Prison-based democratic therapeutic communities,medication,and the power to exclude

Summary

This analysis explores whether a fair, proportionate, and evidence-based rationale exists for several of the prison-based democratic therapeutic communities choosing to exclude those who require psychotropic medicines. It examines the impact of this practice on those whose care pathways comprise both hospitals and prisons.

Introduction

Therapeutic communities (TCs) have a history going back centuries ¹ and provide those made vulnerable by their suffering with mental disorders an intervention in which in interdependence and mutual concern is enshrined within the created communities. ² These communities exist in various settings, including in prisons. ³

In 1962, the first custodial Democratic TC (DTC) was established in the English prison estate at HMP Grendon. ⁴ Today, the Category B male prison estate in England and Wales has three DTCs at HMP Dovegate, HMP Gartree, and at HMP Grendon. Each of these prisons also has an equivalent ‘TC+’ for prisoners with learning disabilities. There is one DTC in the female estate at HMP Send.

DTCs have been used for many years in an effort to help people with personality disorder (PD) and there is evidence of their effectiveness. ⁵ They should be distinguished from addiction therapeutic communities^6,7 which are an intense form of treatment for substance misusers, with 24 h, seven days a week, total immersion into treatment.

DTC treatment is relevant to patients and clinicians working within secure psychiatric hospitals and in prisons, in particular for patients diagnosed with PD, many of whom may be prescribed psychotropic medicines as part of their treatment.^8–13

For those prisoners transferred to secure hospitals from prison for treatment, there is a strong likelihood of a return to prison when their treatment in hospital is complete. Remission, and intended future prison treatment, is a pathway matter that should be discussed with patients early in their admission and integrated into treatment care planning. In so doing, the integrity of the justice process is maintained. ¹⁴

Many of those patients who remit to prison may continue their therapeutic engagement in a DTC or a TC+. The option of a future placement in such a unit and at the point of remission to prison is an appealing one for many patients who are extremely distressed by the thought of returning to a mainstream prison environment. For many patients, hospital transfer has allowed them to feel a sense of belonging and being cared for, possibly for the first time. However, by virtue of engaging positively in treatment and progressing through the course of their treatment in hospital, an exceptional paradox arises. This is because transferred prisoners who engage more meaningfully in treatment are more likely to be liable to return to prison more promptly than those who do not engage as proactively.

For those who remit to prison, DTCs arguably present a more sympathetic custodial environment for those who suffer from PD and offer many a means to progress along a care pathway that helps satisfy sentence plans and resulting parole board requirements.

This paper is descriptive in nature and identifies the hurdles faced by many patients with PD who are detained in secure psychiatric facilities and in prisons and who may hope to secure placements within a DTC.

Accreditation and the offender personality disorder programme

DTC and TC+ services fall under the remit of the offender personality disorder (OPD) programme and descriptions of them are provided in the Brochures of Offender Disorder Services.^15,16 The OPD Programme is a jointly commissioned initiative that aims to provide a pathway of psychologically informed services for a highly complex and challenging group of prisoners who are likely to have a severe personality disorder and who pose a high risk of harm to others, or a high risk of reoffending in a harmful way. ¹⁷

A ‘therapeutic community’ is a treatment in its own right ⁵ and each DTC and TC+, like other offending behaviour programmes, has been accredited by the Correctional Services Accreditation and Advice Panel (CSAAP). This is a body of experts who review programme design, quality assurance procedures and findings, and who inspect the written manuals for all accredited programmes to decide whether or not they are likely to reduce reoffending and so to decide whether or not a programme should be accredited. All programmes are reaccredited every five years by CSAAP.

Entry criteria or a rationale for exclusion?

The OPD brochure sets out a range of information for all of the OPD services. They fall under a number of headings, including ‘Entry Criteria’.

The entry criteria for the DTC at HMP Dovegate include, inter alia, the following:

Every applicant is considered on an individual basis, but in general must be willing to sign up to weaning off any anti-depressants within six months.

And:

Prisoners must not be taking any form of psychotropic or opiate-based medication for a period of two months prior to arrival.

The HMP Dovegate TC+ requires that its entrants must have no current diagnosis of major mental illness, and that their use of psychotropic medication should conform with the ‘Medication Policy’.

The entry criteria for HMP Gartree's DTC states:

They also need to be free of psychotropic medication, such as anti-psychotics, anti-depressants, mood stabilizers and tranquilizers, or be willing to come off such medication in consultation with a GP and/or psychiatrist

At HMP Send, there is a requirement that the prisoner must not be suffering from a severe and enduring mental illness.

The implication then may be clear: prisoners are forced to choose between psychotropic medicines or participation in a DTC or TC+. There has been extensive email communication by one of the authors (CR) with the OPD Programme about the matter. The correspondence began in June 2015, but despite much to-and-fro in the period in the years since, there have been no changes made to the DTC entry criteria.

No argument based in evidence was included in the course of this exchange to set out the reasons why DTCs might choose to exclude those who might be stable in their mental state but who continue to require psychotropic medicine to achieve this. The authors could find no evidence to explain or justify the stance adopted in a search of the relevant literature. One of the stronger arguments identified was that contained in the 2017 book, The Theory and Practice of Democratic Therapeutic Community Treatment ² :

The broader rationale behind this approach is probably related to the emphasis in TCs on agency. Members are encouraged to resist impulsivity and develop the capacity to put their feelings into words rather than actions. This is part of the encouragement and development of personal agency, the idea that each member has the ability to act in ways that are helpful or unhelpful both to themselves and those around them, and that this involves a series of decision which are their responsibility. Medication can undermine this approach, giving the message that you might be unable to control yourself, talk in group, or in extreme cases survive, without psychopharmacological help. The locus of control is located externally (in the pills), rather than internally, thus the patient becomes disempowered. Once prescribed, there is the additional problem of the medication being used as a coping strategy in emergencies, thus undermining the development of psychological coping strategies.

It has also been suggested that medications may interfere with therapy by way of drowsiness or an inability to attend fully, such as with tranquilizers or sedatives, ¹⁸ or a ‘false’ elevation of mood with antidepressants. ¹⁹ Few would argue that the quickly effective and alternative coping strategy offered by benzodiazepines might assist in DTC treatment, given also the impairment upon the formation of emotional memory caused. Most would also accept that opiates produce an altered mental state that people with PD can use to ameliorate distress and might choose as an alternative to establishing longer-term strategies leading to a better quality of life. However, beyond these classes of drugs, there is a dearth of evidence-based reasons to exclude, and it is possible that exclusion may relate to this emphasis placed on personal agency. It is perhaps in this context that one can look to try to understand how a description of a recovery from depression achieved with the prescription of an antidepressant might be described as being ‘false’ in some strands of TC theory.

But in so doing, it also follows that if we might accept that a message is being given to others of a reliance on an external locus of control, then there is also ample opportunity in TC theory to consider the development of an opposite message. The authors see no reason that a message cannot be developed whereby TC participants might come to learn that taking an antipsychotic that might help to prevent a relapse of psychosis, or an antidepressant which might alleviate fatigue, can assist in participants’ engagement in therapy and that this can increase the likelihood of the person benefiting from the intervention.

Of note, the Community of Communities ¹ makes no reference to the use or non-use of medication in TC practice.

The Forensic Faculty of the Royal College of Psychiatrists have made their position clear in 2021:

The Faculty remain concerned at the potential for discrimination if individuals who would benefit from therapeutic communities are excluded because they have a co-morbid mental illness that is stabilised on medication. ²⁰

The Psychotherapy Faculty have confirmed that their position is the same. ²¹

Case examples

The future

The opportunities that TCs may provide our offender population should not be overlooked. Three of the four included studies^22–25 in a 2019 Cochrane review of offenders with co-occurring drug and mental health problems ²⁶ found that TCs were associated with reductions in recidivism.

More recently still, a 2021 systematic review ²⁷ and meta-analysis of 29 RCTs of interventions in prison to reduce recidivism after release found that TCs bucked the trend of no effect and were associated with decreased rates of recidivism (OR 0.64, 95% CI 0.46–0.91). The authors suggested that TCs and interventions that ensure continuity of care in community settings should be prioritised for future research.

However, in the only randomised study of DTC treatment for people with personality disorders we could locate, ⁵ there is no record of its participants’ psychotropic prescriptions. The only reference made to medication is to acknowledge that consideration of psychotropic medication was a constituent part of the treatment as usual (TAU) group. No mention is made of psychotropic usage in the DTC group. The authors stratified to balance for age, gender, and baseline service utilisation only. They did not consider a psychotropic prescription to be a possible confounding variable. They did so in a study where just under half of each arm suffered from a major depressive disorder at baseline.

It is interesting that this RCT did not consider psychotropic prescription and the question of what rationale and evidence there might be for prison-based DTCs to exclude those prisoners prescribed psychotropic medication is not assisted.

To explore this question, a starting point in any research might be to compare the psychiatric histories of the DTC and TC+ graduates with other offenders in the prison population and to examine the relative amounts of psychotropic medicines prescribed in both groups.

It is possible, likely even, that those with treated mental disorders may have had less exposure and experience to DTC and TC+ units. Whether it might also be the case that this mentally disordered group may have had poorer outcomes (and/or served longer sentences before parole) is of course unclear, and future research might attempt to evaluate the possible cost of their possible missed opportunity.

Conclusions

There are many psychiatrists^20,21 who consider that it is counter-therapeutic to prevent prisoners whose lives and health outcomes have been improved by the careful prescription of psychotropic medicines the opportunity to progress in their sentence by way of participation in a DTC or TC+. Such psychotropic regimens established in hospitals for transferred prisoners, or in prisons by prison inreach teams, are carefully constructed in a way that they can continue in prison.

It seems counter-intuitive, and perhaps discriminatory, that such stark exclusion criteria should be set down in print. Many prisoners have missed out on the DTC or TC+ opportunity because they suffer from a mental disorder for which they require effective pharmacological treatment. There is an absence of a clearly reasoned argument that might serve to justify the exclusion of such prisoners.

In the case of those prisoners transferred to hospital for treatment, the fact emerges that some may be denied the means to continue the treatment that has helped them to become well enough to be able to return to prison. In turn, it is possible that a proportion of these persons may be returned to hospital should their mental health decline following remission. There are significant cost implications here.

DTCs have evolved not in isolation but as part of modern health care. They have a place within custodial mental health provision and we should harness their potential to accept and to accommodate more prisoners than they currently do. Tolerance of the status quo for any longer is irrational: there is a need for evidence to permit effective decision-making in patients’ and prisoners’ best interests. The authors argue that there is a need for high-quality and outcome-focused research to examine whether a continued practice of excluding those with mental disorders in need of pharmacological treatment can continue to be justified, or whether it is a discriminatory practice and should stop.