Psychological Interventions in Forensic Settings: The Role of the Therapeutic Relationship as a Mediator of Change

Abstract

The nature of the therapeutic relationship has been consistently recognised as a key factor that influences the outcomes of psychological and psychotherapeutic practices. However, a significant proportion of therapeutic interventions designed to address the causes of violence and harmfulness have adopted a tendency towards manualised and short-term practice, resulting in a lack of opportunity to explore live dynamics. This chapter presents an overview of intervention practices in forensic settings, alongside research evaluating such interventions. Drawing on various studies, the chapter proposes a more relational and trauma-sensitive approach to forensic psychological interventions and highlights a range of key areas that may benefit from a relational and process-focused approach.

1. Introduction

Human beings are fundamentally social animals. We are born into a relational context and remain embedded in a myriad of interpersonal interactions throughout our lives. While our earliest relationships are clearly designed to meet our most essential needs for survival, comfort and nourishment, we gradually begin to encounter relationships that offer opportunities for growth and development. As we navigate our adolescent years, we embrace relationships that offer opportunities for intimacy and, ultimately, reproduction, inviting us to engage in a new type of relationship as parents. As we age, we may become grandparents, thus allowing us an opportunity to engage in alloparenting and provide care for youngsters who are not our own. Simultaneously, we are increasingly likely to experience grief as we lose people we have built relationships with over the years.

Relationships, which clearly manifest in a broad spectrum of contexts, punctuate our lives. The quality of these relationships influences us in a variety of ways; from our emotional tone to our values, beliefs and perspectives. Relationships can nurture us and provide us with security, while conversely can be a source of threat, deprivation and harm. Developments in neuroscience point towards the role of relationships as the scaffolding for brain development [1, 2]. Compassionate and attentive parenting supports the development of neural pathways that facilitate emotional regulation [3], mentalisation [4], identity [5] and self-worth [6, 7]. Inattentive, callous or cruel parenting robs the child of opportunities to learn to tolerate and contain emotions, creates a sense of self that is divorced from reciprocal relating and fractures the developing identity.

This chapter provides an outline of the importance of the therapeutic relationship when we work with people who have a forensic history (people who have convictions for causing harm to others). The chapter begins with a review of the literature that describes the value of the therapeutic relationship in general and then specifically explores the role and value of the therapeutic relationship in psychological interventions designed to reduce risk of further offending. The focus then moves on to consider the relational experiences of people who use forensic services and explores the difficulties and challenges that can arise when working with people with complex needs and complex presentations. The chapter concludes by presenting a rationale for more relationally designed interventions for people who have caused harm to others and focuses on a number of key areas for consideration.

2. The therapeutic relationship as a context for change

The relationship that develops between a therapist and a person who enters into psychological therapy has occupied a prominent role in accounts of the therapeutic process. As the concept of psychotherapy was being developed, Freud [8] discussed a process whereby the client or patient, would attach him or herself to the therapist (doctor) and begin to transfer experiences from previous relationships into the therapeutic relationship. Indeed, in early discussion of the process of transference, Freud and Breuer [9] articulated the view that transference was often driven by unconscious processes and the goal of therapy (amongst others) was to bring these unconscious processes into conscious awareness. While Freud viewed transference as a pathological process, modern psychology takes a more sensitive perspective, recognising that transference is both a natural and an inevitable relational transaction. Whichever lens is used to view the process of transference, it is widely accepted that transference takes place automatically in our relationships. Interactional patterns will emerge in any relationship and the patterns that we bring to our relationships, including the therapeutic relationship, are influenced by the nature of previous relationships. The therapeutic relationship, therefore, from a theoretical perspective at least, provides a conduit to information about earlier life patterns and, as such, would seem to be a critical concern within the therapeutic setting. As we explore the relational experiences of people who cause harm to others, we will begin to see the significance of transference dynamics in forensic psychotherapies.

Similarly, and equally inevitably, the therapist brings their own relationship history into the therapy room. The dynamics that emerge in the relationship—the transference and countertransference as Freud referred to it—is a co-constructed dynamic, influenced by the relational history of both parties (or more in a group therapy setting). While a therapist may have well-rehearsed practices in the therapy room, their own unconscious processes will influence the interactional patterns in the room. Skilful exploration of the co-constructed dynamics may facilitate insight and change, while failure to explore patterns may miss opportunities for change or repeat relational patterns that have been harmful in the past. Indeed, many psychological approaches recognise that the responses of a therapist can evoke reactions in the client, and the process of the interaction can be beneficial or harmful to therapy [10].

The nature of a psychotherapeutic experience is also influenced by the presence of self-conscious emotions; those emotions that evolved to support our awareness of social rank, social inclusion and belonging [6, 7]. Self-conscious emotions are widely considered to play a key role in the way that we mentalise ourselves in the mind of others. Shame and humiliation signal to us that we are considered to be held in mind in a negative manner (with social judgements); [6], while pride tells us that we are held in high esteem [6]. The presence of self-conscious emotions, particularly those that signal a negative social appraisal, can inhibit disclosure and impede the progress of therapy [11].

Furthermore, characteristics of the therapist, or more likely the client’s experience of the characteristics of the therapist, including warmth, empathy and acceptance [12, 13, 14, 15] can facilitate disclosure and reduce inhibitors to engagement. Again, it would seem important for therapists to create opportunities for clients to express their experiences of the therapeutic dynamic so that we are able to create a context that feels sufficiently safe for disclosure, reflection and exploration.

The quality of this relationship between a therapist and their client has been widely cited as a core factor that determines the outcome of psychotherapy. A poor alliance early in treatment predicts premature termination of therapy [16], while an improvement in the nature of a therapeutic relationship is associated with more positive outcomes [17, 18]. Opportunities to explore the nature of the relationship and address potential ruptures would therefore seem to be a critical aspect of such an improvement process, while, conversely, a lack of opportunity to explore the relationship may therefore be likely to contribute to ruptures and disengagement.

3. The therapeutic relationship in secure settings

The previous section has highlighted the importance of the therapeutic alliance as a facilitative context, and the potential for this alliance and the exploration of the nature of the alliance, as a source for learning, reflection and change. In the context of forensic work, the nature of this alliance can become strained as a consequence of the somewhat unique circumstances that impact on the relationship. Many therapists who work in forensic contexts may be required to provide reports to official bodies (e.g. parole hearings), may be required to submit information for security purposes, may be able to recommend that psychological work is a necessary component of an individual’s detention (and is therefore mandatory), and may be able to recommend that therapy is terminated prematurely terminated. In addition, while the content of psychological therapy is often driven by the disclosure made by the client, in forensic settings, disclosures are often made by third parties. People who have spent any length of time in a forensic service are likely to have had multiple reports written about them, describing their offending history, their early life (though often without personal meanings or impact) and their adjustment to a confined lifestyle. As people enter into psychological work, they therefore do so knowing that their therapist has been exposed to a third-party narrative that not only documents significant life events but also creates an identity. In short, forensic therapists hold considerable power over their client population, and the imbalance of power seen in psychological therapy generally, is considerably magnified.

Conversely, therapists are clearly working with people who have caused harm to others, often fatally, and will need to remain mindful of risk. Therapists will inevitably carry keys and control access to rooms. There may be risks that require the presence of a third person in the room (a nurse or prison officer) and the physical environment may communicate the dangerousness of the resident population. Furthermore, some people who access forensic services may present with a level of volatility, may experience emotions rapidly or may have acquired a callous or cruel interpersonal style; all of which may texture the therapeutic relationship. When we consider those factors cited earlier (transference, self-conscious emotions, etc.), these relational patterns would seem critical areas for exploration, particularly given the interpersonal context in which most offences take place. However, as we will see in the next section, common practice in certain forensic settings leaves little room to explore these dynamics and therefore, somewhat paradoxically, risks omitting important areas of criminogenic need.

4. Forensic interventions

The nature of forensic interventions will inevitably differ between organisations, and indeed between clinicians. However, in the UK, the majority of forensic psychological work takes place in His Majesty’s Prison and Probation Service (HMPPS) where the delivery of interventions has to be balanced with limited resources. Forensic interventions tend to be guided by the risk-need-responsivity (RNR) model of rehabilitation [19]. Briefly, the RNR model proposes that psychological work should be organised around three primary principles; risk, need and responsivity. The risk principle is concerned with the level of risk, or likelihood of further offending, and highlights the importance of matching the level of intervention to the level of risk. Individuals who present with higher levels of risk should receive higher levels of intervention, while those presenting as low risk should receive minimal psychological work. The need principle then refers to the characteristics, values and lifestyle choices that have shown some correlation with increased levels of offending. Research [19] has highlighted eight key areas of criminogenic need, including attitudes that promote offending, peer and family relationships, employment and substance use. Finally, the responsivity principle is concerned with how interventions should be delivered, with a general recommendation for cognitive-behavioural methods and a focus on individual strengths.

Unsurprisingly, therefore, the majority of interventions that are designed to reduce the risk of reoffending are based on cognitive behaviour therapy (CBT) and delivered according to a manual [20]. Typically, these interventions aim to deliver discrete pieces of information, teach skills and challenge aspects of an individual’s ways of relating that could be considered risk-related. It is rare for these interventions to develop individual formulations or allow therapists to explore the relationship; indeed, programme adherence has been a primary concern with treatment delivery and deviation from a prescribed manual has often been considered to represent ‘programme drift’. The focus is on delivering the curriculum according to the manuals rather than allowing the opportunity to explore dynamics that may emerge in the therapeutic setting. As such, the dynamic relational patterns that do emerge within the context of the psychological intervention, receive little attention and opportunities to facilitate insight into such patterns are typically missed.

Despite this focus, there has nevertheless been considerable interest in the nature of the therapeutic relationship in forensic interventions and forensic settings. In a substantial review of the delivery of treatment programmes for men with sexual convictions within the English prison system, Marshall [21] found that confrontational therapist styles were related to negative therapeutic experiences. It has been suggested that confrontational styles are likely to be experienced as a critical of the self (rather than a critique of behaviour) and therefore stimulate a shameful response from the men engaged in treatment [22]. Furthermore, it has been suggested that the programme effectiveness and dropout rates (in English prisons) could be improved by attending to the personal circumstances of individuals [23]; a practice that arguably was discouraged in the earlier wave of manualized programmes for people convicted of sexual offences. Howells and Day [24] make a similar suggestion that clients may be more easily engaged if their experiences are located within a broad developmental framework that builds on the self-identification of difficulties and places offending within the context of personality development.

Conversely, positive therapeutic experiences have been found to be associated with therapists who displayed empathy, warmth and encouragement for progress. Therapeutic relationships that are experienced as supportive have been found to increase motivation [25] and promote treatment retention [26], while shifting the emphasis from risk to need and focussing on approach goals has been found to enhance collaboration in prison-based intervention programmes [27, 28].

A more interpersonal approach to therapy therefore seems to allow therapists to use the therapeutic relationship to build trust and rapport [29, 30, 31], while group cohesion and reduced pro-offence attitudes are facilitated by a compassionate and non-confrontational therapeutic style [21, 32]. Finally, creating opportunities for individuals to explore the quality of the therapeutic relationship and reflect on the influence of earlier relationships has been found to enhance motivation and support men to feel less shame [33, 34].

In summary, therefore, despite the common adherence to the RNR model and the tendency to deliver interventions according to a manualized protocol, there is considerable evidence that the quality and nature of the therapeutic relationship is a significant factor in forensic settings. Engagement, motivation and insight are all enhanced when therapists pay attention to the interactional style and are open to an exploration of the relationship dynamics.

5. The relational experiences of people who use secure services

People who use secure services have caused harm to another person in some manner. Often, this harm is violent or sexual in nature and may have left lasting repercussions for the individual concerned. In jurisdictions where people are likely to gain release form a custodial setting, the need to reduce risk is understandable, but an exclusive focus on risk, that is the ability and willingness to relate to other people in ways that cause harm, without understanding how the person came to acquire risk related characteristics is problematic, particularly when we begin to explore the experiences of victimisation that have often featured in the life histories of forensic service users.

People who use forensic services are more likely to have experienced childhood adversity than people without forensic histories, with studies indicating that forensic service users experience childhood adversity at significantly higher rates than the general population [35, 36]. Both the Levenson and Taylor studies used a 10-item instrument adverse childhood experiences (ACEs) questionnaire that was derived from the Kaiser Permanente ACEs Study [36], which is composed of two clusters of items associated with child maltreatment (e.g. sexual abuse, physical abuse and neglect), and household challenges (e.g. growing up in a home with a parent with poor mental health, parental imprisonment). Levenson et al. [35] found that both men and women who commit sexual offences were almost twice as likely to have experienced four or more adverse events than are found in the general population, while Taylor [33] found that men with sexual convictions referred to a prison mental health service had typically experienced over seven of the original 10 ACE items. In terms of more general offending, men with convictions are four times more likely to have experienced adverse childhood experiences than people without convictions [37], while adolescents in forensic services have been found to have endured these types of experiences at rates significantly higher than their peers [38].

When we consider the interpersonal nature of most of these items, the likelihood of having experienced direct abuse during childhood or the experience of repeated neglect, this points towards the profoundly harmful experience of relationships that are likely to be a feature of people’s lives. From the experience of the child (as was), there may be a number of learning outcomes that develop from such profound and recurring experiences of adversity. First, the child may develop a fundamental experience that defines power differentials as abusive; the adult, who is the person with power, is able to behave in ways that are experienced as painful, harmful and indifferent to the child feelings. Second, in the case of sexual abuse—which is common in the life stories of people who commit sexual offences—relationships may have become sexualised, and the early ‘culture’ of sexual interaction is likely to have become associated with a range of unhealthy dynamics. Indeed, as Judith Herman ([39], p. 101) eloquently expressed, the experience of sexual abuse teaches the child that ‘…she must develop a basic sense of trust and safety with caretakers who are untrustworthy and unsafe. She must develop a sense of self in relation to others who are helpless, uncaring or cruel. She must develop the capacity for bodily self-regulation in an environment in which her body is at the disposal of other’s needs…and ultimately, she must develop a capacity for intimacy out of an environment where all intimate relationships are corrupt, and an identity out of an environment which defines her as a whore and a slave’. Men who are sexually abused may well carry these experiences into their sexual encounters and ‘transfer’ their experiences into others.

Third, people who have lacked care and attention throughout their early lives, that is, those people whose attachment systems have acquired a representation of relationships based on deprivation, are likely to have developed a sensitivity to negligence and experienced an insensitivity to their own emotional state. Relationships with people in power may have taught them that their own needs were unimportant, their welfare was insignificant and care-seeking is a futile exercise.

Finally, people who have experienced ACEs are also likely to have experiences adversity outside of the family context [2]. Relational instability may have been accompanied by resource instability arising from unemployment, local communities may have been scarred by poverty, inequality, war and high levels of crime.

Taken together, these experiences can have profound and lasting (though reversible) implications for development. While Bowlby theorised about the nature of our attachment systems, contemporary neuroscience highlights the influence of our social context on the development of our nervous system [40, 41]. Neuroplasticity [1, 2, 3] creates the potential for our brain and our body to absorb information from our environment, learn from our environment and ultimately adapt development in ways that are most suited to that environment [1, 2, 40, 41]. The neural pathways in our brain are sculpted by our relationships with experiences—whether caring or harmful—being encoded into our neurological design. For youngsters who grow up in homes and communities that are characterised by ACEs, their fundamental design will therefore be organised around the presence of threat (for physical or sexual harm), deprivation (of nourishment, love and affection) or unpredictability. The encoding of these experiences is not dysfunctional—they do not result in an attachment disorder. Rather, they are learned experiences, adaptive responses that facilitate survival in harsh social climates.

Mark had grown up in a highly adverse context. His mum had not planned her pregnancy and she conceived in the context of a volatile and violent intimate relationship. Throughout his life in his mother’s womb, Mark’s developing body absorbed high levels of stress-related hormones. Throughout her pregnancy, Mark’s mum was acutely aware that her body was vulnerable and that assaults on her could cause injury to both herself and to her baby. Mark’s first care setting was teaching his developing body, brain and mind that adversity was a recurring feature of life.; Mark began his life outside the womb in an unremarkable manner, and a short stay in hospital allowed him to experience his mum’s gentle attention. His return home marked a significant shift in the culture of his setting; his mum was immediately under threat and her ability to provide him with a calm, soothing attachment experience was profoundly undermined. Mark learned, throughout his early years, that people are a source of hostility and simultaneously unable to offer security or opportunities for co-regulation. Consequently, Mark was deprived of opportunities to internalise strategies that help to regulate strong defensive emotions, while his developing body was learning to anticipate violence in the company of powerful others.; Mark’s early school career was populated by challenges. His young brain, cultivated in a hostile context, was dominated by his amygdala; primed to attend to potential threats and mobilise rapid responses. And this learning went with him into the classroom. Faced with unfamiliar people, Mark regularly felt overwhelmed and consumed by anxiety. He avoided contact with others as much as possible and struggled to concentrate during lessons. Initially labelled as having special needs, Mark was increasingly experienced as oppositional by teachers and as he moved through the academic years, his reports increasingly identified him as challenging and problematic. His definition brought a brutal response at home.; Secondary school exposed Mark to repeated social judgements. He was ridiculed for being poor, teased about his academic ability and excluded from social gatherings. At some point during this stage of life, Mark learned that fighting was a more efficient response to threat than avoidance.

These survival strategies may, however, become activated in future social settings with devastating consequences. The relational patterns that we acquire are adaptive in context, but they may not translate into new contexts and may interpret future contexts based on these past experiences. Relational patterns that offer protection in a harsh setting (e.g. a pattern characterised by suspiciousness or a readiness to react rapidly to the presence of threat), may influence the use of defensive strategies in a later context—with some of these strategies having the potential to cause harm. Protective patterns from early life may manifest as risk-related patterns in later life.

Mark entered into his first intimate relationship knowing that intimacy was both a context for violence and carried the potential for rejection. His early learning primed him to be vigilant for rejection cues and his fears of abandonment facilitated repeated misperceptions and an increasing controlling approach towards his partner. Fourteen months of intimacy brought a child and a conviction for a violent assault as he became increasingly suspicious about his partners fidelity. The subsequent prison sentence that Mark served exposed him to repeated threats and taunts as his offence against a woman became local knowledge in the prison. The deep sense of humiliation that Mark felt about his behaviour contributed to a subsequent vengeful assault on his former partner after his release.

These patterns, cultivated by relationship histories and socio-environmental contexts, will inevitably accompany people into the therapy room. The potential for early life experiences to shape capacities and characteristics that may cause harm is beginning to get some traction [42, 43, 44]. In a useful review of the relationship between early sexual adversity and later life offending, Papalia et al. [45] compared police and mental health records of 2759 documented cases of sexual abuse and 2677 community controls. Four key findings emerged from the analysis: (1) people who experienced sexual abuse during childhood were more likely engage in all types of criminal behaviours, (2) gender moderated the relationship between these experiences and offending, with stronger associations found amongst females for general and violent offending, and amongst males for sexual offending; (3) certain features of the index sexual abuse (i.e. developmental period, number of perpetrators, relation to perpetrator), further victimisation experiences, and the development of serious mental health problems were all associated with an increased likelihood of offending; (4) victims who engaged in offending were more likely to present with cumulative risks than victims not engaging in offending.

The finding that characteristics of the abusive experience, such as age at the time, repeated episodes and relationship to the perpetrator, all point towards the role of neuroplastic mechanism [3] in shaping the developmental trajectory. In a relational context that is harmful, this trajectory will need to invest in the development of capacities that increase survival potential. Characteristics that promote this potential will include those that draw attention to the presence of threat signals, support us to make rapid appraisals of threat and implement strategies to manage the immediate threat. Strategies may include, amongst others, a heightened sense of alertness and suspicion, an ability to be physiologically aroused by our emotions so that these in turn can mobilise our behavioural response without delay. These strategies, nurtured in the context of early life relationships, will be on standby, ready to emerge in later relationships that trigger the early trauma responses. The therapeutic relationship, with the inherent imbalance of power, maybe one such relationship.

6. The therapeutic relationship as a primary intervention in forensic services

People who use forensic services have often shattered relationships. Their actions have created a victim or victims and are likely to have left wider scars across family and community systems. As we have seen, however, a large proportion of people who enter into forensic services have experienced harm in an early relational context and for some this harm characterises their relationship history. The experience of relating would therefore seem to be a central consideration of psychological work to reduce risk.

However, as we discussed earlier, CBT-based methodologies have dominated psychological interventions in forensic services, and similarly pointed towards the tendency for these interventions to be delivered by a guided protocol. Whilst there is no doubt that the RNR model has significantly advanced forensic practice, the reliance on protocol-driven interventions clearly neglects the relevance of the relational dynamics that inevitably emerge within therapeutic interactions. Given the relational experiences of forensic service users that we have already discussed, this seems to be a significant omission, and an omission that may undermine the effectiveness of therapy, contribute to ruptures and disengagement and potentially strengthen areas of concern, particularly when relational patterns are implicated in offence related dynamics.

As with all psychotherapeutic processes, forensic practitioners will need to create a safe, containing and secure therapeutic alliance in order to mediate earlier life experiences and create a context for change—change that is often focused on relational styles and interpersonal dynamics. To do this, therapists will need to explore the nature of their relationship with clients and the evolution of this relationship over time. In turn, this is likely to require an explicit consideration of transference, self-conscious emotions (as signatures of social rank and inclusion) and the experience of warmth and affiliation in the therapeutic relationship. Although there are many reasons for attending to the nature of the therapeutic relationship (in terms of managing potential for dropout, enhancing engagement, etc.), I suggest that there are some key opportunities that can arise from relational-focused working in forensic settings, including working with power differentials and social rank, language and identity formation, working with self-conscious emotions and understanding relational patterns as indicators of adversity experienced and adversity caused. We will now consider each of these in turn.

6.1 Power

Although not discussed in detail in this chapter, the power differential between a therapist and their client is considered to be significant [46]. Much of this power differential is considered to flow from the differences in knowledge and expertise that characterise the different therapeutic roles (as the therapist or as the person seeking therapy), while an additional contribution to the power difference(s) comes from the vulnerability that is associated with the process of therapy, where the client exposes aspects of the self that have caused difficulties.

The power differential that is considered to exist in psychotherapeutic relationships is multiplied considerably when the therapist may also have some direct authority over their clients’ lives, which is an inevitable aspect of relationships between staff and clients in secure or forensic settings, and aspects of the self have led to significant social judgements and sanctions. Furthermore, as we have already seen, many people who use forensic services have had poor relational experiences across their life and are likely to have experienced significant misuse and abuse of power. The baseline for the therapeutic relationship in forensic psychological interventions is therefore potentially characterised by a significant imbalance of power, a client experience of profound misuse of power and authority and highly compromised attachment experiences. The potential for these dynamics to influence the therapeutic relationship, whilst perhaps not inevitable, is significant and brings with it the potential to create a trauma-inducing context that resembles earlier life experiences and leads to iatrogenic consequences [47].

Whilst serving his second prison sentence Mark again sought help. He was assessed for a group intervention that consisted of a set number of sessions run over 3 months. The group was delivered according to a protocol and while he found the facilitators to be knowledgeable and considerate, Mark found that he was not able to introduce material that he thought was relevant for him. He felt increasingly dismissed as he tried to discuss his own past experiences and tried to create a context for his own acts of violence, and found it increasingly difficult to maintain a rapport with therapists. He was eventually excluded due to missing some sessions and offering limited contributions. A post-intervention report described him as resistant and unmotivated and Mark was aware that the report would follow him through his sentence. Mark again felt humiliated and developed a strong sense of mistrust towards psychologists.

To mitigate, the alliance in the room can become a legitimate, if not central consideration. There would seem to be a number of key aspects to this:

1. What are the client’s experiences of power?

2. How has the client learned to manage power inequalities?

3. What are the clients’ experiences of power in the room?

4. How can the alliance be moderated to create a different and potentially healing experience of power?

Much of this can be achieved by promoting those key qualities of the therapist referred to earlier; trust, empathy and warmth. However, while these qualities may create a sense of warmth, they are unlikely to facilitate an understanding or power experiences and their manifestation in therapy. To develop understanding around these dynamics, a more explicit consideration of transference processes and the experiences of self-conscious emotions is needed.

6.2 Working with self-conscious emotions

It is beyond the scope of this chapter to discuss the function(s) of self-conscious emotions in detail. In brief, however, self-conscious emotions developed over time in order to signal vital information about our place within social groups [48]. Being part of a group and being able to retain our membership of a group became increasingly important across our evolutionary history, and self-conscious emotions provide a powerful mechanism that draws attention to our social rank and social inclusiveness. Although there is a broad spectrum of self-conscious emotions, three specific emotions are considered here; shame, humiliation and pride.

6.2.1 Shame

Psychotherapeutic research [5, 49, 50] shows that a proportion of people conceal some significant information—particularly in relation to sex, aggression, and personal failure—when they engage in psychotherapy. Hook and Andrews [51] found that 54% of psychotherapy clients reported concealing symptoms of depression from their therapists and the most common reason cited was shame. Shame was also found to be associated with non-disclosure of distressing experiences, while shame-proneness was also found to inhibit disclosure. Shame may also indicate that a client experiences a therapist as dominant [6]. It would follow from this that for an individual to remain in a therapeutic alliance and undertake meaningful personal change, then they will need to experience therapeutic interactions that do not stimulate shame in relation to their harmful behaviour.

By observing the process in the room, noting the body language and remaining aware of their own feelings towards the group/client, the therapist can be alert to the patterns of relating and be able to use these patterns for direct therapeutic work. Questioning the motivation behind certain patterns and being willing to explore how the clients feel allows them to be held in the mind of the therapist and communicates their intrinsic value.

Where it may be therapeutically helpful to stimulate shame to explore experiences of shame and it will be important that we approach this collaboratively with our clients and be clear about the function of this type of work and our intention behind it. When we stimulate shame or humiliation in error (through clumsy work) then it is important that we own the responsibility for this and acknowledge the process/dynamic that we have generated.

It is perhaps pertinent to note that as human beings we (practitioners) are just as vulnerable to the experience of shame as those people whom we work alongside. And, just like the people we work alongside, we can respond to shame in a variety of ways that may interrupt or interfere with the process of group therapy. A particular concern is the possibility that therapist shame could inhibit us from exploring the relationship for fear of negative or hostile feedback. The usual avenues for the exploration of therapist material should be available here—supervision for a facilitator group as well as individual supervision for clinicians.

6.2.2 Humiliation

While humiliation may start from a similar dynamic to shame (in terms of perceived social rejection), humiliation stimulates more overt attempts to regain social rank and prevent rejection. These attempts may include a denigration of the therapist, a passive-aggressive resistance to the therapy or more overt anger directed towards the therapist (with the intention to elicit submissive signs). In many forensic settings, displays of anger are often (understandably) interpreted as a sign of risk and risk management procedures may be quickly implemented. As is discussed in other parts of this chapter, the management of immediate risk has to take priority. However, it also seems important to create a therapeutic space that feels safe enough to express emotions as they are felt (at least to some degree). Developing a balance between risk management and emotional expression, possibly towards the therapist, may therefore be an important consideration early in the therapeutic process.

Mark entered therapy for a second time with a strong sensitivity to judgements and primed to feel humiliated. He found himself with a female therapist and immediately anticipated that she would view him as a ‘wife-beater’. He looked for signs in the room that she could be frightened of him and readily interpreted her body language as evidence that she expected him to be hostile. He was not aware that she had been threatened previously and that her cautiousness was a natural reaction to her experiences, rather than an anticipation about him in particular. Nevertheless, Mark reacted to his observations with his learned responses; a shamed withdrawal initially, moving into a more hostile humiliation. He began to denigrate his therapist in relation to her professional competence and made personal remarks about her appearance.

6.2.3 Pride

Pride has been conceptualised as a feeling that signals a social message that is fundamentally opposite to that of shame. Pride tells us that not only are we feeling good/happy, but that we are feeling good about ourselves. Furthermore, this sense of pleasure arises in a social context or as a result of an achievement and is typically associated with the attainment of a high status [52]. Pride experiences and the desire to attain these experiences motivate achievement, while these achievements are in turn rewarded with social approval and the opportunity to climb the social ladder.

Pride appears to have two particular pathways, which can manifest as distinct facets. Some authors describe these two facets in terms of attributions; alpha pride refers to the self as a socially valued person, while beta pride refers to a particular behavioural act as having social value [53, 54]. An alternative conceptualization focuses on the behavioural repercussions of pride [55]. From this angle, hubristic pride is marked by a more arrogant and conceited demeanour (self), while authentic pride is fuelled by feelings of accomplishment and success (behaviour). Henrick and Gill-White [56] propose a useful model, particularly for forensic services, based on the distinction between prestige and dominance. Authentic pride facilitates enhanced social rank and prestige by motivating and rewarding social competence and behaviours that serve the social group. Hubristic pride, on the other hand, with its focus on the self rather than behaviour, promotes social rank by dominance. Dominance obtains social status by subordination rather than admiration, with threats, intimidation and aggression serving as highly effective strategies. If someone experiences authentic pride in the therapeutic context, then they feel motivated to behave in ways that gain acceptance and status. If, on the other hand, a client is driven by hubristic pride, then they may search for signs of subordination from the therapist.

Given the social function of these emotions, their presence in the therapy room may provide useful information about a client’s experience of the therapist or therapeutic context. Signs of shame and humiliation may indicate that the client is feeling judged; something that we have already seen is likely to inhibit disclosures [6] and reduce engagement [12].

Self-conscious emotions are often manifest in the form of a primary emotion. Shame may be presented as disgust (towards the self) or as depression (a hopelessness about the self), while humiliation is often manifested in anger. Although we may want to explore the primary emotional expression, it is likely that we will need to get beneath this and consider the context for the self-conscious emotion—what triggers the shame or humiliation. This can be particularly challenging when humiliation is expressed as anger.

6.3 Transference/countertransference

While self-conscious emotions may manifest in the room as indicators of the sense of inclusion at the moment, transference highlights the experience of earlier relationships. The experience of transference might be thought of as a means used by the brain to make sense of current experience by seeing the past in the present and limiting the input of new information.

Although traditionally associated with psychodynamic therapies, the role of the therapist as a mediating factor in the therapeutic climate has been increasingly recognised. Transference and countertransference are, by their nature, complex and interrelated. However, they cannot be understood solely within a model of attachment and its re-enactment. Power dynamics in interpersonal relationships also play a role.

Mark’s therapist noticed the changes in his ways of relating and gently commented on her observations.; Th: ‘I could be wrong, but it seems like you are feeling more angry towards me recently. Can we try and figure out what I’ve don’t that is causing this?’; M: ‘You’re too right I’m pissed with you. You sit there judging me for what I’ve done. You’re supposed to be helping me, not making me feel crap’.; Th: ‘Just let me check, what do you mean by crap?’; M: ‘You’re looking down on me, like I’m a loser…because I hit a woman. And expecting me to do it again’.; Th: ‘I don’t mean to look down on you, but when you spot it, how does it make you feel?’; M: ‘Like shit. Like you think I’m a low life’.; Th: ‘And when you feel like that, what happens?’; M: ‘I want to stop it. Want to make you stop judging me’.; Th: ‘And given what you’ve learned in life, how would you stop me?’; M: ‘If I tell you, you will put a security report and if I don’t you will say I have no insight’.; Th: ‘I don’t want to do either of those things, I just want to understand what I’m doing, or whats happening between us that makes you feel like this?’

However, it is prudent to recognise that there will be a number of factors that may challenge this process that therapists will need to attend to. First, many of the individuals we are likely to encounter within forensic settings will have entrenched and engrained defences; as we have seen many will have needed to construct robust defences to psychologically survive their life experiences. People are likely to resist the de-construction of their defences and exposure to the emotional memories that contributed to the development of the defences in the first instance. This resistance may take the form of people’s preferred defensive strategies; internalising (self-harm) or externalising (aggression). Clearly, therapists will need to work within organisational procedures and document and report any risk concerns. However, they will also need to manage their own threat system as such behaviours emerge and retain a compassionate approach to the recognition and reporting of risk concerns.

In this context, it is also possible that the experience of a holding, containing and empathic relationship may generate confusion and threat sensitivity. There seem to be two processes that can contribute to this. First, for some clients, the experience of empathy may serve to illustrate the lack of care in early stages of their life. Therapeutic attempts to validate the emotional experience of group members can leave some people curious about the lack of validation from their childhood and exposes group members to a reality that may feel increasingly neglectful. This seems to be particularly apparent for those men whose emotions were met with an incongruent emotional reaction from caregivers. In the context of physical abuse, there may be a pattern where the child’s fear was met with anger, while in the context of sexual abuse, the child’s fear was met with sexual pleasure and excitement—both of which fail to validate the sensory and emotional experience of the child. Some people may resent being exposed (vicariously) to a lack of care and project their distress and anger outwards towards the therapists.

Second, as men experience empathy (either from therapists or group members), there is a possibility that this mimics a superficial, inconsistent or even absent empathy that was used to facilitate a grooming process. The experience of empathy in this context can stimulate threat, trigger defences and may encourage behaviours that have traditionally been interpreted as treatment interfering or ambivalence. As with other aspects of the therapeutic alliance, it is important that these processes are explored in order to model a compassionate understanding of threat sensitivity. Through a trauma aware and compassion focussed understanding the label of treatment interfering misses the defensive function of such strategies and we would avoid such language. Rather, we would look to validate the feelings that sit behind the behaviour and understand the defensive intentions.

Finally, the crimes that some of group members have committed may evoke powerful emotional responses in practitioners. Practitioners need to be aware that their own feelings, whilst understandable, may be communicated across the therapeutic space and stimulated by the types of self-conscious emotional reactions referred to earlier. Equally, the sense of shame that an individual may feel in relation to their offence(s) may be communicated and, when left unexplored, stimulate a counter-transferential response from the therapist.

6.3.1 Sexualised transference

As we saw earlier, the tragic truth for many people who reside within secure settings is the experience of sexual abuse. While we know that the potential repercussions of sexual abuse are wide-ranging [39, 41], sexual abuse also has the potential to create a toxic sexualisation of relationships, a blueprint for relating that may be transferred into other relationships, and particularly those that carry a similar imbalance of power.

Sigmund Freud was the first to describe the phenomenon of erotic transference, a theory that he initially developed from an analysis of Breuer’s therapy with ‘Anna O’ [57]. Over time, Freud formulated a theory about the relationship between erotic transference and the experience of love, recognising that feelings of love draw on earlier life experiences, typically the maternal relationship [58].

Contemporary psychodynamic theories differentiate between two different types of sexualized transference. Erotic transference is generally reserved for positive transferences accompanied by sexual fantasies that the patient understands to be unrealistic. Eroticized transference on the other hand is an intense, preoccupation with the therapist characterised by a desire for love and intimacy. Engagement in therapy, albeit mandated at times, may be motivated by a desire to be in close proximity to the therapist rather than by the potential for change and harm reduction. The therapeutic usefulness of these forms of erotic transference is reported to be twofold: the psychological material it revels in understanding both erotic and power issues and the strength of the emotional charge that initially sustains the patient through some hard work [59].

In forensic settings, sexualised transference can be highly challenging, particularly when the client has a conviction for a sexual offence. The desire to be near a therapist, motivated by a sexualisation of the therapist and a desire to manage power inequalities may resemble offence related dynamics and present significant risk for the therapist. The balance between managing risk and exploring a live dynamic that may facilitate insight and promote change is a delicate one and the wellbeing of the therapist should always take precedence. However, while a change of therapist or the introduction of an additional staff member may be necessary, it would seem important that such dynamics are explored.

While it is being suggested that an exploration of transference dynamics is important, making any connection between early childhood experiences and transference early in the therapeutic relationship might be inappropriate as there may not have been enough time to establish positive rapport. As has been argued throughout this chapter, the therapist qualities that facilitate the development of trust need to permeate the relationship.

6.4 Language and meaning construction

A final area for consideration within the therapeutic relationship is the use of language. The way we talk to and the way we talk about the people we work with will create meaning in our minds as therapists and in the minds of the people we work alongside. There are a number of ways that professional language can shape meanings that can be unhelpful, shame-inducing and disempowering of the people we work with (and thus resonating with earlier adverse experiences). First, we can use language that reduces a person to an action. Although this is common practice in many ways—we have footballers and musicians and solicitors and psychologists after all—we tend to do this to establish role rather than identity. In forensic practice, however, we often do this to establish identity rather than role and describe people as sex offenders or murderers, while in forensic mental health settings, it is common to hear someone referred to as ‘personality disorder’ (PD). By introducing a relational frame to our work we can shift from labelling to curiosity, from what is wrong with you to what has happened to you [60] and from what we can do to you to what we can do with you. We can begin to see (and experience) people as people, albeit people with convictions for violence, sexual violence or other forms of harm.

Second, we can begin to use a language that draws on our common humanity rather than amplifying our differences. Many of the psychiatric diagnoses are an illustration of the way that we can use our power status to impose meaning on people and highlight their difference (and often faulty difference). Attachment disorder, personality disorder and post-traumatic stress disorder are all examples of the ways that we can describe a human reaction in a manner that pathologises a person and therefore shifts our attention, perception and ways of relating—effectively shifting our social mentality.

Third, we can shift our attention (and therefore our perception and description) away from disorder and risk so that we notice when someone achieves, succeeds or progresses. We can highlight differences and support clients to identify the characteristics that facilitate resilience.

7. Summary

This chapter has attempted to explore both the nature and the significance of the therapeutic relationship in forensic settings, primarily those settings that deliver psychological work in a prescribed manner. Throughout it is recognised that psychological and psychotherapeutic interventions are heterogenous in nature and that there will be examples of transference-based or relationally-based interventions. However, it is similarly recognised that many, if not most people who engage in psychological work to address risk, experience CBT influenced and protocol-driven interventions. While these interventions are designed to address risk, they rarely consider how risk factors emerge across the lifespan and rarely allow the flexibility to explore the relational dynamics that can emerge in the context of a psychotherapeutic process. The theory of transference and attachment theory propose that early relational experiences texture and often contextualise subsequent relationships. Given the early relational experiences of people who engage in forensic interventions, the potential for toxic early relationships to texture the therapeutic relationship is significant. By considering the nature of this relationship, the dynamics that are brought into it and the dynamics that emerge within it, we may be able to add benefits to those that are sought through teaching skills and challenging offence related ways of being.