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

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