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Therapeutic communities with restorative justice and mentoring are effective
solutions to community problems. Our own experience of positive responses to
trust and sharing are entirely applicable in the area of crime. The Alexander
Maconochie’s Norfolk Island experience, Jimmy Boyle’s story of the Barlinnie
Unit in Scotland, and the Special Care Unit in Long Bay are documented
examples of how they work effectively.

Therapeutic Communities Discussion Paper download

Prepared by Rachel Curry from research undertaken by Whitney Tipton.
7th August 2008   

This discussion paper is prepared in response to the Department of Corrective Services (‘DOCS’) decision to ’lock-in’ forensic patients in its high security hospital facility at Long Bay Correctional Centre for 18 hours day. Patients were previously ‘locked-in‘ their cells at 9pm but in April DOCS made the decision to reduce that time to 4pm. Since the announcement of this decision there has been much debate and discussion regarding the appropriateness of this management strategy.

 

Many critics believe the decision was made to reduce staffing numbers and therefore reduce the cost of managing the facility without due consideration to the impact this would have on the rehabilitation and medical treatment of these forensic patients. Luke Grant, Assistant Commissioner, DOCS said that it’s decision was made “…not based entirely on an economic rationale. It was based on the fact that surveys of inmates indicated that a number of them preferred to be removed from the face-to-face contact…and a lot of people like to have the time in their cells as opposed to being out when they are exposed to risks that they may perceive exist in that environment.”

Critics of the ’lock-in’ of mentally ill inmates have included mental health professionals  from both within and external to the prison system. They have argued that this approach has the capacity to exacerbate the symptoms of mental illness and make the rehabilitation and treatment of these patients more difficult. Ray Gregory, a Psychiatric Nurse at the hospital argues that, “It’s not just a matter of giving patients a tablet and expecting them to improve…Social interaction and mental health assessments is a huge part of those therapies and they go hand in hand.“  Clinical Director of Forensicare, Paul Mullen has stated that, “Left to themselves, the delusions and hallucinatory experiences become the sole way in which they understand and experience the world. The effect of this over any lengthy period is to potentially drive them further and further into their psychotic state.”  The CEO of the Mental Health Council of Australia reported that, “…attending to people’s mental health problems early is a very good investment, because if you don’t, you end up with greater problems in the prison, not only around management, but around the need for acute care for hospital beds and more intensive supervision. Isolating them further by locking them up at 4 o’clock is only going to make the situation worse and end up costing you more…”

For prisoner advocacy and rehabilitation organisations this has prompted a review of effective approaches to improve the management of inmates, their subsequent rehabilitation and eventual return to life in the general population. One such strategy is Therapeutic Communities (‘TCs’). TCs by definition are “a structured method and environment for changing human behaviour in the context of community life and responsibility.”  This discussion paper will detail what a therapeutic community is, how it has been used historically and how it is currently being used in prisoner rehabilitation, what practical implementation considerations are required for a TC, how the DOCS can increase their use of TCs as a method of prisoner rehabilitation.

“TCs try to produce an overall reshaping of lifestyle, ranging from abstinence from drug use and elimination of antisocial activity to enhancement of employability and inculcation of pro-social attitudes and values.”  TCs do this by “gradually building or rebuilding a new life… where…TC residents are able to change their behaviour and become productive members of society.” 

TCs generally use a ‘community-as-method’ approach where through social learning community members are “taught to use the peer community to learn about themselves, to change lifestyle and identity...Residents learn by identifying with others, through participation, observation and interaction with others to change thoughts, feelings and behaviour patterns.”  Residents in TCs also participate in work for the purpose of identifying and addressing their “attitudes, values and emotional growth issues.”  Participating in work serves as a method of rehabilitation and therapy in improving individual’s “personal habits, work habits, work relations, self management and work values.”

While being part of a TC members are expected to, and therefore change their ’lifestyle identity’ by “abiding by community rules, remaining drug free, steadily participating in daily regimen of groups, meetings, work, and education functions, meeting all obligations, maintaining a clean physical space, and maintaining a clean personal hygiene.”

Therapeutic communities are staffed by trained professionals who Alcorn describes as playing the role of facilitator, guide, counsellor, community manager and a rational authority with relapse plans and strategies to support community members if and when required.     

The ultimate goal and planned outcome of residence within a TC is to have individuals “internalise change and apply what they are learning in the TC to new situations inside and outside of the program.”  From the perspective of prisoner rehabilitation this could be taken also to refer to what they learn ‘inside’ being transferred to their life ‘outside’ once they are released from prison. More specifically residence in a TC has the therapeutic and rehabilitative effect of; shaping of personal behaviour, promoting positive interpersonal relationships, creating a sense of community, instilling attitudes that promote right living and teaching job skills. 

Historically TCs first appeared in the Australian prison system in the  first half of the 19th century with the reforms introduced by Alexander Maconochie.  Maconochie introduced a communal system as opposed to the isolation-based treatment regimes that had traditionally been used. As described by Robert Hughes in The Fatal Shore, Maconochie believed that a communal system, in which each individual’s behaviour would affect the privileges of the entire group, would help to instil the values of mutual dependence and social responsibility. Through his initiatives Maconochie achieved a recidivism level of 2% among the most difficult inmates (Robert Hughes, The Fatal Shore, 1987).  While it is difficult to make a direct comparison it is worth noting that NSW’s current recidivism rate is 47%. 

Currently in Australia, Emu Plains Correctional Centre for women in NSW uses a system where up to eight inmates reside in a house together where they have separate rooms that can be locked from the outside. (Insert more details regarding how this approach works and other associated programs at Emu Plains/Any other prisons in Australia with similar programs?).

The ACT government has also recently approved funding for the trial of a TC program within one of it’s correctional centres.

Throughout the world other penal jurisdictions are implementing TC approaches to inmate rehabilitation.

Genders and Players in their book Grendon: A Study of a Therapeutic Prison  detail the use of TCs in prisons across the world. In Scotland at Barlinnie Prison TCs are used successfully with high level security prisoners. Barlinnie was established as a prison that utilises a TC model to reduce serious violence and tension within the Scottish prison system. Its population consists of men who have experienced difficulty conforming with the mainstream prison system. Barlinnie also operates to prepare long-term inmates for release.  Genders and Player also describe other prison systems that use a method of TC for treatment and rehabilitation purposes. The Herstedvester Special Institution in Denmark houses 131 inmates and provides intensive psychiatric therapy for prisoners suffering from severe personality disorders as well as sex offenders. At Champ-Dollon Prison in Geneva the treatment model for offenders is based on pedagogy and social education for prisoners suffering from severe personality disorders with sociopath traits. Within this prison 12 inmates are housed within a single TC. In New York, the Clinton Diagnostic and Treatment Centre houses 100 inmates who are repeat offenders using a method of TC that specifically focuses on pre-release and pre-parole for a period of between 6-18 months preparing inmates for re-education and re-socialisation. Grendon Prison, the subject of Genders and Player’s research has three adult therapy wings that operate as TCs.

Send is a women’s correctional facility in the UK which operates a democratic TC that houses women between the ages of 21 to 65 that can have either life or determinate sentences. In this TC the community meets twice weekly and group therapy is undertaken within a community structure three times a week. Targets for therapy are reviewed six-monthly using multi-disciplinary assessments and is focussed on covering both personal issues and offending behaviour. Women can work out in the community in the afternoon or undertake education activities. New members joining the TC are required to sign a contract of TC rules. Gartree Prison, also in the UK, manages a twenty-three bed self-contained TC facility for life sentence male prisoners. In this TC residents live as a self-regulating community focussed around group therapy and full community meetings. Eleven staff manage the facility and referrals are based on need for long-term rehabilitation and treatment of personality disorders where the average stay is two years.

Also in the United States, there are two other examples of TCs operating in a prison environment for the benefit of prisoner rehabilitation, treatment and management. Delaware Prison’s Key-Crest program has become a model example of TCs within prisons. Key-Crest is particularly unique in that it encompasses three stages: in-prison, residential work release, and post-release supervision within the community. “The Key-Crest program is a treatment program operating within the Delaware State correctional system. The program is designed around two TCs, the ‘Key‘, a prison-based therapeutic community for men, and the ‘Crest‘, a residential work release centre for men and women. The Key-Crest program is distinctive because of its secondary stage of treatment—a ‘transitional TC’ that is a TC work release program.”  Program participants have been shown to have “higher rates of  abstinence and nonarrest, with those participating in both the Key and the Crest programs achieving more positive results than either program alone or a comparison group.”

California’s Amity Prison program includes staff members within the TC,  being managed by recovering substance abusers with criminal histories of their own. These individuals are available as mentors, role-models, and counsellors. Both Key-Crest and Amity participants have re-offended and been re-incarcerated at rates lower than control subjects.  Though both of these programs are intended primarily for prisoners with substance-abuse issues, the majority of Amity participants also have histories of violence, and the United States’ National Institute on Drug Abuse suggests that TCs can provide effective treatment for those with “special or complex needs,” including mental illness. Indeed, “there is accumulating evidence…of the effectiveness and particular suitability of the TC model to the treatment of personality disorder, and particularly severe personality disorder.”  Furthermore, there is evidence of “the efficacy of therapeutic communities, modified for prison security needs, in managing difficult prisoners, and significantly reducing serious prison discipline incidents after admission, including fire setting, violence, self-harm and absconding.”

Based on the number of reports that indicate the success of TCs especially because of their ability to achieve positive outcomes from both an offender management and rehabilitation perspective it is disappointing to see their limited use within the Australian prison system.  A review of the Colorado’s Prison Therapeutic Community for Sex Offenders  provides a more thorough understanding of what is required in establishing a TC in a prison context. Understanding these concepts will assist prisoner advocacy and rehabilitation organisations in their discussions and debates with policy makers and DOCS management about the more widespread implementation of TCs within DOCS facilities. The findings of the Colorado Prison review are summarised below.

Pre-program implementation considerations
Program administration
1. Where possible, get ‘buy-in’ from correctional centre employees as well as the general community who may view the approach as being ‘soft on crime‘. This can include training of correctional centre staff to understand the aim of the TC and it’s place in offender management and rehabilitation.
2. There should be a documented philosophy and the TC program should be based on theory and research. Where possible this program should have the ability to integrate the philosophy of the TC with the philosophy of the correctional centre where it operates.
3. The program should include well documented policies and procedures for staff as well as admission, termination and suspension policies for inmates that is documented in a contract. 4. There should be a long-term systematic procedure to observe groups and review files to monitor program milestones and achievements as well as areas for improvement.
5. The role of therapists should be clearly defined. It is a multi-faceted role, requiring trained and skilled professionals modelling pro-social behaviour and attitudes with the ability and skills to respond to requests of inmates. The role is not to lecture inmates but to support them. Attracting and retaining quality therapists in a prison setting with group facilitation and community training experience is essential.
6. Ensure adequate funding so that TC can be properly staffed and have the facilities and resources it requires.
Program management
1. Determine whether group therapy or living and interacting with others will be the primary way of delivering treatment.
2. Determine how the ‘right mix’ of participants will be chosen for the group that should include an intake screening and assessment. Will participation be compulsory or voluntary?
3. Determine the impact of group participation versus individual needs. What support will be provided to individuals who are not participating fully in group activities, where sharing an environment may inhibit their willingness to be open and honest?
4. Determine the theoretical role of work in the TC and what priority it is given compared with treatment and therapy. Work supervisors should be integrated into the TC program for intervention opportunities that relate to treatment and therapy.
4. Treatment contracts should be developed that outlines rights and responsibilities of the therapists and offenders in the TC.

Program implementation considerations
1. Understanding about how and when the program operates. Does it operate 24 hours a day, 7 days a week or are there times when individuals operate in isolation from the TC?
2. Determine how accountability amongst all members of the TC will be managed.
3. Determine how the ‘no secrets’ approach of TCs will be managed versus the need for inmate confidentiality and privacy.
4. Use of treatment plans that are working documents that guide interventions and measure progress toward goals.
5. Use of senior group members as ’big brothers’ to teach new TC members about group sessions, group expectations and as a  model of TC behaviour. In addition the ‘big brother’ can provide information that is essential to success in the group. It also provides an extra opportunity for people to learn from one another.
6. Determine whether the program will have cardinal rules and how breaches of those will be managed. Under what circumstances may someone be  suspended from the TC? Will they have an opportunity for their place in the TC to be reviewed?
7. Determine how the group will deliver and receive positive feedback, celebrating achievement of milestone and honour progress, in what forum?

Post-program considerations
1. Will inmates be released back into the general prison population after they have participated in the TC or will the TC be an ongoing program.
2. Determine whether it will be possible for some inmates to be simultaneously released to help each other in the reintegration into the general community.

This paper has provided evidence that TCs are being widely used as a method of prisoner management and rehabilitation. It has also provided practical detail of the ways in which a TC can  be successfully implemented. The TC approach mirrors DOCS mission to “manage offenders in a safe, secure and humane manner and reduce risks of re-offending.”  This paper has also provided evidence of that through researching current models and application of TCs in prisons throughout the world. The evidence is supportive of a TC model for prisoner rehabilitation. “Participation in treatment is significantly associated with success on parole. We analysed parole completion/revocation rates for 1,585 sex offenders released to parole between 1 April 1993 and 30 July 2002. Nearly half (47.7 per cent) of the offenders in the no treatment group were revoked back to prison. This revocation rate for offenders who did not participate in treatment is three times higher than the group that participated in the TC…”  Viable, cost-effective alternatives to isolation do exist, and must, for the sake of patients and community members alike, be further explored. Existing TCs have been successful in treating mentally ill prisoners, and “in the absence of conclusive evidence of the effectiveness of any alternative treatment, we ought to protect and develop those therapies which can demonstrate some efficacy in treating personality disorder”  and other severe mental illnesses.

On this basis DOCS should review the  widespread implementation of TCs as a model in it’s service provision of offender management and rehabilitation and as a way to actively reduce recidivism rates and therefore the cost of imprisonment to the general community.

 

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