TREATMENT OF VIOLENT BEHAVIOR / PERSONALITY PSYCHODYNAMIC PSYCHOTHERAPY

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Forensic Psychology (PSY - 513)

Lesson 29

TREATMENT OF VIOLENT BEHAVIOR / PERSONALITY

PSYCHODYNAMIC PSYCHOTHERAPY

OBJECTIVES:

To get an insight about the stages of change

To understand the use of violence reduction scale, integrating the risk assessment and

change measurement together for therapeutic purposes

To understand that while using VRS, How we actually measure change

To find the answer that how psychodynamic model works for the treatment of violent

criminals

Topics from previous lectures

Stages of Change

The Trans-theoretical Model of Change or the Stage of Change Model was developed by Prochaska et

al, 1992, it addresses the issue of treatment readiness, treatment change and the need to match treatment

delivery to client readiness. The model postulates that individuals who modify their problem behaviours

progress through a series of five stages:

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Pre-contemplation

Is marked by absence of any desire to change.Criminals in the pre-contemplation stage have neither

insight nor intention to change in the foreseeable future. They are often in denial and blame external

factors. Do not consider crime as some thing bad. Like a chain smoker denying the adverse effects of

smoking on health.

Contemplation

Those in the contemplation stage are fence-sitters; they acknowledge their problems but have shown no

relevant behavioural change: `all talk, no walk'. But at least in this stage they have started thinking about

the change. Like a smoker has started thinking about quitting the smoking, although no behavioural step

is taken yet.

Preparation

Those in the preparation stage combine intentions to change with relevant behavioural changes to

address problems. However, changes tend to be recent and/or quite unstable.( e.g.cutting down the

number of cigarettes)

Action

Those in the action stage actively modify their behaviours, attitudes and environment to address their

problems; overt behavioural changes are made, commitments followed through and energies expended

to change.( a smoker has completely quitted the smoking but only three to six months have passed so

we can not say that he will maintain his behaviour)

Maintenance

In the maintenance stage, the desired behaviour is maintained over a long period of time like one year or

more. Relapse prevention techniques are used to consolidate, strengthen and generalize the gains made

in the action stage.

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Forensic Psychology (PSY - 513)

Treatment is a process of change. The primary goal of correctional treatment is to bring about positive

changes in criminogenic needs leading to risk reduction. Treatment changes must be assessed

objectively and systematically to determine the amount of risk reduced. Assessment and treatment must

be closely integrated: assessments of the clients' risk, need and responsivity should inform treatment

providers of who to treat (risk principle), what to treat and how to deliver treatment, in particular to

treatment-resistant clients Clinicians who provide correctional treatment require the appropriate tools to

assess risk, needs, responsivity and treatment readiness, and to measure treatment change.

The VRS was developed by Wong & Gordon, 2006 and is designed to integrate the assessment of

risk, and treatment change into a single tool. It assesses the clients' level of violence risk, identifies

treatment targets linked to violence, assesses the clients' readiness for change and their post-treatment

improvements on the treatment targets. Treatment improvement or lack thereof is linked to quantitative

changes in violence risk.

Qualities of Violence reduction scale

The VRS allows the practitioner to exercise reasonable clinical discretion while maintaining structure

and scientific rigor. This scale is one of the best, as integrate the idea of risk assessment and change

measurement together for therapeutic purposes.

It provides a quantitative measure of the risk of violent recidivism of forensic clients, in

particular, those who are to be released from an institution to the community

It uses both static and dynamic variables that are empirically or theoretically linked to violence to

assess and predict violence.

Identifies treatment targets linked to violence; dynamic variables that receive high ratings (rated 2

or 3) are considered relevant treatment targets.

It uses the well established Transtheoretical Model of Change to assess change as a function of

treatment linking changes in treatment to changes in risk.

It identifies the client's stages of change (treatment readiness) which tells the service deliverer

what therapeutic approach to take that would maximize treatment efficacy.

It allows service deliverers to assess pre- and post-treatment risk levels.

How Do We Actually Measure Change?

Move from one stage to the other is measured as a decrease of one point

Total change in dynamic factor is added together.

Sum of the all change points is taken as measure of change.

In addition, according to the Transtheoretical Model of Change, the client's ideal behaviours at each

stage of change should be matched with appropriate intervention: the responsivity principle. As such,

assessment of the client's stage of change also identifies the most appropriate therapeutic approach to

take. A brief summary of therapist tasks that correspond to each stage of change follows:

Pre-contemplation

The therapist should: focus on developing a working alliance, enhancing motivation for change and

engagement in treatment; raise doubts and create dissonance regarding the client's current functioning

and his hopes of achieving future goals; use cost-benefit analyses to highlight the cost of criminal

behaviour.

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Forensic Psychology (PSY - 513)

Contemplation

The therapist should: tip decisional balance; evoke reasons to change in order to reduce dissonance;

strengthen the client's confidence to effect change (i.e. increase self-efficacy).

Preparation

The therapist should assist the client in: determining the best course of action to change; setting and

achieving shorter-term behavioural goals that are planned, observable, measurable and relevant;

highlighting successes and emphasizing change potential.

Action

This is the main skill-teaching and skill-building phase of treatment. The therapist should assist the

client in strengthening skills through over practice and reinforce client's self-efficacy in problem-solving

and achieving treatment goals.

Maintenance

The therapist should: assist and encourage the client to practice and generalize learned skills to new and

challenging situations by providing access to such situations; identify strategies and interventions to

prevent lapses and relapses. Obviously, strengthening and reinforcing the client's self-efficacy is

important whenever the client takes steps to make changes, regardless of the stage of change.

How to treat a violent personality?

Gordon & Wong, 2000 developed a program with the Integration of assessment and treatment of

violence-prone offenders. A risk reduction focused correctional treatment program for violence prone

forensic clients.

We have discussed different psychological models of violence. Now we will discus s that how these

approaches can help in treating a violent, crimnogenic personality.

Psychodynamic model

Psychodynamics provides a unique opportunity for therapist and patient to discover and to explore the

violence, both conscious and unconscious. We have discussed in detail the basic concepts of this model;

now will view the application of those concepts into forensic psychology.

Freudian assessment

Using a psychodynamic approach, clinician may assess through HTP. As discussed earlier, individual

is asked to draw a house, tree and person and then those drawings are interpreted. No special equipment

is required for this test.

House drawing represents family

Tree drawing tells about the ego strength and growth potential.

While drawing of person depicts the self esteem and ego strength.

Two qualities /benefits of using this test are that:

1. It not only allows assessing the personality.

2. But also permit to begin communication in a meaningful way.

HTP is a very good test to start a therapeutic relationship, because it permits a window into the soul of

the person. On one hand therapist is communicating with criminal so working toward making a rapport

on the other hand by interpreting the drawings treatment targets are identified like if the ego is too much

strong are weak, steps are taken to balance them.

The primary use of the HTP, however, is related to the qualitative scoring scheme in which the test

administrator subjectively analyzes the drawings and the responses to questions in a way that assesses

the test taker's personality. For example, a very small house might indicate rejection of one's home life.

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Forensic Psychology (PSY - 513)

A tree that has a slender trunk but has large expansive branches might indicate a need for satisfaction. A

drawing of a person that has a lot of detail in the face might indicate a need to present oneself in an

acceptable social light.

Other methods of interpretation focus on the function of various parts in each of the drawings. In the

house drawing, the roof might represent one's intellectual side, the walls might represent the test taker's

degree of ego strength, and the doors and windows might represent the individual's relation to the

outside world. In the tree drawing, the branches might indicate the test taker's relation to the outside

world and the trunk might indicate inner strength.

One crucial thing for consideration is the cultural differences in interpretation of HTP, a chimney on

roof with smoke may indicate warmth and satisfaction in England but the same drawing has totally

different indication in our culture, smoke can points to the aggressive and violent environment of

family.

Common sense is more important then the HTP manual in forensic settings.

While heeding a psychodynamic approach, a clinician will also explore the following phenomena and

will estimate the severity of problem. We are not going to dwell on description of these concepts as we

have already discussed in detail.

Psychosexual stages (how individual developed and what was the surrounding environment

and family attitude toward child)

Fixations at different stages

Oedipal conflict ( relationships with father , mother are analyzed)

The role of defense mechanisms (which defense mechanism is person using more frequently

like blaming others all the time, or rationalizing e.t.c)

Personality factors (presence of any personality disorder is identified as individuals with PD

are comparatively difficult to treat)

Starting therapy

In psychodynamic methods, focuses on the depth and breadth of the clinical experience itself: entering

into the inner world of patients and their object relationships, meeting and facing feelings as they

emerge within transference and the countertransference. No relationship starts with out transference and

counter transference. A therapist needs to be alert and attentive to resolve the transference counter

transference issues.

Transference

Transference is the client's unconscious redirection/projection of feelings for one significant to the

therapist. (Perceiving therapist as father or mother)

Counter Transference

From a psychodynamic perspective, countertransference is an inevitable part of all patient-therapist

contact. In its broadest sense it means the therapist's emotional response, which stems both from the

specific relationship with the particular patient and from the character and disposition of the therapists

personal life. Conscious countertransference can usually be controlled and may shed useful light on

aspects of the patient's personality and ways of relating. Clearly, it remains an essential task for the

clinician to meticulously observe the inner feelings after every session and discuss under supervision to

crystallize the vision.

Therapeutic relationships

Once the therapist has resolved the all transference and countertransference issue and fantasy

relationship evaporates, the real therapeutic relationship emerges.

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Forensic Psychology (PSY - 513)

Techniques

Following techniques are used:

Free association (client is asked to express what ever comes in mind with out any censor)

Dream interpretation (earlier dreams are considered as current sate of mind and later dreams in

therapeutic process are considered as a change that has occurred as a result of therapy)

Re-parenting

Is the emotional support from therapist (will discuss in detail in next lesson)

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