It has been well established that people with learning disabilities are over represented in the prison population, Loucks (2007) reports that about 20-30% of the prison population may have a learning disability and yet little is known about the mental health needs of this group.
Women account for only 5% of the prison population and yet 47% of all recorded incidents of deliberate self-harm are by women. Furthermore, 51% of women who leave prison are reconvicted; this suggests that programmes in place in prison are not effective for women (Cabinet Office Social Exclusion Task Force 2009).
The Cabinet Office Social Exclusion Task Force (2009) reported that 51% of women in prison have severe and enduring mental health problems and upon their arrival in prison 73% are on medication. If transferred to a healthcare forensic service, women are often referred to high security services (Coid et al., 2000) and even though women are only 5% of the prison population, they represent 25% of the forensic health population (Woods & Collins, 2003).
It appears as though female offenders differ significantly from men in relation to offending, and psychiatric diagnosis and resulting mental health needs but there has been little research on treatment for challenging behaviour displayed by women with learning disabilities and mental health problems, Coid et al . (2000) report that this means there is little known to help with specific service provision for female offenders with LD and mental health needs.
The paper being summarised here systematically reviewed the current evidence for Cognitive Behavioural Therapy (CBT) for women with learning disabilities and mental health needs that have forensic care needs.
The review focused on research based, peer-reviewed publications between 2000 and 2013. This was decided due to recent changes in legislation and service development for people with LD.
The researchers searched the main online databases for social sciences and medical research. The keywords they used to complete the search appear to be complete. However they did not report undertaking a manual search of reference lists, which seems to be usual when undertaking a systematic review. They also did not report searching grey literature, such as doctoral theses.
The search included descriptive designs, correlational studies, quasi-experimental or experimental designs and had the following inclusion criteria:
- Peer reviewed paper, published in English, between 2000 and 2013.
- Focus on evidence regarding the use of Cognitive Behavioural Therapy (CBT) in the treatment of offending by women with forensic care needs who have a dual diagnosis of LD and mental illness; and/or
- Gives evidence-based advice on service development.
The initial search revealed a total 2,124 articles. 98% of these were excluded when screened on the basis of their title and the year of publication and gender, reducing the number of articles to 138. Following removal of duplicates and review of abstracts four papers were left that met the above criteria.
All the studies used CBT based group interventions, with all but one reporting a single group design. The other used a quasi-experimental design.
Two aimed to reduce factors associated with fire setting and two aimed to reduce anger.
All reported some improvements following interventions, although not all improvements were significant. The authors reported that the progress after treatment varied due to the complex histories of women with LD.
The authors also state that
[…]the literature suggests that reducing anger by applying relaxation techniques appears to be non-effective. This implies that women’s aggressive behaviour is not the result of arousal in a particular situation but might be more deeply rooted in the women’s biographies (Allen et al. 2001).”
Taylor et al. (2002) are reported to have some concerns about the use of groups with fire setting behaviour and so they recommended:
part of their group intervention to be reviewed […] as some group dynamics appeared to reinforce rather than challenge motivations for female fire-setting behaviour.”
The authors note that there is an evidence base that indicates that the needs of women with LD in forensic services are different and distinct and yet…
…the evidence base in relation to women with ID with forensic care needs is limited.”
Strengths and Limitations
It seems as though the authors have made good use of this systematic review to highlight the limited evidence for psychological interventions for women with learning disabilities and forensic needs. However, this report leaves me wondering whether the level of detail included was necessary to help us understand the current evidence base. It would seem that a briefer report may have been as useful.
The authors report searching online databases; however they did not also do a manual search of references lists to ensure that they had not missed any studies.
With these things taken into account, the authors have undertaken and presented a good account of a systematic review that would be replicable by others in the future as the research base increases.
Summary and Analysis
It is clear from this review that, although women with learning disabilities account for a substantial minority of people with LD in forensic services, the evidence for specific psychological interventions is lacking.
The type of offences that women with LD commit vary substantially from men with LD. It is apparent that there has been much more research focus on treatment programmes for the type of offences that men are more likely to commit, such as sexual offences, and it would seem that the number of studies excluded on gender highlights this point.
From the description of the research that has been reviewed it is apparent that Taylor et al. (2002, 2006), Allen et al. (2001) and Lindsay et al. (2004) have demonstrated promising results.
It seems from John Taylor’s group’s work that a CBT treatment group for fire setting behaviour is effective at stopping this behaviour at a two year follow-up.
Bill Lindsay’s group show that anger treatment groups are a useful treatment in reducing in self-reported anger. These are positive results that need to be taken forward and repeated in other forensic settings.
It would seem unjust for women with LD to be admitted to forensic health services when there is so little research about their specific treatment needs. By undertaking and publishing this review the authors have shown a substantial gender bias in forensic LD research, which needs to be addressed. It would seem that a research and treatment collaboration, such as SOTSEC-ID, which supports professionals providing treatment to men who display sexually offensive behaviour may be a way to expand the research base for treatment for women with LD who offend.
Hellenbach, M., Brown, M., Karatzias, T. & Robinson, R. (2015) Psychological interventions for women with intellectual disabilities and forensic care needs: a systematic review of the literature. Journal of Intellectual Disability Research 59, 319-331 [abstract]
Allen R., Lindsay W. R., Macleod F. & Smith A. H. W. (2001) Treatment of women with intellectual disabilities who have been involved with the criminal justice system for reasons of aggression. Journal of Applied Research in Intellectual Disabilities 14, 340–7.
Cabinet Office Social Exclusion Task Force (2009) Short Study on Women Offenders. Home Office, London.
Coid J., Kahtan N., Gault S. & Jarman B. (2000) Women admitted to secure forensic psychiatry services: I. Comparison of women and men. The Journal of Forensic Psychiatry 11, 275–95.
Lindsay W. R., Allan R., Parry C., Macleod J. C., Overend H. & Smith A. H. W. (2004) Anger and aggression in people with intellectual disabilities: treatment and follow-up of consecutive referrals and a waiting list comparison. Clinical Psychology and Psychotherapy 11, 255–64.
Loucks N. (2007) Prisoners with Learning Difficulties and Learning Disabilities – Review of Prevalence and Associated Needs. Prison Reform Trust, London.
Taylor J. L., Thorne I., Robertson A. & Avery G. (2002) Evaluation of a group intervention for convicted arsonists with mild and borderline intellectual disabilities. Criminal Behaviour and Mental Health 12, 282–93.
Taylor J. L., Robertson A., Thorne I., Belshaw T. & Watson A. (2006) Responses to female fire-setters with mild and borderline intellectual disabilities to a group intervention. Journal of Applied Research in Intellectual Disabilities 19, 179–90
Woods P. & Collins M. (2003) Exploring relationships between inside communication and social skills in mentally disordered offenders. Journal of Psychiatric and Mental Health Nursing 10, 518–25.