An exploratory study on the issues and challenges clinicians encounter in the application of cognitive behavioural therapy with mentally disordered offender patients

Abstract

Abstract.Cognitive behavioural therapy (CBT) is widely acknowledged as a treatment of choice for a range of psychological disorders, including those that affect criminal offenders and mentally disordered offenders. Meta-analyses of multiple studies provide evidence of CBT's efficacy and have led to its recommendation as a first line treatment for anti-social personality disorder (ASPD; NICE, 2009). However, there is comparatively little evidence about the effectiveness of CBT in relation to complex problems faced by offenders in prison and secure psychiatric services. The aim of this study was to examine how clinicians conceptualize and respond to complexity in the practice of CBT treatment with high-risk mentally disordered offenders. Using a qualitative methodology, semi-structured interviews were conducted with six practitioners. The interviews were analysed using thematic analysis. The first main theme was 'critical challenges and issues' which included subthemes addressing patient characteristics, the therapeutic context, ethical challenges, and treatment challenges. The second main theme was 'overcoming obstacles' which included subthemes on promoting safety, an emphasis on non-specifics, how to create an enabling space and creative practice in the application of CBT. The study emphasizes the importance of creating an enabling safe space by being 'responsive' to the patients' needs and also emphasizes the importance of working to establish a baseline for 'safety' in all alliances wherever possible.

Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance

“…These findings are consistent with previous research that emphasized factors such as trust, sensitivity and using the patient's language (Ferrito & Moore, 2017; Sturm et al, 2021). Some of these factors are generic and important for establishing a good TA with patients in general, such as showing interest, respect, and genuineness (Blasko et al, 2018; Hatcher, 2010; Nienhuis et al, 2018; Wampold et al, 2017).…”

“…For example, a study involving offenders exhibiting antisocial behaviour, though not necessarily diagnosed with ASPD, highlighted the importance of developing trust between probation workers and offenders in establishing a TA (Sturm et al, 2021). In a qualitative study by Ferrito and Moore (2017), therapists offering cognitive behavioural therapy to mentally disturbed offenders emphasized the importance of responsivity and creating a safe treatment environment. Therapists were recommended to be sensitive to patients' cues, demonstrate trustworthiness, and use language that resonates with the patient.…”

“…In addition, many of these patients are treated in a forensic psychiatric setting, which presents further obstacles. Risk assessments and reports for legal authorities must be delivered; information about the patient and his offending behaviour can affect the therapist's attitude towards the patient; and motivational problems may also complicate the development of a constructive TA, both in a voluntary and involuntary treatment context (Ferrito & Moore, 2017; McGauley et al, 2011; Ross et al, 2008; Shaw & Edelmann, 2017).…”