Forensic Psychology and Mindfulness
Case presentation for Sophie
This was for a Y3 university assessment. Sophie is a representation, not a real person.)
Sophie is a young, unmarried mother, aged 31, currently serving a three-year sentence for supplying class A drugs. She is three months into her sentence and is already reporting difficulty settling in, drug abuse, and mental health issues revolving around depressed mood.
While no diagnosis was given in the case study notes, her reported symptoms (e.g., low mood, withdrawal, low energy, and a sense of hopelessness) are consistent with the criteria for depression (e.g., NHS, 2019).
Furthermore, while there is no direct mention of suicidal ideation, or other problems (e.g., flashbacks), her personal history (e.g., child abuse, separation, neglect, drug usage, and unprotected sex) are consistent with a high ACE (Adverse Childhood Experiences) score1. It also corresponds with some of the criteria for Complex PTSD2 and or BPD (Borderline Personality Disorder)3 (e.g., 1Ford et al., (2019), 2Cloitre, (2020), Salters-Pedneault3, (2020a,b)).
Given the high correlation between ACE and BPD, especially inside prison settings, and the latest research (e.g., Jowett et al., 2020) showing overlap and correlation / co-morbidity between BPD and cPTSD, this report will consider these factors when formulating the intervention.
Possible causes for Sophie’s problems
While the provided case study offers valuable insights into Sophie’s background, history and immediate concerns and offers a tentative diagnosis and direction for therapy, it may take several sessions before uncovering the full extent of her mental health problems. This, of course, assumes Sophie is describing her problems truthfully and accurately.
Sophie’s problems and their direct and underlying causes may be divided into self-reported symptoms, whose understandable problems lie in her current incarceration, and external reports of issues whose cause may lie in actual and perceived events in her past. However, this analysis is complicated by the dearth of correlatable information, which may be filled in later sessions.
The BPS (2011) recommends that any formulation for the service user consider past abuse and trauma. As Liebling and Maruna point out (2005, cited in Harvey & Smedley, 2010), the symptoms Sophie reports (e.g. loneliness and depression) are “part of the experience of prison life”, so what stands out such that Sophie needed to be referred?
Sophie claims a lack of enthusiasm for ‘previously enjoyable pursuits, but no insight is offered into what these may be or how they are diminished. Similarly, questions may be raised over the accusations of her laziness. It may be inferred that because of her past, where she describes herself as ‘slave labour’ and ‘forced to work’, she directly relates her kitchen work in the prison to those experiences and is rebelling. Alternatively, though far less likely, she may have been coached over what to say in therapy and sees these sessions as an easy way to avoid work, or may simply be seeking attention.
Seen from a mindfulness perspective, given her dysfunctional childhood, one devoid of kindness and stability, it is reasonable to assume her schemas – her worldviews and ‘internal working models’ – are distorted. Her early childhood was traumatic and impoverished, her teenage problematic and resulting in pregnancy at 16, her adulthood disassociative and self-interested, culminating in her current situation. Her focus then has been on survival.
Now, removed from her perceived safe place, she is left to ruminate on her life – past, present, and future.
Using the arrows metaphor (Barker and Troy, 2017), the first arrow is her initial thought (e.g. “I am lonely”), and instead of focusing on that feeling, she is ‘constantly ruminating’. This rumination is the second arrow, actually a barrage of arrows, each flying to a new thought, feeding a spiralling downwards trend of negativity and hopelessness.
For instance, her first thought could be, “I miss my son, Olaf.” This could be quickly followed by wondering about her life if she had stayed with the child’s father. Still it leads to her missing her brothers. To “If only I had had better parents”. These then feed on fears of Olaf experiencing her life, an effect known as the cycle of violence (e.g. WHO, 2007).
The five areas models (Williams, 2003, cited in OU VLE, CBT (2.1), 2020) can help the flow of type of Sophie’s most challenging negative automatic thoughts. However, completing records of her dysfunctional thoughts outside of the therapy session can create more issues as Sophie would be worried about others seeing these. (e.g. Padesky, 1995, cited in Harvey and Smedley, 2010)
As several studies have suggested (e.g. Harvey and Smedley, 2010, Reavis et al., 2013), any treatment hoping to reduce recidivism needs to tackle these underlying schemas. The intervention needs to help Sophie focus on the now instead of dwelling on that past. To introduce helpful and positive thoughts to replace and reverse this process.
Factors maintaining Sophie’s problems
This report works on the assumption that Sophie is suffering from depression, complicated by as yet undiagnosed and pre-existing underlying mental health concerns. Using mindful rock stacking as a metaphor, her currently presented problems are balancing atop and supported and maintained by the other ‘stones’ she carries.
Just as pebbles can support boulders, Sophie is probably maintaining and worsening her depression by drawing on the negative support of these memories, thoughts and fears.
Consider attachment theory (Bowlby, 1982, cited in Barker and Cooper, 2017; Fraley, 2018). Supported by her case notes, there are associated psychological, cognitive, and physiological reasons that are likely to bolster and maintain Sophie’s problems (e.g. Ackerley, 2011a;; De Zulueta, 2001, cited in Barker and Cooper, 2017).
She cannot easily make friends because her life has taught her “not to trust other people”. Because she cannot make new friends easily, she is increasingly lonely and isolated, leading to further negative thoughts. It is a vicious circle.
Furthermore, this detachment is emphasised by systemic approaches and by even the briefest of genograms. Additionally, and by inference, the sparsity and conflicting nature of data gathered using this approach tentatively support a hypothesis that the lack of and need for connectively – for attachment – drives her emotions and conflicting mental states.
For instance – seen from a child’s perspective – her father, a violent alcoholic, effectively abandoned her aged seven. Her mother (in choosing unsuitable boyfriends over her welfare) abandoned her when she was ten. The child support agencies, separating her from her siblings and forcing her to be a “slave”, also abandoned her. The council, moving her away from her friends and her child’s father, caused her further abandonment. Then, arguably, as a consequence of being drawn to drug dealing, her dealer boyfriend (Alexie) abandoned her.
Furthermore, compounding this abandonment, there is no mention of any other relatives (e.g. aunts, grandparents, nor her now-adult brothers), no mention of friends visiting her, no further mention of her son. A son that, it must be emphasised, she left with ‘friends’ and neighbours – so abandoned – so she could visit old acquaintances, “people she used to hang out with.”
Thus systemic psychotherapy reasons and solutions can be ruled out as her social network appears limited to her son (now in care, presumably) and Alexei, also in jail.
Summed up from a mindful point of view, and using Bachelor’s metaphor (2001, cited in Barker and Cooper, 2017), rather than objectively analysing her anguish, she is clinging tightly to the pain, and lashing out, suffering and causing suffering, rather than letting go and moving on.
Factors that might help Sophie facilitate change
Several approaches may help facilitate change and improvement for Sophie, but many of these are problematic, a consequence of her childhood and subsequent life choices, and present unknowns. As mentioned at the start, in the case presentation, and supported by criminogenic theory (e.g., Howells, Day & Thomas-Peter, 2007, cited in Barker and Cooper, 2017), these factors need to be addressed, rather than take a reactive approach (e.g., Pederson, 2015, cited in Barker and Cooper, 2017).
Mindfulness may help. However, as many have pointed out, (e.g. Loy, 2013; Rockman, 2016; Barker and Cooper, 2017; Purser, 2019), it is not a panacea and is not without problems of its own, particularly in complex cases. That said, it can be used to calm her thoughts, and to be more compassionate towards herself. (Williams et al., 2007, Gilbert, 2010, cited in OU VLE, Mindfulness (5), 2020)
Rather than consider a solution that may help, it is sometimes better to consider what will not work and why and see what is left that may help. As we have seen above, systemic psychotherapy – apart from perhaps pointing out the broader societal damage her criminality caused – has little chance of helping. Cognitive Behaviour Therapy (e.g. Bruce, 2017) would prove less effective for potential complex causation in cases like Sophie’s, though helpful for individual concerns.
I would suggest that her currently presented problem (depression) results from underlying abandonment, so attachment-based counselling might seem to be a solution. However, given her case history, this is problematic as it originates in early, pre-verbal childhood and is a fixed schema (e.g. Ackerley, 2011a; Wallin, 2015, cited in Haley, 2017). Furthermore, it requires asking a person with deep-seated and automatic distrust to open up to and trust (an agent of) the people that locked her away. That is keeping her from the one comforting person in her life, her son. As Vossler et al. (2017) point out, this can be challenging.
It seems contrary, but the factors preventing Sophie from improving, from getting treatment that will help her change perhaps point to the best way to facilitate this change. From a mindfulness perspective, these are some of her ‘second arrows’. The ruminations, social avoidance, hopelessness, and other difficulties result from her thoughts running away from her emotions, her first arrows. This, I find, is particularly evident where she describes “difficulty concentrating, particularly on the jobs in prison.” Instead of focusing on the moment, on mindful appreciation for her job’s positive aspects, she is ruminating. Work becomes drudgery, drudgery becomes past ‘slavery’, which – perhaps – drags her thoughts to earlier and even less pleasant thoughts and memories.
Sophie has stated that she is ‘keen’ to overcome her difficulties, improve, be a better person, and be a better mother. However, she may not know how to.
The intervention needs to help improve her schemas. It must offer her some self-forgiveness, remind her that she is not responsible for her childhood programming.
Conversely, it requires her to fully understand the cost of her actions and accept responsibility for those choices. (Mitchell and Tafrate, 2014, cited in OU VLE, CBT (4.1), 2020). Awareness that her ‘lucrative’ business, the nice car, the holidays were funded by homes and businesses burgled by drug addicts to feed their habit. The depression, upset and hurt that causes. Equally, the families that are torn apart by addiction – another generation of children experiencing the trauma of her childhood – so she can have ‘nice’ things.
Suggested interventions and treatment plan
Previously, above, I have discussed CBT, attachment theory, touched on mindfulness and other topics, and while pointing out why this will not work, I feel there is also a way, in combination, they can help.
Approached from a common viewpoint, and indeed some forms of prison therapy (e.g. Gilbert, 2010), mindfulness is taught more physically – sitting correctly, breathing mindfully, or taking a moment to consider the food you are eating, its colour, taste, texture. Just doing, mindfully, but not mindlessly, Directing her conscious to observe, but not judge, not allowing it to take flights of fancy.
Unfortunately, while teaching her mindfulness techniques as above may help Sophie relax in her cell, to be more productive in the prison kitchen, even to improve her depression, such treatment is ineffective. It is unlikely to affect any meaningful or lasting improvement as it fails to approach her supporting maladaptive schemas.
Instead, I feel Sophia requires a multi-modal approach, something with the nurturing of attachment counselling, the cognitive rebalancing of CBT, the self-understanding, awareness and self-compassionate teaching of mindfulness. Sophie, to escape her past, to avoid falling back into old habits, old connections and recidivism, needs to learn to let go.
That therapy needs to agree with her understanding of the world – without undermining or dismissing it. Trust cannot come easily for someone like Sophie, but the right person can agree; yes, things were terrible. Nevertheless, also remind Sophie that she did bad things too – because her childhood did not teach her any better. That it does not excuse adult mistakes, but it allows forgiveness, stilling rumiination. As Gilbert (2010, p250) observed, you cannot sleep by asking yourself if you are asleep yet.
The treatment plan then involves Mindful Schema Therapy, which incorporates mindfulness, CBT, and other practises to help people with complex histories accept their past and learn to be present. This intervention is similar to the mindfulness of Dialectic Behaviour Therapy (DBT) and includes Mindfulness-Based Cognitive Therapy, but is less structured. The two do overlap, but this would be less structured and focuses on uncovering and acknowledging maladaptive schemas as a way of release; it is also better adapted for triggers for preventing ‘second arrows’ becoming overwhelming (e.g. Flink et al., 2018).
As the multi-agency partnership paper by Ford et al. (2019) concludes and recommends, “The criminal justice system could consider the provision of trauma-informed services.” This intervention plan supports that ideal.
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This essay was written for a year three paper on forensic psychology. It was praised for it’s content, then given a low grade of only 56% as, it seems, it didn’t fit the narrative of the university.
(It should be noted that other papers, one’s that tick the right boxes, get graded as high as 99%).
I had previously been told to
told to play the game and that
at this level of study you are not required to have your own thoughts. This, I remind you, was for the final year of an honours degree in forensic psychology! It seems they want you to critically assess – but to only think what they tell you to think!
I pointedly told them I’m not playing their game. My grades dropped accordingly. How can they ask you to ‘critically assess’ and tell you ‘there is no right or wrong answer’ – they fail you for not giving the ‘right’ answer? I could have written what they wanted, but I’d have learnt nothing. I would not have critically assessed, I would simply have believed the lie they tried to cram down our throats. The lecturer agreed with my views, but had to mark according to university doctrine.
It sounds like I’m bitter about my grade, but really I’m just disappointed in the university and question the point and usefulness a degree in these ‘modern times’. As I said to the tutor, words fail me, but it makes sense in this twisted world of ours. If you are not required to think, what is the point of a degree? Chomsky* is making more and more sense to me! This saddens me, but I guess it is what it is.
In one interaction with my tutor, I said, “paraphrasing a colleague, Naom Chomsky commented that “It’s not important what we cover in the class; it’s important what you discover.“. The module, interesting as it is, is basically a £20 book from Amazon, the sort of thing I’d normally read in a few days before picking up another and tossing it on a bookshelf with books like ‘Schema Therapy, a practitioner’s guide‘ and ‘The MIT encyclopedia of Cognitive Science‘.
Her reply was this:
I agree, if you are doing the degree purely for yourself, then the learning that you take from it is the most important thing. Perhaps you could reflect on, in this case, how much do the marks really matter if you have to compromise yourself to reach the higher ones?
Corporate Attack on Education, by Chomsky, 2012
(A Powerpoint presentation I did on paraphilias got a much higher grade, but, well, not something to share on a family site!)
(All links above are correct as at March 2021)