Abstract
BackgroundMental health professionals working in correctional contexts engage a double role to care and control. This dual loyalty conflict has repeatedly been criticized to impede the development of a high-quality alliance. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma.MethodsThis qualitative interview study investigates patients’ perceptions of their therapists’ dual role conflict in court-mandated treatment settings. We interviewed 41 older incarcerated persons using a semi-structured interview guide, the interviews were subsequently analyzed following thematic analysis.ResultsWe first present the patients’ perceptions of their treating psychotherapist’s dual loyalty conflict, which was linked to their overall treatment experience. In a second step, we outline the study participants’ reasons for this judgment, which were most commonly linked to feelings of trust or betrayal. More specifically, they named certain therapist characteristics and activities that enabled them to develop a trustful therapeutic alliance, which we grouped into four topics: (1) respecting the patient’s pace and perceived coercion; (2) patient health needs to be first priority; (3) clarity in roles and responsibilities; and (4) the art of communication – between transparency and unchecked information sharing.DiscussionDeveloping a high quality alliance in mandatory offender treatment is central due to its relationship with recovery and desistance. Our findings show that some therapists’ characteristics and activities attenuate the negative impact of their double role on the development and maintenance of the alliance. To increase the effectiveness of court-mandated treatments, we need to support clinicians in dealing with their dual role to allow the formation of a high quality therapeutic alliance. Our qualitative interview study contributed to this much-needed empirical research on therapist’ characteristics promoting a trustful relationship in correctional settings.
Highlights
The goal of court-mandated treatment orders is to reduce the risk of recidivism in mentally ill persons in detention (Dowling et al, 2018)
Correctional settings come with specific challenges and characteristics to treatment (Meyer et al, 2019) such as handling limited confidentiality during interactions with representatives of the justice system or being asked to manage risk and restrictions posed on this population (Dowling et al, 2018)
All study participants positioned their psychotherapist on the triangle indicating that they were aware of the mental health professionals’ dual role in this setting
Summary
The goal of court-mandated treatment orders is to reduce the risk of recidivism in mentally ill persons in detention (Dowling et al, 2018). Correctional settings come with specific challenges and characteristics to treatment (Meyer et al, 2019) such as handling limited confidentiality during interactions with representatives of the justice system (e.g., therapists have to provide a report on a person’s treatment progress and the risk of further offending) or being asked to manage risk and restrictions posed on this population (e.g., privileges are granted and revoked by legal authorities, these decisions may be based on therapists assessment on the therapy progress) (Dowling et al, 2018) This requires additional skills specific to this environment to create a therapeutic alliance with their clients. As therapeutic alliance is a robust predictor of outcome measures of psychotherapy, it is essential to investigate the effects of this ethical dilemma
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