Letter to the Editor: Responding to Civilizing the ‘Barbarian’
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Transcript of Letter to the Editor: Responding to Civilizing the ‘Barbarian’
Letter to the Editor: Responding to Civilizing the �Barbarian�
Dear Editor,
While we applaud Holmes and Murray (2011) for
looking at the ethical implications of behaviour modifi-
cation programmes in vulnerable, disadvantaged forensic
and correctional populations, we find their paper,
�Civilizing the �Barbarian�: a critical analysis of behaviour
modification programmes in forensic psychiatry settings�to be rather one sided. A recent meta-analysis of behav-
iour modification programmes done in correctional
settings done by Paul Gendreau et al. (2011) looking at
29 studies (n = 1033) between 1965 and 2004 found that
the mean percentage improvement on the target behav-
iours during experimental phases, compared with base-
line phases, was 62%, an effect size as good or better than
other interventions. The authors of this study also sug-
gest, based on their review of the literature, a number of
practical implementation and treatment principles for
developing such programmes to be effective, not the least
of which is emphasizing positive reinforcement over
punishment. Certainly there are ethical concerns and
cautions that need to be heeded when behavioural
modification programmes are implemented in forensic
milieus, but our experience also suggests such pro-
grammes can be developed in such a way that the benefits
outweigh the negatives.
Our facility is a 100-bed hybrid correctional centre
and mental health centre whose mandate is to provide
mental health services to seriously mentally ill adult
male inmates serving a provincial sentence (<2 years).
Correctional staff are primarily responsible for the
safety and security of the residents and staff, and the
operation of the building, while health-care staff are
responsible for the provision of mental health care.
Health-care staff prioritize health-care needs, while
correctional staff prioritize correctional treatment and
security requirements. Often these needs are comple-
mentary, and when challenges arise, case consultation
ensues to ensure the most appropriate response.
We first implemented a rewards-based behaviour
modification program (BMP) in 2009 to address con-
cerns that we were overly relying on correctional
practices to manage inmate behaviour, rather than
providing incentives to follow institutional rules and
collaborate constructively with staff and co-residents in
treatment. We would concur with Holmes and Murray
(2011) that punishment-based programmes such as the
one described in their article are ethically unacceptable.
In our BMP residents earn points for following institu-
tional rules and engaging in specific pro-social behav-
iours and, depending on the number of points earned
each week, they obtain tickets which can be redeemed
for privileges they would not otherwise have (e.g. late
night, extra yard time, extra gym time, small snack
items, etc.) There is no consequence for not earning
points or opting out of the programme, except for
having a lower point tally (or no points if they opt out)
at the end of a week, hence fewer or no tickets. Resi-
dents are also given an opportunity to make up points if
they violate the rights of others by making amends
through carrying out a plan if it is acceptable to the
aggrieved person(s). It should be noted that, on average,
in a given week about 80% of residents earn maximum
points. It should also be pointed out that residents have
been repeatedly surveyed for their feedback on this
programme, which continues to evolve based on their
response. Although there have been, and still remain,
valid criticisms of this programme, it is our intention in
the future to carry out a more formal evaluation of this
programme in order to provide further validation of the
benefits and potential gaps in the BMP.
We would concur with Holmes and Murray (2011)
that it would be ethically dubious if a BMP were to be
the only treatment modality provided. However, it
should be noted that our BMP is only a very small part
of what we offer. Residents undergo a comprehensive
biopsychosocial assessment looking at risk factors and
rehabilitation needs, including psychiatric diagnoses,
addictions, and educational, vocational and leisure
needs. Based on these assessments they are then offered
a personalized care plan. These plans can include
medication management, levels of responsibility, indi-
vidual and group psychotherapy (over 20 group treat-
ment options), education, vocational counselling, work
placements, recreation and spiritual care. On occasion,
owing to a resident�s unique needs, he may be offered an
individualized behaviour plan that operates indepen-
dently from the BMP. In an ideal world, such individ-
ualized plans might be offered to all, but resource
limitations make this impractical.
Letter to the Editor, 2012, 20, 296–297
DOI: 10.1111/j.1365-2834.2011.01370.x296 ª 2012 Blackwell Publishing Ltd
In their paper, Holmes and Murray (2011) appear
to reify autonomy as the primary ethical consider-
ation to the exclusion of all others. They lose sight
that unimpeded autonomy for one individual can in-
fringe on the autonomy, safety and rights of others,
and this is especially relevant in a correctional milieu.
It should also be noted that they do not offer any
practical alternatives for milieu management which
rewards-based BMPs try to address. It is our view
that mental health treatment in such settings requires
balancing autonomy with the utilitarian principle of
what is the greatest good for the collective. While we
do not claim to have perfected this balance by any
means, we do believe our experience with BMPs
demonstrates their potential utility towards achieving
this.
References
Gendreau P., Litswan S. & Kuhns J. (2011) Making prisoners
accountable: the potential of contingency management
programs. Criminal Justice & Behaviour (submitted).
Holmes D. & Murray S.J. (2011) Civilizing the �Barbarian�: a
critical analysis of behaviour modification programmes in
forensic psychiatry settings. Journal of Nursing Management
19, 293–301.
Colin Cameron M D C M , F R C P C 1
and Wendy Stewart M S W 2
1Clinical Director and 2Director, Patient Care Services,
Integrated Forensic Program – Secure Treatment Unit,
(St. Lawrence Valley Correctional & Treatment Centre),
Royal Ottawa Health Care Group,
Brockville, Ontario, Canada
E-mail: [email protected]
Journal of Nursing Management, 2012, 20, 296–297
ª 2012 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 296–297 297