Treatment Options for Mentally Disturbed Offenders - Research Paper Example

Treatment Options For Mentally Disturbed Offenders Modernization comes with much stress and realizations of various disorders which were not officially identified in the past. The prevalence of psychological disturbances due to several causes is now being observed, pushing some of the afflicted to criminal behavior. Whereas in the past, offenders who are proven to be mentally ill are ordered to be confined to a mental health institution, nowadays, jails are now being repository for the mentally ill. This is for the simple reason that the keeping offenders in jail instead of in a mental health institution, is less expensive. Forensic hospitalization averages $500 per day while a jail’s housing cost is only $50.00. Buelle (2003) comments that “shifts in public policy regarding public safety, de-institutionalization of mental health populations and complexities in accessing funding for mental health treatment all have contributed to this problem” (p. 141). Sabbatine (2007) add that jail is the only institution that accepts everyone legally presented for custody unlike some mental health institutions which have admission criteria. That is why there is a growing population of mentally disturbed offenders in correctional facilities. However, since these inmates are psychologically ill, they have the right to be treated while incarcerated. The American Psychiatric Association, the National Commission on Correctional Health Care and the American Correctional Association all agree that these inmates need to go through screening and diagnosis so the necessary treatment can be done. Diagnosis is determined from the Diagnostic and Statistical Manual, fourth Edition (DSM-IV). This system has a five axis/ level structure. The most significant disorders are on the first axis and are termed Axis I disorders, which include schizophrenia, bipolar disorders and major depression, among others. Mentally ill offenders are at times identified by these Axis I disorders. (Norton, 2005). Treatment would include a variety of care options incorporating crisis intervention, ongoing psychiatric treatment – accompanied by psychotropic medication, if prescribed, and well-trained mental health staff who undergo an ongoing training program in the treatment and care of the mentally ill (Maloney, Ward & Jackson, 2003). There are many available options for treatment of mentally disturbed offenders ranging from simple psychotherapy to psychotropic medication to community-based therapy. These shall be described in detail as follows: A number of counseling and psychotherapeutic approaches have evolved through the years. Some of the predominant ones were based on the theories of distinguished psychologists Freud, Rogers, Beck, etc. Others followed suit and injected their own theories. The Psychoanalytic or Psychodynamic theory is premised on the belief that human nature is greatly affected by a person’s early childhood experiences and conflicts between impulses and prohibitions (Myers, 1995). Its founder, Sigmund Freud’s idea of the three systems of personality, the id, ego and superego being in constant battle within a person is likened to a person’s continual debate of what is right and wrong, and then behaves according to his moral decisions. Such decisions are affected by what society dictates as well as what the person truly desires for himself. Freud views human behavior as determined by irrational forces, unconscious motivations and biological and instinctual drives evolving in the first six years of life (Corey, 2005). He has associated each life stage to a body fixation and namely the Oral, Anal, Phallic, Latency and Genital stages. He theorized that if a traumatic experience has happened in a particular psychosexual stage, an individual gets fixated on that stage, thereby retaining the characteristic of behavior associated with that stage. It is theorized that mentally disturbed offenders may have experienced a traumatic experience during his life that has left him unable to cope with the damage in his psyche. The goals of Psychodynamic therapy are settling unresolved conflicts in a person’s past that deeply affect his current patterns of behavior and personality. It may involve bringing repressed painful memories to resurface to be dealt with consciously through the techniques of free association, dream analysis, hypnosis, transference, and analysis of resistance handled by a skilled psychoanalyst (Corey, 2005). This tedious process intends for the client to reach a level of self-understanding for him to be able to move on with his life without the heavy emotional baggage he has been carrying all his life. This understanding is necessary for an eventual change in views, personality and character. Person-centered therapy stems from the theories of Carl Rogers, a noted psychologist who espoused humanistic views in therapy. This approach has great respect for a client’s subjective views and potential for self-actualization. It offers a fresh and hopeful perspective on its views on human nature. Being congruent means being real and authentic – no discrepancy between one’s perceptions and one’s being. A therapist needs to be congruent himself before he can decipher incongruence in his clients. His wisdom enables him to spot clients whose ideal self-concept is far from the truth, (i.e. the mistaken perception of one’s greatness in a skill when in reality, he is very poor at it). His goals include helping his clients have an openness to experience, a trust in themselves, an internal source of evaluation and a willingness to continue growing (Corey, 2005). Solution-Focused Brief Therapy (SFBT) is one practical therapeutic psychological strategy which will likely work with inmates in a correctional facility. Since it is brief, it can cover several inmates for each day to spend time on a session. SFBT does not emphasize the need to understand the original cause of the problem in order to solve it. More time is spent in focusing on the present and future circumstances rather than the past, and on the client’s strengths and resources rather than the problem. It is what makes it stand out from other therapeutic approaches. Such discussions provide the advantage of helping the therapist form better rapport with the offender which otherwise may be difficult to establish considering the problematic situation. (Smith, 2005). Giving the client control as to the brevity of the treatment is likewise effective, as most clients aim to get better sooner than later so they are motivated to be cooperative with the therapists’ strategies. For youth offenders, Froeschle, Smith & Ricard (2007) used SFBT techniques in developing a program for female adolescents who are substance abusers. The program, named SAM, short for solution, action, mentorship, is “designed to reduce substance abuse, increase negative attitudes toward drug use, and reduce negative behaviors while increasing positive behaviors, knowledge of the physical symptoms of drug use, student achievement, and self-esteem. Group sessions were based on solution-focused brief therapy and action learning theory and were supplemented by mentorship from community members and peers.” (Froeschle, Smith & Ricard, 2007, p. 498). The SFBT strategies incorporated in this program greatly help the girls in the realization that dropping the drug habit will be very beneficial to them, and this eventually becomes a goal they intend to meet. Problematic youths are taught to shift their focus from despair and deficiency to hope and potential. This is achieved in a nonjudgmental environment that allows for open dialogue using solution-oriented language emphasizing exceptions and potential solutions. (Newsome, 2005). The miracle question allows at-risk youth to imagine a life without the problem and create goals toward such ideal. The therapist’s kind attitude towards the young client and his direct and indirect compliments help the youth focus on his inherent strengths and resources that would assist him in the fulfillment of his goals. Psychologically ill inmates are prone to depression, especially when incarcerated, as they spend more time thinking about their pathetic existence. Inmates suffering from psychological problems are assumed to focus more on their flaws that pull them down than on their potentials that may spur them up to success. Aaron Beck agrees that much of our psychological problems are caused by “cognitive distortions” due to our acknowledged human fallibility. “In depressed people, these belief systems, or assumptions, develop from negative early experiences such as the loss of a parent, rejection from peers, an unrelenting succession of tragedies, criticism from teachers, parents or peers, or even the depressed behaviour of a parent. These negative experiences lead to the development of dysfunctional beliefs about the world, which are triggered by critical incidents in the future.” (Field, 2000). Beck (1987) came up with the concept of “negative cognitive triad” that describes the pattern that triggers depression. In the first component of the triad, the client exhibits a negative view of himself. He is convinced that he is to blame for whatever pathetic state he is currently in because of his personal inadequacies. Secondly, the client shows negative view of the world, hence, a tendency to interpret experiences in a negative manner. He nurtures a subjective feeling of not being able to cope with the demands of the environment. Third and lastly, the client projects a gloomy vision of the future. He can only anticipate failure in the future. Beck (1975) developed a model to treat depression called Cognitive Behavior Therapy. He writes that, in the broadest sense, “cognitive therapy consists of all of the approaches that alleviate psychological distress through the medium of correcting faulty conceptions and self-signals” (p. 214). The goal of therapy is to help the psychologically disturbed offenders realize that reorganizing the way they view situations will call for a corresponding reorganization in behavior. In therapy, clients are taught “thought catching” or the process of recognizing, observing and monitoring their own thoughts and assumptions and catch themselves especially their negative automatic thoughts when they dwell on it. Once they are aware of how their negativity affects them, they are trained to check if these automatic thoughts are valid by examining and weighing the evidence for and against them. Ellis’ Rational Emotive Behavior Therapy (REBT) is considered to be the forerunner of Cognitive Behaviour therapies. Its basic hypothesis is that emotions stem mainly from the beliefs, evaluations, interpretations and reactions to life situations of people. Ellis believes that individuals have an inborn tendency towards growth and actualization but we often sabotage our movement toward growth due to self-defeating patterns we have learned (Corey, 2005). Through therapeutic processes, the client learns skills to isolate and dispute their irrational views which were mostly self-constructed and maintained by self-indoctrination. REBT helps clients replace such irrational views with rational and constructive ones, thus resulting in more productive change in behavior and reactions to situations. The same thing happens in the Egan model, however, the skilled helper has a lot to do with the client’s broadening of perspectives, due to his strategic communication skills that may lead clients to be more enlightened. An alternative to REBT is Donald Meichenbaum’s Cognitive Behavior Modification. It features an inmate’s self-verbalizations that involve a heightened sensitivity to his thoughts, feelings, actions, physiological reactions and ways of reacting to others. Inmates are also taught more effective coping skills practiced in real-life situations. An inmate may be considered his own coach because his self-talk reminds him of how he should restructure his thinking and behavior. Meichenbaum also puts emphasis on stress management which can be very helpful to inmates when faced with stressful situations not unlike those that caused their flawed thinking (Corey, 2005). Reality therapy is the kind of therapy that makes tough inmates accountable for whatever state of life he is presently in. It is a product of the choices he has made, and so, makes him in control of his own thinking, feeling and behavior (Corey, 2005). It is premised on Choice theory that advocates that we are born with five genetically encoded needs – survival, love and belonging, power or achievement, freedom or independence, and fun. If one need is not satisfied, it becomes a source of instability, and reality therapists teach clients to identify and satisfy that need (Corey, 2005). Reality therapy’s goal is to help clients make the right choices through intensive reflection and introspection guided by realistic questions. Such questions are like bitter pills to swallow, as they force the inmates to confront reality and deal with it. Reality therapists are direct, frank and open about their opinions without being intimidating to their clients. The art of balancing confrontation and unconditional acceptance is to be mastered to ensure success. A common case of mental disturbance of offenders is the Antisocial Personality Disorder (APD). According to the DSM 3rd and 4th editions (American Psychiatric Association, 1987, 2000, respectively), individuals with APD demonstrate continuous irresponsible and impulsive behavior: “The essential feature . . . is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood . . .” and “. . . [people with APD] fail to conform to social norms with respect to lawful behavior. They may repeatedly perform acts that are grounds for arrest, such as destroying property, harassing others, stealing, or pursuing illegal occupations” (American Psychiatric Association, 2000, pp. 701-702). These inappropriate behaviors attributed to APD renders it difficult to have a one on one session with a therapist for the safety of the therapist himself. McKendrick, Sullivan, Banks & Sacks (2006) agree that the disorder gives rise to behavior that is reckless, self-serving, manipulative, and/or dishonest, accompanied by a lack of self-reflection or remorse, and a propensity to break social norms, which includes expressing criminal behavior (Kaylor, 1999). Such absence of introspection and an apparent lack of anxiety about self decreases the affected individual’s motivation for change, and this limits the therapist’s ability to encourage the offender to stay throughout the therapy sessions, thereby diminishing the desired behavioral change (Reid & Gacono, 2000). A more likely option that may work with offenders with APD is community-based treatment. The Modified Therapeutic Community or MTC program is designed to meet the needs of co-occuring disorders of the population within a correctional setting, especially those with mental illness and chemical abuse (MICA). It changes attitudes, behavior and lifestyles in the three critical areas of substance abuse, mental illness, and criminal thinking/behavior. MTC reduces the intensity of interpersonal interactions, individualizes treatment planning and increases the flexibility of treatment programming. Psycho-educational classes, cognitive-behavioral protocols, medication and a variety of other therapeutic interventions specifically tailored to the client with MICA disorders (e.g., conflict resolution groups, dual recovery groups) were included (McKendrick, Sullivan, Banks & Sacks, 2006). Standard mental health (MH) services provided intensified psychiatric services which included medication, weekly individual therapy and counseling, and specialized groups. Therapy addressed anger management therapy and education, domestic violence, parenting, and weekly drug/alcohol therapy. De Leon (2000) comments that the MTC and MH programs are similarly focused both on mental and substance abuse disorders, in their use of medication and in their application of cognitive-behavioral elements targeting criminal thinking. However, MTC utilizes the community as the healing agent and it relies on mutual peer self-help. Stahl & West (2001) recommend a continuum of care for mentally unstable inmates. It includes various treatment options depending on the severity of inmates’ psychological cases. Inmates with chronic or acute needs will be treated by a high-observation medical services unit. Such program will also cater to offenders with mental illness related to chronic medical conditions like Alzheimer’s disease. Those posing lesser security risks will be allowed to reside in a therapeutic community setting where they function more independently. Custody of mentally ill offenders may range from maximum-custody to minimum-custody, with an administrative segregation unit providing continued treatment and management of high-security inmates. This is expected to be the most challenging to manage since it will include inmates who are unstable, resistant to treatment, displaying severe character disorder and those who undergo punitive confinement (Stahl & West, 2001). What is commendable about this proposed continuum of care is that the supportive environmental setting will provide continuing services for inmates requiring further monitoring and psychiatric consultation so they become responsive to psychotropic medication. When these inmates are cleared of their illness, they may be returned to the general population after their treatment period. They will be eased into the mainstream with a transitional program which emphasizes individualized plans for each inmate in their life outside jail and access to community service agencies so they will not be left without the crutches of the continuum of care all at once. Of course all these treatment methods for the mentally ill offenders in correctional institutions will require a great deal of funding from the government as well as highly trained professionals who are expected to deliver the necessary treatments and therapies. It will be so worth the taxes charged of the citizens of the state to raise funds for such a noble cause… that of giving a fallen fellowman another shot at a better life. References American Psychiatric Association. (2000). Fourth Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, Committee on Nomenclature and Statistics. Beck, A. T. (1987). Cognitive models of depression. Journal of Cognitive Psychotherapy: An International Quarterly, 1, 5-57. Buelle, M. (2003) Facilitating Collaboration Between Correctional and Mental Health Systems, Corrections Today, October 2003 Corey, G. (2005) Theory and Practice of Counseling and Psychotherapy, 7th ed. Brooks/Cole, a division of Thomson Learning Inc. De Leon, G. (2000). The Therapeutic Community: Theory, Model & Method. New York, NY: Springer Publishers. Field, A. (2000) Cognitive Therapy, retrieved on October 20, 2010, from http://www.sussex.ac.uk/Users/andyf/depression.pdf Froeschle, J.G., Smith, R.L. & Ricard, R. (2007) “The Efficacy of a Systematic Substance Abuse Program for Adolescent Females.”, Professional School Counseling;, Vol. 10 Issue 5, p498-505, 8p (June, 2007) Kaylor, L. (1999). Antisocial Personality Disorder: Diagnostic, Ethical and Treatment Issues. Issues in Mental Health Nursing, 20, 247-258. Maloney, M.P., Ward, M.P. & Jackson, C.M. (2003) Study Reveals that More Mentally Ill Offenders are entering jail, Corrections Today, April 2003 McKendrick, K., Sullivan, C., Banks, S. & Sacks, S. (2006) Modified Therapeutic Community Treatment for Offenders with MICA Disorders: Antisocial Personality Disorder and Treatment Outcomes, Journal of Offender Rehabilitation, Vol. 44 (2/3). Pp. 133-159. Newsome, W.S. (2005) “The Impact of Solution-Focused Brief Therapy with At-Risk Junior High School Students”, Children & School, Vol. 27, No. 2 (April, 2005) Norton, S.C. (2005) Successfully Managing Mentally Ill Offenders: Thoughts and Recommendations, Corrections Today, February 2005 Reid, W.H. & Gacono, C. (2000). Treatment of Antisocial Personality, Psychopathy, and Other Characterologic Antisocial Syndromes. Behavioral Sciences & the Law, 18(5), 647-662. Sabbatine, R. (2007) An "Extended Care" Community Corrections Model for Seriously Mentally Ill Offenders, Mental Health Issues in the Criminal Justice System. Pp. 55-57. Available online at http://jor.haworthpress.com Smith, I.C.(2005) “Solution-focused brief therapy with people with learning disabilities: a case study” British Journal of Learning Disabilities, 33, 102–105 Stahl, E. & West, M. (2001) Growing Population of Mentally Ill Offenders Redefines Correctional Facility Design, Corrections Today, August 2001 Read More