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: Colin.Cameron@theroyal.ca

Journal of Nursing Management, 2012, 20, 296–297

ª 2012 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 296–297 297