Psychosocial interventions in forensic mental health

The purpose of this essay is to examine the evidence based approaches of psychosocial interventions in the forensic mental health setting and the effects they have on patients, how we can implement psycho-education as an intervention for the families of the patient of schizophrenia. The sex offender treatment programme SOTP and the implementation of Anger management treatments for offenders whom suffer from problematic anger, in this essay also outlined will be the aims of the stated interventions and the outcomes.

What are psychosocial interventions?

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Psychosocial interventions are defined as a series of interventions based on psychological principles; however they also address the individual’s social environment. Integrated are evidence based interventions such as psychological supervision of symptoms assessment and management of medications.

Psychosocial interventions are aimed at reducing overall stress, recuperating an individual’s ability to cope with day to day issues and endorse excellent recovery in order to continue a normal and fulfilling life.

The stress vulnerability model as defined by Zubin and Spring (1977) Projected that every human is prone to have a distinctive biological, physiological and social element, which includes the individuals’ strengths and vulnerabilities in dealing with stress.

The stress vulnerability model is a very valuable model in allowing early intervention with regards to patients subjected to the symptoms of psychosis. E.g. the mental health nurse may try to understand the triggers which induce the onset of psychosis for the patient.

Cognitive behaviour therapy (CBT) was utilized by Aaron Beck in the 1960s and has been used in the treatment of schizophrenia, depression and also applied to sex offenders.

Meta-analyses have also revealed that CBT is effective in treating patients whom experience schizophrenia and The American psychiatric association contains CBT as evidence based treatment for its effects on sufferers of bipolar disorder and/or severe depression.

Psychosocial Interventions for Anger

Anger is very widespread in the forensic setting and must be tackled delicately as the damaging behaviour due to anger can lead to significant offences within the community or even once in the forensic mental health facility. Anger does not only have negative psychological aspects (Kassinove, Tafrate and Dunedin 2002) but also negative physical aspects (Hambarger and Lohr 1990). A study by Williams et al (2000) suggests that anger also places middle aged adults at higher risk of developing coronary heart disease and eventual death.

Psychosocial interventions such as programmes for anger management and stress relief do profit such patients from enduring long-standing psychological problems and physical ailments, thus permitting them to integrate into the community and lead socially fulfilling lives.

Throughout my research Anger management training or Anger control training (Deffenbacher, Dahlen, Morris, Lynch and Gowensmith 2000; Feindler, Iwata, Marriot and 1984) has been recommended to be the most proficient psychosocial intervention for the treatment of anger problems (Kassinove and Tafrate 2002). However, although such psychological interventions are widely used in the treatment of anger, there is an insufficiency of theoretical evidence which funnels the diverse perspectives concerning standard anger response in addition to pathological anger (Tafrate et al 2002).

In 1999 Beck proposed a cognitive theory due to surroundings which associated the matter of anger for instance, hostility and violence. The theory regarding the cognition of anger consisted of a congregation of concentrated values, automatic analysis and judgments therefore could then encompass the trigger of anger enthused encounters.

However, DiGiuseppe in the same year contended that cognitive interventions such as cognitive restructuring could transpire expected impacts of the cognitive process more positively than physiological and behavioural progressions.

Moreover the nonattendance of satisfactorily compiled theories and analytical evaluation of evidence which verifies the effectiveness of psychosocial treatments of anger is indeed much more time consuming, also providing the explanation of an emergent recognition of such interventions in the forensic mental health profession. However, up to date consultations have been addressing aspects, for instance alliances of therapeutic consideration which could make possible a resolution intended for anger treatments (Day and Howels 2003). And thus supplementary concentration and time should be sited on the efficiency of treatments for the sufferers of anger.

Another psychosocial intervention which emerged during research was that of R. Novaco who developed an outline of Anger management training (AMT) in 1975 by amending Meichenbaum’s (SIT) stress inoculation training which was originally developed for anxiety disorders (Burish, Rimm, Hollon and Masters 1987; Novaco 1977).

During SIT the subject would be exposed to considerable quantities of stress engaging dilemmas whilst managing skills such as self talk are taught. The Theory of SIT is that tension takes place once the demands of a structure go beyond reservations or if adapt responsiveness’ are not able to unite such demands (Deffenbacher and Meichenbaum 1988). The intervention of AMT is based on the primary assumption that anger response is in a similar approach once in occurrence. In probability of SIT Novaco’s AMT course of action consisted of such treatments which were sequential in nature. The phases of treatment are as follows: Phase 1, Education: provides the subjects with concepts of their dysfunctional anger. Phase 2, Acquisition: This is when the individuals are schooled about coping skills such as self talk. Phase 3, Application: clients will then be rendered towards anger provoking scenarios and are then persuaded to apply the skills they have acquired in phase 2 which is the acquisition phase.

Skills such as the application phrase are exceptionally beneficial to patients in the forensic setting for day to day living, so when stress inducing situations do emerge they will be better equipped to control their anger or anxiety in a different manner to which they are used to.

Since AMT was developed there have been many other psychosocial interventions which have also been applied to problematic anger. Treatments such as, cognitive restructuring training, muscle relaxation techniques, biofeedback, meditation, social skills, systematic desensitization, self instructional training, exposure therapy, problem solving skills, assertiveness skills, flooding, education also stress inoculation therapy (Tafrate and DiGuiseppe 2003). Such psychosocial interventions have been deemed foundational and time limited therapies which may also be applied as detailed psychosocial interventions or in an extended clinical treatment background (Tafrate and Kassinove 2002). In spite of expressive identity of the technique and purposes, it remains unspecified how psychosocial remedies for anger connect to an overextended speculation which could clarify remedy procedures.

Psychosocial Interventions for sex offenders

Sexual offence can be seen as one of the most distressing crimes especially if the initial offence is against children. There are many doubts whether a sexual offender can be rehabilitated as the offences are more imprinted than that of a one off time murder/offence. The public at large are more inclined to feel a bitter hatred towards someone whom has committed a sexual offence against a child; even once the offender has been rehabilitated it does not mean the public will accept that they have been so. The public may then resort to abusing the offender. When such instances occur, are the interventions which have been provided beneficial to the ex offender? Or because they are being abused will they re-offend?

Which types of interventions are currently available for sex offenders? In 1991 SOTP (Sex offender treatment programme) was introduced into prisons (Hudson 2005) and was part of a new tactic for the assessments and treatments of the sex offenders. SOTP is based on the psychological conduct of cognitive behavioural therapy (CBT) (Beech 2003). The initial behaviour treatments are aimed at schooling the offenders to control sexual fantasies, arousals and to develop additionally appropriate fantasies as a substitute. CBT helps seize misshapen thinking prototypes which are most commonly found in sex offenders (Fisher, Beech and Beckett 1998). This approach is most successful in the rehabilitation of sex offenders from a considerable range of intervening methods.

The seven components of SOTP are: Enhanced thinking skills programme – Core programme – Adapted programme – Extended programme – Rolling programme -healthy sexual functioning programme and Better lives booster programme. The main intention here is to recuperate the sex offenders and reduce reoffending (Falsahw 2003) and is attempted so by changing the individuals internal cognitive and emotional functioning as well as their behaviours (Hudson 2005) which enables more self control. There are previous suppositions such as Finkelhors precondition model (1984), Marshall and Barbarees integrated theory (1990) suggested factors such as poor social skills and lack of empathy, and these are factors which can lead to sexual offending (Ward 2003) the programme involves creative thinking, social perspectives, social skills, problem solving skills and critical thinking skills in order to help the offenders control their sexual needs (Lovbakke and Debidin 2005). SOTP is currently commencing in England and Wales which includes participants of around 1,000 men who are completing treatment every year (Beech 2005).

A highly contemplated topic is the effectiveness of sex offender treatments programmes (Brown 2005). As the public are extremely fearful of this type of crime even though in proportion to other crimes committed it is a small percentage. The argument is that the public fear sexual offenders as there are moral concerns involved, along with the Media’s portrayal of such offences which also installs fear into the public (Thomas 2000).

The importance is the assessments of sex offenders and whether they can be treated to refrain from the reoffending of such crimes, therefore monitoring whether an offender has in fact been rehabilitated by such programmes. Investigation of the effectiveness of the programme include research such as step projects 3 (1998) and 4 (2005) which were commissioned by the Home Office in evaluation of the effectiveness of SOTP in prisons (Beech 2003). The projects had taken views of the offenders and feedback from the facilitators of the programme in order to observe their effectiveness. Hudson (2005) also looks at the sex offenders perspectives of the treatment and managements they are undergoing. However, there has also been use of experimental control groups in order to examine the programmes effects which include Friendship’s (2003) estimation of SOTP usage in the prison services and Falshaw’s (2003) study on searching for what works.

Such studies do endeavour to examine reconviction rates of offenders after treatment in association with offenders whom have not yet been treated. However so research studies do not always give a true picture of the programmes effectiveness as many sex offences could be undetected (Walker 2006) initially a sex offender is capable of a re-offence without being caught. In which the case of re-offending rates may be higher than that of the reconviction rates, which is why it is important to scrutinize other manifestations of effectiveness such as offender reports (Hudson 2005).

As SOTP is based on CBT the cognitive aspects involve recognition of distorted patterns in thinking processes which allow contemplation of deviant sexual acts and understanding the negative psychological impacts on the victim. The behavioural aspects involve the diminution of sexual arousal of unacceptable sexual fantasy or sexual activities (Cobley 2005).

The main aspiration of SOTP is the reduction of reconvictions of sexual offending (HM prison services 2007) by assisting the offenders and filtering ways for them to lead satisfactory lives without the need to re-offend (HM prison services 2008) in addition to helping them the public will also be protected from future re offences (Hudson 2005).

Psychosocial interventions such as SOTP are extremely valuable resources for assisting sex offenders in recovery. Along with time and perseverance it is fast becoming a very successful initiative in protecting the public and also enabling the ex sex offender to re join the community.

Psychosocial interventions for schizophrenia

The illness of schizophrenia will at one point affect one in a hundred individuals and the onset is usually during the late adolescent years. However, it may also affect individuals during their 20s and 30s. Schizophrenics endure positive symptoms such as thought disorders, hallucinations and delusions and also negative ones such as social withdrawal, self neglecting tendencies and major lack of motivation which could contribute to the deteriorations of social and personal relationships. During episodes of either positive or negative a schizophrenic individual is more vulnerable to committing a crime. Schizophrenia is also a highly stigmatized illness and the lack of understanding which the public omit leads onto social inclusion for the individual. Unfortunately we live in a world which is very critical; however in a schizophrenic’s world critics and rejections may lead to unfortunate events in which the schizophrenic has no control over.

Which types of psychosocial interventions are assisting schizophrenics to live within the community? Psycho educational programmes for the individual address their illness and helps them to understand it from the familial, biological, medication and social perspectives as outlined by Quality in Health Care 2000-2009. Aspects of the program are that of providing support, information and management strategies. Psycho educational techniques also enhance medication concordance and the patient’s attitude towards treatments (Thornicroft 2001). There is also an underlying need of overcoming barriers of incorporating families during psycho education routines (Amenson and Liberman 2001).

The family intervention for schizophrenia has emerged as a great assistance as a long term intervention (Tarrier 1994). As the model consists of psycho education for the individual and the family it creates a better overall understanding of the illness. Included in the family intervention are strategies which help to reduce stress in the individual and the family, increases independence and encourages problem solving (Leff and Lam 1992; Barrowclough and Tarrier 1992). In educating the families about Expressed emotion or EE is a vital component of this intervention. Relatives who show high levels of criticism, emotional involvement and hostility are examples of high EE environments and studies show that individuals living within a high EE environment have a higher chance of relapse (Kavanagh 1992). Tarrier et al (1988) suggests family interventions for schizophrenic individuals could reduce relapses, increase social functionality and reduce the burden of their families. More recent studies also put forth the benefits of family intervention. In which patients’ receiving such an intervention resulted in lower admission rates to in-patient wards (De Jesus Mari and Streiner 1994).

Other interventions for schizophrenia are social skills training which assists in focusing on the individuals’ interpersonal skills and life goals without the process hindering stress. This is aimed at enhancing levels of social performances without the elevated distress in which schizophrenic patients encounter. Social skills training goals are to assist in building behavioural elements into more complex behaviours allowing the development of more socially approved communication. However a study by Psychological Medicine, 2002 (S Pilling, P Bebbington, E Kuipers P Garety J Geddes, B Martindale G Orbach and C Morgan) suggest that Social skills training does not have clear enough evidence of any benefits with regards to social functioning or quality of life.


I hope the evidence provided has to a significant degree informed the reader of the vastness of psychosocial interventions and how they have an immense effect on the forensic patient, the positive outcomes, also helping them define their life goals in order to integrate once more into the community setting. Psychosocial interventions do not only benefit the individual in the forensic setting but also benefit their families and the public from crimes which may have been committed if the treatment of certain psychosocial interventions were not issued. However some interventions such as the social skills training have yet to be characterized in their full potential for the schizophrenic patients.

When we examine such evidences intended for the sex offenders and the intervention of SOTP we can conclude the major positive impact such an intervention has on those individuals, allowing them to fulfil and generate widespread approved ideas and goals for the future and allowing them their place once more in the community. Nonetheless, The Sex Offender Treatment programme still has matters in which it should be improved and are in need of prompt resolving (Evenden Lewis 2008). Also suggested is that word must be carried out to the public via the national media, in order to inform the public that sex offenders are not homogenous individuals and can be part of everyday society (Evenden Lewis 2008). Evenden also considers that up to date psychometric tests are not allowing direct divergence between treatments and the outcomes of treatments (Internet journal of criminology 2008).

The AMT (Anger management training) psychosocial intervention such as SIT is also a vast improvement so it seems, in endeavours towards assisting individuals whom suffer from the negative impact of anger issues thus also allowing them to gain appropriate interpersonal relationships without out lashes or bouts of anger which would hinder social functioning and relationships.

Interventions whether recent or older all include areas in which they could be improved. Nonetheless the evidence and research gathered suggests a majority of positive patient recovery within the forensic mental health field. Particularly that of the family interventions for schizophrenia and in allowing access of psycho-social education to the families generates more stable interpersonal relationships for the sufferer by reducing high EE (Expressed Emotion) within the family environment. And as suggested by De Jesus Mari and Streiner 1994 a lower admission rate to hospitals.

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