A window of opportunity: psychological work in a women’s

prisonDawn Whittaker

Health Adviser, Women’s Health Clinic,

HMP Holloway

11th September 2009

Thanks

• Teams, present and past

• Elizabeth Howell, my clinical supervisor

Outline

• Work of WHC

• Range of counselling interventions

• Case study 1: HIV throughcare

• Case study 2: brief one-to-one intervention

• Case study 3: in-depth work informed by attachment theory

Women’s Health Clinic

• Sexual health clinic• Contraception• Cervical screening• Gynaecological assessments and referral• Breast examination and referrals• Facilitating HIV care• Facilitating Hep C treatment• Counselling and advice

Vulnerable clients:findings Gabriel et al (2008)

• Sample of 289 young women offenders (aged 17 to 21) at Holloway

• 13.2% chlamydia prevalence

• 80% no condom during LSI

• 18% CSW

• 53% previous STI

• 63% previous pregnancy

Further findings

• 60% used crack cocaine

• 42% injected heroin

• 48% left school at 16

• 43% left school at 14

• 4% left school at 11

Common presenting problems

• New HIV diagnosis• Living with HIV (in prison and the community)• Hepatitis C• Risk-taking behaviour • Sex work• Sexual assault• Childhood sexual abuse• Sex trafficking

Range of counselling interventions

• Crisis intervention counselling

• Contract-based time-limited counselling

• On-going and intermittent supportive work

• Advocacy and casework

• Assessment and referral

• Sexual health is the primary focus

• Type and level of counselling depends on patient need

• Even information giving depends on use of counselling skills

• Time frame that has to be worked within(Leach 2004, SSHA Manual)

Key aspects of counselling

Window of opportunity

Window of opportunity

• Una McCluskey (2005) To be met as a person: the dynamics of attachment in professional encounters. Karnac.

• Jeremy Holmes (2001) The search for the secure base: attachment theory and psychotherapy. Brunner-Routledge.

HIV clients - audit data

• Vulnerable clients, with complex medical, psychological, and social problems

• 8/17 (48%) had a serious addiction• 7/17 (41%) had a severe and enduring mental health

problem• 5/17 (29%) had a dual diagnosis• 7/17 (41%) were homeless (NFA)• 10/17 (59%) had immigration issues • 11/17 (65%) were irregular or non-attenders at their

treatment centres

HIV throughcare

• A process from admission to release• Timely assessment• Identification and organisation of medical,

psychological and social needs• Liaison, referral and advocacy• Counselling and advice• Pre-release planning

Case Study 1

• HIV throughcare

• Intermittent supportive work

• Advocacy and casework

• Assessment and referral

Context for Case Study 2

• NICE guidelines (2007)- Identify high risk individuals

- One-to-one structured discussion

• Motivational interviewing- Clinical style for eliciting from patients their own good motivations for making behaviour changes in the interest of their health. - Guiding and listening. - Collaborative, evocative and honouring patient autonomy.

(Rollnick, Miller and Butler 2008)

Readiness for change

• Importance (the why of change)

• Confidence (the how of change)

In brief conversations these two words are sufficient to access the motivational features, both restraining and encouraging change.

(Miller and Rollnick 2002)

Case study 2

• Brief one-to-one intervention

• Risk reduction counselling

Attachment theory

• Three dimensions of insecure attachment laid down in infancy:

Avoidant, Ambivalent and Disorganised• Template for how we negotiate

relationships throughout life (Perry 2009)

• Adult narratives reflect childhood attachment patterns (Holmes 2001)

Case study 3

• In-depth work informed by attachment theory

References

Gabriel G, Burns T, Scott-Ram R, Adlington R, Bansi L. (2008) ‘Prevalence of Chlamydia trachomatis and associated risk factors in women inmates admitted to a youth offenders institute in the UK’ Int J STD AIDS;19(1):26-9.

Holmes, Jeremy (2001) The search for the secure base: attachment theory and psychotherapy Brunner-Routledge

Leach, George (2004) ‘Counselling’ The Manual for Sexual Health Advisers SSHA

McCluskey, Una (2005) To be met as a person: the dynamics of attachment in professional encounters Karnac

Miller, William and Rollnick, Stephen (2002) Motivational interviewing: preparing people for change Guildford Press

Perry, Andrea (2009) ‘Insecure attachment and its consequences’ HCPJ, July 2009, 3-7.

Rollnick, Stephen, Miller, William and Butler, Christopher (2008) Motivational Interviewing in Health Care Guildford Press