How the Good Lives Model Can Complement Mentalization-Based Treatments for Individuals Who Have Offended With Anti-Social Personality Disorder and General Forensic Mental Health Needs: Practice Update

Abstract

Limited research to date has focused on strengths-based rehabilitative approaches, such as the Good Lives Model (GLM) and the additive benefits such approaches have in ameliorating mental health needs of those in contact with forensic services. Mentalization-based therapies (MBTs) may be an effective treatment in forensic settings. This article aims to provide an overview of how GLM theory can integrate MBT within forensic settings. The review provides a conceptual overview of the many commonalities between GLM and MBT principles and provides information about how MBT can be embedded within forensic communities adhering to GLM principles. The article closes by offering an overview of the evidence of MBT approaches for individuals with anti-social personality disorder (ASPD) and those in contact with forensic services.

Keywords

mentalization Good Lives Model anti-social personality disorder mental health rehabilitation

Introduction

The reduction of violence is a priority of many disciplines, bisecting analyses that traverse the micro and the macro, from individual psychosocial factors to structural societal dimensions. Exposure and injury from violence has been associated with significant physical and mental health difficulties as well as financial costs associated with treatment and societal costs (Bellis et al., 2012).

The impact of violent crime is not confined only to the victims, as perpetrators with a diagnosis of anti-social personality disorder (ASPD) have a high level of comorbid physical and mental health difficulties (Byrne et al., 2013; Lenzenweger et al., 2007). Rehabilitation is therefore a multifaceted process that includes the reentry and integration of the individual into society and needs to focus on capacity building, skill acquisition, and the enhancement of emotional well-being along with the reduction of risk (Ward & Maruna, 2007). A number of strengths-based rehabilitative theories have been put forward to help clinicians and practitioners negotiate the challenges associated when working with incarcerated individuals. The aim of this article is threefold. First, it aims to highlight how mentalization-based therapies (MBTs; Bateman & Fonagy, 2016) can be readily adopted into broader strengths-based rehabilitative theories, such as the Good Lives Model (GLM; Ward & Brown, 2004) in aiding treatment goals and informing practice for incarcerated individuals with mental health difficulties, namely, ASPD. Second, the article highlights how strengths-based rehabilitative theories can complement and guide MBT informed treatments. Finally, a brief review of the effectiveness of the current MBT literature used either in forensic settings or with individuals diagnosed with ASPD is provided.

Rehabilitative Theories

Rehabilitative theories are comprehensive practice frameworks that have provided forensic practitioners with a blueprint in the management of individuals who offend for nearly the past 50 years. Such theories provide guidance on issues such as the level of risk and how to best manage and promote the individuals’ needs as well as that of wider society. Theories such as the Psychology of Criminal Conduct (Blackburn, 1993) and the General Personality and Cognitive Social Learning (GPCSL) perspective have attempted to provide frameworks as to the cause of criminal behavior. The dominant theory over the past number of decades has been the Risk–Need–Responsivity (RNR, Andrews & Bonta, 1998) model. Under the RNR model, the individuals’ level of risk, various responsivity factors, and criminogenic needs are targeted in an effort to reduce offending (Andrews & Bonta, 1998; Hanson & Morton-Bourgon, 2004). While RNR is seen as an important framework for offender treatment, criticism has increased of its sole focus on criminogenic factors to the detriment of other areas of need such as interpersonal and personal resources (Lindsay et al., 2007). Alternative approaches that attempt to factor in both criminogenic and individual needs have developed over the past decades—the most prominent being the GLM. The GLM (Ward & Gannon, 2006; Ward & Maruna, 2007; Ward & Stewart, 2003) distinguishes itself from the RNR model as it emphasizes a strengths- or capabilities-based approach to offender rehabilitation. Treatment, adhering to GLM principles, aims to provide individuals with the necessary competencies (internal conditions) and opportunities (external conditions) in achieving personal well-being that are socially acceptable and personally satisfying. While the central aim of the GLM is to build psychological and social capacities that help men and women to live more fulfilling lives, it also sets out to reduce the risk of further offending.

The GLM of rehabilitation posits that incarcerated individuals are given the skills, knowledge, and opportunities to achieve a life consistent with their individual values and in ways that do not harm others, and a recognition that differing individuals will require varying levels of support to develop the necessary skills required to devise and implement an offense-free, pro-social life (Ward, 2010). The model distinguishes between primary and secondary human goods. Primary goods, within the model, include the following: life, knowledge, excellence in work and play, agency, inner peace, relatedness, community, spirituality, happiness, and creativity. Secondary goods represent the means as to which primary goods are ascertained. It is through the pursuit of primary goods, individuals are given a sense of meaning and purpose in their lives. Alternatively, incarcerated individuals can use maladaptive means in attempting to secure primary goods. The GLM has been applied to various offending types, including domestic violence (Langlands et al., 2009) and sexual offending (Ward & Marshall, 2004), but little research to date has focused on using GLM to focus on incarcerated individuals with mental health difficulties, as well as those with ASPD. Conflicting evidence has emerged regarding the benefit of GLM theory on treatment outcomes. Some findings indicate that treatments adhering to GLM may enhance treatment outcomes (Barnao et al., 2015; Willis et al., 2014; Willis & Ward, 2013) dependent on the operationalization and integration of the approach, but other studies suggest no additive effects of GLM when added to RNR treatment practices (Andrews et al., 2011). Critics of GLM theory have queried as to whether all primary goods are equally weighed and the need to consider the extent to which GLM applies to all those who engage in offending behavior (e.g., Is it possible for individuals to value offending behaviors and see these as key aspects of their primary goods identity such as mastery, agency, and creativity?). Further criticism has focused on the relative lack of empirical support for GLM (Ogloff & Davis, 2004) and whether GLM adds anything to RNR theory (Wormith et al., 2012). Proponents of GLM argue that rehabilitative models are not treatment theories that focus on behavior change but more so integrative practice frameworks (Ward et al., 2012), and thus may be more difficult to evaluate in terms of effectiveness.

What is clear is the relative lack of research papers regarding the application of the GLM to incarcerated individuals with serious mental health difficulties (Vandevelde et al., 2017) such as personality disorders and those dealing with complex trauma. The application of the RNR model to persons with mental illness involved with the criminal justice system is at a far more advanced level than GLM (Wormith et al., 2012). Recent analysis has also found preliminary evidence of cognitive-behavioral therapy (CBT) being effective in addressing general risk factors but that there is limited evidence for the application of other RNR principles in treating an incarcerated population (Skeem et al., 2015). A further review of the extant literature found that many forensic practitioners tended to blend discrepant orientations together in attempting to provide a holistic treatment package for complex presentations and high client needs (Barnao & Ward, 2015). The authors noted the absence of an overarching theoretical framework that could provide practitioners with the breadth and scope to address the multiple needs of forensic clients. Regarding GLM, the limited treatments to date have focused primarily on CBT approaches that are to the fore in the management of physical and sexual violence (Fortune & Ward, 2014), but there is a marked absence of empirical support for GLM in improving treatment programs in addressing both public safety and public health goals. A number of recent systematic reviews of other third-wave therapies have suggested varying levels of adherence to rehabilitative frameworks, mainly RNR (Byrne & Ní Ghrada, 2019; Tomlinson, 2018), but it is unclear how many incarcerated individuals included in these reviews had a diagnosis of ASPD and how each RNR principle helped address and guide treatment.

Mentalization

The last decade has seen a growth in the use of psychodynamic approaches and the application of these to forensic populations (Yakeley & Williams, 2014). One such approach is MBTs. Mentalizing refers to the human imaginative ability to perceive and interpret the behavior of self and others as guided by mental states (Bateman & Fonagy, 2016). This entails an awareness of the dynamic and ever-changing nature of mental states in explaining how individuals behave. The act of mentalizing, as an imaginative mental state, entails a level of uncertainty and opaqueness in understanding minds. Although all individuals have a capacity to mentalize, there are innate variations in the ability that are linked to early experiences in the social environment (Allen, 2013; Bateman & Fonagy, 2008; Levinson & Fonagy, 2004). MBT, initially devised for individuals with borderline personality disorder (Bateman & Fonagy, 2004; Fonagy, 1991), has garnered an increasing level of interest from the correctional and forensic fields. Recent research has provided an overview of the potential use of psychodynamic approaches in both the formulation and treatment of violence (Taubner et al., 2017; Yakeley & Adshead, 2013) with MBT treatments coming to the fore.

The mentalizing model has been specifically applied to the development of anti-social behavior. The developmental conceptualization of the model posits that dysfunctional attachment systems may be associated with specific deficits in affect regulation and mentalizing abilities. ASPD has been characterized as a disorder of early attachment with a genetic vulnerability interacting with early environmental adversity resulting in difficulties of affect regulation, impulse control, and mentalizing ability (McGauley et al., 2011). Specific facets of mentalizing ability may therefore be compromised especially under certain conditions and specific circumstances such as threats to self-esteem, rejection, and psychosocial/environmental factors, leaving the individual vulnerable to violent and anti-social behavior (Holmes et al., 2001; Newbury-Helps et al., 2017). A number of studies have demonstrated higher insecure attachment styles with individuals incarcerated for violent crimes diagnosed with ASPD (Abi-Habib et al., 2020; Adshead, 2004; Frodi et al., 2001; Levinson & Fonagy, 2004); however, the exact mechanisms underlying the relationship between early trauma/rejection and the potential for violence are still not well understood (McCrory & Viding, 2015) and not all individuals with ASPD will necessarily have an insecure attachment style. Within this article, ASPD and associated violence will be conceptualized within a mentalizing framework that emphasizes the association between early maladaptive attachment styles (Shonk & Cicchetti, 2001) and behavioral responses to negative interpersonal interactions (Bateman & Fonagy, 2008). However, it is important again to stress that disorganized attachment alone cannot possibly explain the level of complexity inherent in interpersonal violence and aggression.

Mentalization Deficits

Regardless of attachment patterns, temporary problems of mentalizing arise in everyone when emotional arousal is elevated. ASPD has long been cited as impairing personal and social functioning (Wilson et al., 2017), and research suggests that individuals with ASPD demonstrate specific mentalizing deficits (Dolan & Fullam, 2004; Marsh & Blair, 2008) that may lower emotional reactivity and increase the propensity for offending behavior. However, a recent systematic review which included 22 studies found that individuals with ASPD did not present with specific empathy deficits but aberrant patterns of emotional reactivity and difficulties processing negative stimuli (Marsden et al., 2019). This suggests pockets of strengths as well as deficits in such individuals’ mentalizing abilities. Bateman and Fonagy (2016) argue that ASPD clients may show some enhanced mentalizing abilities without accompanying empathetic responses in certain areas to deceive and exploit others but that this hypermentalizing is not generalizable to more complex, interpersonal situations (Blair et al., 2006). Newbury-Helps and colleagues (2017) found that when compared with a non-offending control group, 83 male offenders on community license, 65% of whom met the threshold for ASPD, presented with a range of mentalizing impairments. The study also indicated that those diagnosed with ASPD had greater deficits in areas including hypomentalizing and non-mentalizing when compared with those individuals with no diagnosis of ASPD. Similar mentalizing deficits were also reported in a sample of 42 young individuals in contact with forensic services who exhibited poor reflective functioning (Möller et al., 2014). The differing array of findings indicates significant differences in the complexity and sensitivity of measures of social cognition and mentalization. This suggests that treatment targeting mentalization deficits in offender populations may be important in improving not only mental health difficulties but also offense-specific problems. The above also attest to the idiosyncratic nature of mentalizing difficulties occurring within specific contexts with this population and that mentalizing treatments track and treat specific impairments as they arise.

Can a Strengths-Based Approach Accommodate Forensic MBT?

A recent systematic review reported positive findings regarding strengths-based approaches specific to mental health issues (Tse et al., 2016). The review, comprising of seven studies, found that treatments adhering to strengths-based approaches can be implemented and are acceptable to clinicians. Specifically, the review found that such approaches are broadly effective in promoting treatment retention and helping to promote positive recovery attitudes in non-forensic individuals with severe mental health difficulties. It cannot be assumed that such positive findings can be inferred within a forensic setting due to a number of specific factors that may impede treatment type and delivery (e.g., incarceration, custody vs. care). GLM has garnered a growing research base regarding rehabilitation of various offender groups, but it is only relatively recently that its potential use as a framework for mental health difficulties with incarcerated individuals has been broached (Barnao, Ward, & Robertson, 2016). Very few studies to date have specifically focused on GLM for forensic mental health populations, but the limited findings so far accumulated broadly support GLM theory (Bouman et al., 2009; Simons et al., 2006) that fulfillment of primary goals reduced both short- and long-term offending among those with mental health difficulties.

A cursory glance indicates that the GLM could be a framework that sits comfortably alongside MBT theory in the treatment of incarcerated individuals with mental health difficulties. The former has been conceptualized as a broad map that is supplemented by other theories regarding intervention (Fortune & Ward, 2014). A strengths-based approach posits that incarcerated individuals’ personal priorities and interests are given full consideration when developing an intervention plan. Second, individuals are given the opportunity to build both psychological and social capacities to implement a Good Lives Plan (GLP) while also reducing the risk of offending behaviors (Fortune et al., 2014). These tenets are consistent with MBT treatment considerations. Like other evidence-based therapies, MBT provides a framework in understanding the mind, the possibility of change, and the implicit understanding that the offender has agency. Furthermore, building on the individuals’ capacity to reflect and think about mental states relevant to their mental health as well as pertinent to offense-focused work is a key component of MBT. MBT supports individuals to develop increased self-reflection on their own and others’ minds as well as meta-cognition and improved perspective taking, all things considered very important in the treatment of violent states of mind (Adshead et al., 2013) and all in alignment with GLM theory. Finally, the GLM and MBT take an implicitly relational approach in conceptualizing general human functioning and specifically how aggression and violence can manifest, especially in response to affect disturbances in relational contexts (Adshead et al., 2013). GLM has recently further explored this relational component through the development of the 3e framework that conceptualizes human functioning as embodied, embedded, and enactive (Dent et al., 2020). Specifically from this perspective, patterns of behavior and offending are enacted by embodied, sense-making agents, striving to survive and adapt in context. This viewpoint takes a more holistic understanding of the behavioral, affective, and, we would argue, mentalizing ability of the individual over more offense-focused theories. Advocates of 3e posit that it is a useful framework to serve at the locus of functioning in forensic theory as it focuses on presenting the individual as a functional whole. It also emphasizes affect and emotionality as drivers of behavior (Dent et al., 2020) and looks at idiosyncratic meanings and purposes underlying behavior and relationships. We would argue that mental states would also be an important consideration in helping understand behavior which is tantamount to mentalizing.

Similarly, supporting the capacity to identify mental states in others and self may not only be a protective factor for reducing violence but also increasing pro-social interactions and general functioning (Bateman et al., 2016). Interestingly, forensic male inpatients that completed personality disorder treatment indicated that among factors that promoted therapeutic change, one was increased trust in others that led to a reduction in egocentricity and improved empathy skills (Willmot & McMurran, 2013). Fonagy and Allison (2014) argue that epistemic trust (a belief in the authenticity and personal information interpersonally transmitted) helps the individual to relinquish the rigidity that is common among individuals with enduring personality difficulties. An increase in flexibility allows the individual to be open to learn from new experiences and achieve change in their understanding of their social relationships and their own behavior and actions. Fonagy and Allison (2014) suggest that the ability to feel understood opens biological routes to more appropriate information transmission and that this knowledge is generalizable and relevant to the individual. Thus, the ability to feel as though “kept in mind” enables further learning about the social world. This is someway consistent with the GLM idea of secondary goals and providing incarcerated individuals with more adaptive ways of meeting and obtaining their values. Whereas more cognitive models may look at attempting to change thinking or promote new behavioral repertories, MBT posits that reducing epistemic hypervigilance through therapy increases the individual’s ability to be open to learning new ways about the self and others. This recovery in the capacity for social information exchange (Fonagy & Allison, 2014) that occurs outside of the therapy room is seen as a proposed mechanism of change in MBT and is entirely consistent with an abilities-focused model such as GLM.

The GLM puts forward four areas of difficulties that reflect problems in the manner that convicted individuals use to pursue primary goods and seek to meet their needs. These include the individual having difficulties with the means of pursuing their primary goods, a lack of scope or variety in the types of goods being sought, and conflict in the goods being sought. Finally, and especially relevant for treatment approaches like MBT, GLM suggests that convicted individuals may lack the capacity in both internal (rigidity, perspective-taking problems) and external (lack of social support or pro-social friendships) means in pursuing goods (Langlands et al., 2009). MBT processes are broadly in line with the phase model of the GLM rehabilitation approach (Laws & Ward, 2010) that stresses the clear delineation of both the internal and external conditions that are required to accomplish the individual’s plan, which revolves around core goals/values. MBT is clear on gaining an awareness of interpersonal patterns activated when the offender forms relationships and how these manifest. MBT also notes that treatment goals should have a broader focus than just preventing violence and aggression, and this is not the sole focus of therapeutic work (Bateman et al., 2019a)—clearly in line with a strengths-based model and broader desistance theory in general (Farrall & Calverley, 2005).

In MBT groups, a focus is placed on affective understanding of self and others as well as relational patterns that can lead to both adaptive and maladaptive outcomes. Treatment aims to help incarcerated individuals identify and understand how others feel and be empathetic by continuously building representations of accurate affect states of others and self (Bateman et al., 2019b). These treatment goals are in line with emotional regulatory difficulties often witnessed in clients presenting with ASPD. Other related concepts such as alexithymia, impulsivity, and emotional non-acceptance have been found to be relevant treatment considerations when working with such clients. Garofalo, Velotti, and Zavattini (2018) reported that alexithymic traits, and motor and attentional impulsivity, explained unique variance in physical aggression, anger, and hostility in community and forensic samples. This may go some way in explaining the rigidity and inflexibility of non-mentalizing modes often displayed by such individuals with ASPD. The capacity to reflect on one’s feelings within a group may lead to significant emotional arousal for those with ASPD. In addition, asking an individual to speculate on the mental state of another in the group can be fraught with hostile interpretations as well as hypersensitivity and paranoid arousal (McGauley et al., 2011). This is complicated further by the fact that ASPD traits are associated with difficulties controlling impulsive, potentially aggressive behaviors when dysregulated (Garofalo, Velotti, Callea, et al., 2018). The natural wariness and distrust shown by individuals with certain mental health difficulties require an understanding of their values and identified goals before starting treatment. Exploration of interpersonal interactions, activation of attachment patterns within group, and exploration of sensitivity to hierarchies are all strategies within MBT for ASPD (Bateman et al., 2013). In line with GLM theory, MBT processes help individuals to develop a deeper awareness of life goals, priorities, and other primary goals. For example, a person’s interpersonal pattern can be summarized in a relational passport that is developed collaboratively during the MBT Introductory Group (MBT-I) and reflects an understanding of attachment strategies as well as focusing on the key process, namely, promoting the recovery of mentalizing within complex interactional and emotional processes (Bateman, Unruh, & Fonagy, 2019).

GLM can be conceptualized as an overarching structure within which MBT can be embedded. Similar to other therapeutic approaches used within the GLM framework, MBT can be seen as “wrapped around” individuals’ primary goods (Fortune & Ward, 2014). MBT posits that key to attaining these primary goods is the facilitation and development of mentalizing skills. The GLM has specifically focused on the iatrogenic aspects of treatment provision and what individuals perceive as repressive and coercive environments that limit access to and benefit from treatment (Barnao et al., 2015; Lilja & Hellzen, 2008) and subsequent access to primary goods. MBT has long stressed the importance of supervision given the challenges faced by such populations. Practitioners treating incarcerated individuals with mental health difficulties often have to simultaneously offer both support and restriction given the structured and segregated nature of forensic mental health services. Regular supervision of clinicians is important in not only maintaining treatment fidelity but also ensuring that a mentalizing environment is fostered. Practitioners are required to maintain a not-knowing stance and tracking non-mentalizing both in themselves and the group in helping individuals develop more appropriate secondary goods (means) in achieving primary goods (Bateman, Motz, & Yakeley, 2019). This is not limited to the therapeutic group room but also the wider prison environment, as well as when individuals leave custody and require supports in accessing other primary goods such as housing and work.

The GLM is able to accommodate an integration of the various components of forensic rehabilitation including treatment interventions focusing on mental health and offense-specific work, as well as issues relevant to practitioner and environmental factors. GLM theory puts to the fore the agency of the individual as does MBT in helping them formulate their wants and personal goals. MBT is not beyond the integration of more practical supports such as helping individuals overcome stressors and difficult social environments by having an MBT informed social focus (Bateman et al., 2019a), an area that GLM is ideally placed to provide guidance with. For example, the GLM also addresses the likely social environment that the individual will be returning to in the development of a GLP as part of the five-phase GLM approach. This GLP may focus on areas such as vocational, employment, or social networks, and is able to provide an overarching intervention framework. Whereas more traditional cognitive-behavioral approaches focus on improving certain skills or changing thinking, MBT instead focuses on linking actions to affect and internal mental states (Bateman et al., 2013; Yakeley & Williams, 2014) in the development of more appropriate mentalizing and the reduction of mentalizing for nefarious means. There is a clear need for more research on the specific elements of GLM and how they add to offender treatments. The increasing use of MBT approaches within forensic settings and with individuals diagnosed with ASPD may provide an opportunity to formally assess GLM as a means of enhancing service provision.

Effectiveness of MBT Approaches for ASPD and Forensic Populations

The field of forensic interventions for individuals incarcerated for violent and sexual crimes has historically been heavily weighted toward interventions adopting a cognitive-behavioral approach (Gibbels et al., 2019; Yakeley & Williams, 2014). The last decade has seen an increase in other therapeutic approaches, but this has led to limited advances or novel initiatives in the treatment of ASPD. A number of early reviews (Duggan et al., 2007; Warren et al., 2003) provided scant evidence for the effectiveness of psychological interventions with ASPD populations, with a number of studies focused on reducing comorbid difficulties rather than ameliorating ASPD traits. The NICE (National Institute for Health and Clinical Excellence) Clinical Guidelines for ASPD published in 2009 also confirmed that interventions for ASPD demonstrated limited effectiveness, in part due to high heterogeneity of offenders included and limited methodological rigor. This would suggest that alternative treatments are needed in addressing the needs of this client group. There has been a nascent evidence base for MBT approaches in the forensic field that we will briefly review here.

Adshead and colleagues (2013) reported on a pilot study using group MBT in a secure hospital for individuals convicted of serious sexual and violent offenses, as well as exhibiting violent behavior during admission. The group comprised of nine men, four who had a primary diagnosis of paranoid schizophrenia. Others in the group were diagnosed with dissocial personality disorder and mixed personality disorder. A total of 48 group sessions were conducted, and adherence to MBT was assessed although not reported. Self-report and behavioral data were assessed at 12-, 18-, and 6-month follow-up. Two men dropped out from therapy. Three individuals reported improvements in mindfulness although scores did not reach clinical significance. One individual reported clinical and reliable change on all scales of an interpersonal problem measure. The authors reported that findings were inconclusive. Methodological limitations, including small sample size, no control condition, or reporting of inferential statistics, combined with the lack of an objective measure of mentalization further temper findings.

McGauley et al. (2011) included a review of clinician’s experiences of running MBT treatment as part of a multi-site, outpatient pilot study. The article included therapist’s reflections on the patient profile and the difficulties in establishing the group and waning motivation of those presenting as potentially suitable. All males accepted on to the intervention were diagnosed with ASPD (n = 9). The ASPD-MBT program comprised of weekly group therapy and monthly individual therapy over an 18-month period. As well as measurements of risk and psychopathy, the study included a measure of aggression and violent behavior (the Overt Aggression Scale–Modified [OAS-M]; Coccaro et al., 1991) and general psychopathology (the Brief Symptom Inventory [BSI]; Derogatis & Spencer, 1993). Preliminary results indicated that patients reported a reduction in their aggression toward others and themselves over the first 6.5 months of treatment, but no improvement was noted on measures of irritability. Reductions were also observed on distress at 6-month follow-up as measured on the BSI, most noticeably on Depression, Anxiety, and Hostility subscales. Many of the limitations outlined in the Adshead et al. (2013) study are present in the reporting of these preliminary findings, and little conclusive evidence of MBT with ASPD can be drawn from these findings.

Byrne and colleagues (2016) piloted a four-session, alexithymia-specific intervention in the Irish Prison Service. Thirty-two men incarcerated for sex offenses attended a mindfulness and MBT informed intervention that aimed to increase emotional awareness and psychological mindedness. The psychoeducation program was informed by MBT psychoeducational components highlighted in Haslam-Hopwood et al. (2006). Findings indicated that those in the intervention group, compared with those in the control group, demonstrated significant improvements on both self-rated and interview measures of alexithymia, with large effect sizes noted. Similar improvements were also found on measures of psychological mindedness. No difference was found among incarcerated individuals on a measure of emotional regulation. The study provides preliminary evidence of the use of MBT principles in helping foster emotional awareness and identification, a noted area of deficit for a subcategory of individuals incarcerated for sexual offenses (Gillespie et al., 2012, 2018). However, the study’s lack of information regarding type of sexual offense and possible personality difficulties of group members limit the generalizability of these findings. Furthermore, the study did not include any treatment adherence measure or information on what other safeguards were included in ensuring fidelity. Findings from the Byrne et al. (2016) study raise some interesting questions. Research has indicated that clients with ASPD can struggle with specific aspects of mentalizing ability noticeably mindfulness (i.e., self-mentalizing) and that deficits in this area are associated with certain ASPD traits (Velotti et al., 2016). The above intervention seemed to be able to target and improve psychological mindedness through the use of mindfulness and MBT psychoeducational material. Mindfulness is just one process that focuses on mental states, which belong to a broader network of mentalizing abilities. Others have argued that although related, these concepts such as mindfulness and alexithymia are distinct enough aspects and may have differing links to aggression and anti-social tendencies and that this has ramifications for treatment depending on levels of mentalizing and aggression pre-treatment (Velotti et al., 2019).

A randomized controlled trial that included 40 individuals with dual diagnoses of ASPD and borderline personality disorder (BPD) aimed to assess the effectiveness of MBT (n = 21) as opposed to structured clinical management (SCM; Bateman et al., 2016) in an outpatient clinic delivered by non-specialist practitioners. The MBT intervention comprised of 18 months of weekly individual and group therapy. Irritability and aggressiveness were assessed using the structured clinical interview (SCID-II). General interpersonal functioning and psychological distress were also measured. Those in the MBT group demonstrated a significantly greater reduction in anger and hostility symptoms than those in SCM. Neither group showed any significant changes in domineering interpersonal style. Findings also indicated that at treatment end, those in MBT presented with fewer impulse control difficulties and social adjustment problems. This study provides the most promising evidence of MBT in the treatment of ASPD although the lack of a specific mentalizing outcome measure limits evidence of supposed mechanisms of change. The generalizability of the study’s findings into correctional and forensic settings requires more research. At this time, there is only tentative evidence highlighting the potential utility of MBT in promoting mentalizing among individuals in contact with forensic services or diagnosed with ASPD. To date, there is little evidence that MBT has been used as a means of addressing offense-specific work and its impact on reducing recidivism.

Discussion

The Future Use of GLM for Forensic Mental Health Needs and MBT

This article has attempted to explore how GLM can help titrate the implementation of MBT that aim to address forensic mental health needs. MBT has been shown to be an effective treatment for a range of presenting difficulties (Byrne et al., 2020; Malda-Castillo et al., 2018), but evidence for its use in forensic settings and with clients presenting with ASPD is at a nascent level. Advocates of GLM informed mental health interventions have argued that it can provide an overarching and holistic framework that enables seamless integration of various components of offender rehabilitation, including risk management, assessment, process, and practitioner issues relevant to a forensic population (Barnao, Ward, & Robertson, 2016). This article contends that MBT and the processes and therapeutic stances taken within, in theory, are compatible with an abilities-focused rehabilitation model such as GLM. Both approaches focus on pragmatic concerns in establishing interventions that take into account the high needs of those with ASPD and other mental health difficulties, as well as the wider contextual factors the can hinder and impede interventions both inside and outside of the secure setting. This focus is not unique to GLM or MBT. However, both of these approaches highlight the need for content and delivery of interventions that are consistent with promoting the individuals’ primary needs, the procedural aspects of therapeutic programs, and practices to be tailored to the needs of the individual rather than automatically slotting individuals into already existing treatments that focus on skills deficits or risk. MBT groups in forensic settings offer individuals with an opportunity to promote mentalizing skills that are underdeveloped and decrease those that are overdeveloped.

At this time, there is only preliminary evidence that suggests additive effects of GLM over other rehabilitative theories, as well as minimal evidence for the use of MBT in forensic settings. Recent research has provided qualitative accounts of both GLM (Barnao et al., 2015; Barnao, Ward, & Casey, 2016) and MBT (Thomas & Jenkins, 2019) in both forensic settings and with clients with ASPD. Although these accounts are illuminating, further adequately powered studies are required to see not only the respective benefits of each approach but also what additive effects could MBT gain from inclusion in forensic settings that adhere to GLM principles. MBT principles do not stop at the treatment door, and further research may focus on the factors that promote embedding of the intervention into the wider forensic setting and with other custodial staff. The positive effects of MBT have been reported at macro levels, for example, in school settings (Fonagy et al., 2005), and further research may benefit from looking at how to foster an atmosphere of mentalizing in forensic settings and how this could boost individual’s experience of moving toward their primary goals and the adaptive means as to how they gain them.

Conclusion

The current study is, to the author’s knowledge, the first that aims to address the implementation and conceptual issues related to the use of MBT treatments within the GLM. MBT, its principles, and goals are readily compatible with a strengths-based approach to forensic rehabilitation specific to individuals with significant mental health needs. The current study provides an overview of the application of MBT in both forensic settings and with individuals diagnosed with ASPD. Ultimately, the application of MBT and GLM informed principles in the rehabilitation of incarcerated individuals with mental health difficulties will be dependent on whether such approaches are effective in not only addressing anti-social behavior but also fostering an atmosphere in which the individual has the capacity to move toward a desired life.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gary Byrne

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