk. (2002). Correctional mental health handbook. SAGE: London. Flannery, D.J. (2005). Violence and mental health in everyday life: prevention and intervention strategies for children and adolescents. Illustrated Edition: Rowman Altamira. Freeman, C and Power, M.J. (2007). Handbook of evidence-based psychotherapies: a guide for research and practice. Illustrated Edition: John Wiley and Sons. Gabbard, G.O. (2004). Long-term psychodynamic psychotherapy: a basic text. Illustrated Edition: American Psychiatric Pub. Grieve, Lorraine. The assessment and management of offenders, Power Point Presentation, Slide 4. (provided by the customer) Hart, S.D. Dynamic Risk Factors Underlying Violence. Responses to Treatment and Managing Violence. Power Point Presentation, slide 4. Retrieved May 6, 2009, from: http://www.kids.nsw.gov.au/uploads/documents/DrHart.ppt House of Commons-Public Accounts- Fifty Third Report. (2002). Reducing Prisoner Re –offending. Retrieved May 6, 2009, from the Parliamentary Official Website: http://www.publications.parliament.uk/pa/cm200102/cmselect/cmpubacc/619/61903.htm Martin, SE, Sechrest, L and Redner, R. (1981). New directions in the rehabilitation of criminal offenders. Assembly of Behavioral and Social Sciences (U.S.). Panel on Research on Rehabilitative Techniques: National Academy Press. National Center for PSTD Fact Sheet: Empirical Evidence Regarding Behavioral Treatments for PTSD. Retrieved May 6, 2009, from the National Center for PSTD website: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_empiricalinfo_treatment_dis.html?printable-template=factsheet National Standards for the Management of offenders. (2007). Standards and Implementation Guidance 2007. Ministry of Justice. Retrieved May 6, 2009, from NOMS website: http://noms.justice.gov.uk/news-publications-events/publications/guidance/OM_National_Standards_0907?view=Binary Scraton, P, Scraton, P and McCulloch, J. (2008). The Violence of Incarceration. Taylor & Francis. Shoham, S.G, Beck, O and Kett, M. (2007). International Handbook of Penology and Criminal Justice. Illustrated Edition: CRC Press. Xeniditis, K, Russell, A and Murphy, D. (2001). Management of people with challenging behaviour. Advances in Psychiatric Treatment, 7: 109-116. Retrieved May 6, 2009, from The Royal College of Psychiatrists: http://apt.rcpsych.org/cgi/content/full/7/2/109 Read More