Implementing a Therapeutic Service in a Women’s Prison

Summary

This report evaluates the suitability of four therapeutic approaches—

attachment-based therapy (ABT), cognitive behavioural therapy (CBT),
systemic therapy, and mindfulness—for implementation in a women’s
prison. The request follows an inspection that identified high levels of
trauma, self-harm, and suicide attempts, particularly among women with
histories of domestic and sexual abuse. After considering the complex
needs of this population and the institutional challenges of prison settings,
attachment-based therapy is recommended as the most appropriate
intervention. ABT is a trauma-informed, relational approach that
addresses emotional dysregulation, trust issues, and self-harming
behaviours commonly observed among incarcerated women. Although
CBT and mindfulness offer useful tools, and systemic therapy provides
broader contextual insight, ABT most effectively addresses the
psychological and relational needs of this population. It is recommended
that ABT be delivered through individual sessions, supported by peer-led
support groups and staff training in trauma-informed care, to maximise its
effectiveness within the constraints of the prison environment.
Implementation considerations and evidence-based justifications are
outlined in support of this recommendation.

Introduction

As an external consultant with knowledge of trauma-informed

psychological approaches, I have been asked by the governor of a
women’s prison to produce a report following a recent inspection. The
inspection raised serious concerns about high levels of self-harm, suicide
attempts, and complex psychological needs among the prison population.
This report evaluates four therapeutic approaches and recommends the
most appropriate intervention for this setting.
Background

A recent inspection identified significant concerns about high levels of self-

harm and suicide attempts among the women in custody, many of whom
have complex psychological needs. These include long-standing trauma
histories, such as childhood sexual abuse, domestic violence, and
disrupted caregiving relationships, which are known to contribute to
emotional dysregulation and insecure attachment styles (Haley, 2017).
These difficulties are often intensified by the prison environment, where
limited privacy, high surveillance, and an institutional focus on control can
directly conflict with the conditions needed for psychological work to take
place (van Linschoten, 2020, p. 284). As a result, therapeutic
relationships in prison may be influenced by forensic priorities such as risk
assessment and sentence planning, which can affect the development of
trust and emotional safety (DD310, Week 2, Section 3.1).

Types of Service Provision in a Prison Setting

When designing a therapeutic service for a women’s prison, it is essential

to consider the format of delivery as well as the therapeutic approach.
Common models include individual therapy, group therapy, and
therapeutic communities. Individual therapy offers a confidential and
consistent space for exploring sensitive experiences such as trauma and
abuse, at a pace that suits the client. This format is particularly valuable
for women with insecure attachment styles, as it supports the
development of a secure therapeutic relationship, a key mechanism of
change in attachment-based therapy (Haley, 2017, p. 191). This is
especially important in prison settings, given the relational challenges and
mistrust often experienced by female inmates (DD310, Week 17,
Section 3.1).

Group therapy may offer peer support and help reduce isolation, but it is
often unsuitable as a primary intervention for trauma survivors. Group
settings can unintentionally replicate dynamics of judgment, exclusion, or
competition, particularly damaging for women who have experienced
abuse or betrayal in interpersonal relationships (DD310, Week 17,
Section 3.1). According to Bright, Higgins and Grealish (2022),
women in prison often prefer therapeutic environments where they feel
safe, heard, and individually supported, which is more reliably achieved in
one-to-one sessions (Bright, Higgins and Grealish, 2022).

Peer-led support groups, however, differ in structure and purpose. They

are not designed to deliver therapy, but to create informal spaces for
shared experience, emotional validation, and skill reinforcement
(Covington and Bloom, 2007). When paired with individual ABT
sessions, these groups can complement therapeutic work while avoiding
the pressures and risks of formal group therapy dynamics. Women with
complex trauma histories may find it difficult to trust others or feel safe in
a group setting, especially in the early stages of recovery (DD310, Week
17, Section 3.1). Therapeutic communities are rare in the prison system
and require significant time, space, and cultural buy-in. While promising,
they are not easily implemented in most custodial environments due to
institutional priorities around control and risk management (van
Linschoten, 2020, pp. 284–285). These challenges are also reflected in
the difficulty of establishing sustained therapeutic provision in forensic
settings (DD310, Week 2, Section 3.1).

Given the constraints of the prison environment, a combined model

comprising individual ABT sessions, peer-led support groups, and staff
training in trauma-informed care offers the most realistic and effective
structure. This approach supports psychological safety, consistency, and
relational depth—elements consistently prioritised by women receiving
mental health care in prisons (Bright, Higgins and Grealish, 2022). It
also aligns with the core mechanisms of change outlined in attachment-
based therapy, which emphasise the importance of a secure therapeutic
relationship (Haley, 2020, p. 191).
Overview of Therapeutic Options

There are four main therapeutic approaches under consideration for

implementation within the prison: attachment-based therapy, cognitive
behavioural therapy (CBT), systemic therapy, and mindfulness. Each has
different aims, techniques, and suitability levels for a forensic setting.
These approaches are widely used and evaluated within prison-based
psychological interventions (Yoon, Slade and Fazel, 2017).

Attachment-based therapy is grounded in the work of Bowlby and focuses

on how early relationships with caregivers shape our ability to form secure
emotional bonds in adulthood (Haley, 2020, p. 190). If these
relationships were disrupted, individuals may develop insecure
attachment styles, leading to difficulties with trust, emotional regulation,
and relationships. These patterns can be explored and reshaped in
therapy within a secure therapeutic relationship (Haley, 2020, p. 191).
This approach is particularly valuable in working with behaviours linked to
trauma and neglect, both of which are common among women in the
criminal justice system (DD310, Week 17, Section 3.1).

Cognitive Behavioural Therapy (CBT) is a short-term, structured approach

that helps individuals identify and change unhelpful thinking and
behaviour patterns. It focuses on the “here and now” rather than
exploring childhood or unconscious processes (Bruce, 2020, p. 206).
CBT is widely used in prisons and frequently integrated into offending
behaviour programmes because of its clear structure, measurable
outcomes, and effectiveness in addressing issues such as anxiety,
depression, and impulsive behaviours (DD310, Week 18, Section 1.3).
Systemic therapy views psychological problems not as individual failings,
but as patterns that emerge in relationships and social systems (Vossler,
Squire & Bingham, 2020, p. 224). It is often used in family and
community settings and explores how individuals relate to others. In
forensic contexts, systemic therapy may help address relational patterns
contributing to offending behaviour. However, it can be more challenging
to implement in prison due to the limited access to family or community
systems (DD310, Week 19, Section 2.2).

Mindfulness-based approaches involve helping individuals become more

aware of their thoughts and feelings without judgment. This can support
better emotional regulation and reduce reactivity, particularly useful for
individuals who struggle with anger, impulsivity, or distress (Barker &
Cooper, 2020, p. 239). Mindfulness has become increasingly common in
forensic and prison settings and is often delivered as group-based
programmes such as Mindfulness-Based Cognitive Therapy or Dialectical
Behaviour Therapy (DD310, Week 20, Section 2.1).

Evaluation of Approaches in a Forensic (Prison) Context

Attachment-based therapy (ABT) is particularly well-suited to the needs of

women in prison, many of whom have complex trauma histories, including
abuse, neglect, and disrupted relationships (Richards and Reid, 2020,
p. 126). These types of early adversity are also discussed in relation to
psychological outcomes in prison populations (DD310, Week 12,
Section 1.2). Such experiences often result in insecure or disorganised
attachment styles, leading to emotional dysregulation, difficulties with
trust, and high levels of distress in adulthood (Haley, 2020, p. 190). ABT
works to create a secure therapeutic alliance that replicates the nurturing,
attuned caregiving that may have been absent in childhood.

In forensic settings, ABT can offer significant benefits. It fosters long-term

emotional healing and helps individuals develop healthier interpersonal
skills, which are crucial for both reintegration and long-term rehabilitation
(DD310, Week 17, Section 2.3). Furthermore, ABT aligns with the
trauma-informed care model advocated for vulnerable populations,
including female offenders (DD310, Week 24, Section 3.1).

However, the practicalities of implementing ABT in prison are challenging.

It is a long-term, relational therapy, which contrasts with the short-term,
outcome-focused culture of many correctional services. Confidentiality
and trust may also be compromised in a prison setting where security
often prioritises therapeutic needs (van Linschoten, 2020, p. 284).
Nonetheless, it remains one of the most appropriate approaches for
addressing the deep-rooted issues of the prison’s female population,
particularly when supported by staff trained in trauma-sensitive practice
(DD310, Week 2, Section 3.1).

CBT is widely used in forensic settings and has strong institutional support
due to its structured, manualised format and focus on measurable
outcomes (Bruce, 2020, p. 206). These characteristics make it
particularly suitable for prison-based interventions (DD310, Week 18,
Section 1.1). CBT is also effective in helping individuals manage anxiety,
depression, and anger by challenging unhelpful thoughts and behaviours
(Bruce, 2020, p. 206).

Furthermore, when applied through targeted programmes, CBT has been

shown to reduce reoffending by addressing criminogenic thinking
(DD310, Week 18, Section 4.1). However, CBT’s focus on the “here and
now” may be less effective for individuals with unresolved trauma. Women
with histories of abuse may require relational and emotional safety before
they are ready to engage in cognitive work (Reeves and Taylor, 2020,
p. 270). CBT also assumes a level of mental and emotional insight that
may not be accessible to individuals experiencing severe distress or
dissociation (DD310, Week 18, Section 3.2). Additionally, it can feel
overly clinical or detached, failing to account for the gendered and
systemic roots of many women’s offending (DD310, Week 8, Section
2.2). As such, it may be best used as a complementary rather than a
stand-alone intervention in this context.

Systemic therapy offers a relational lens on psychological distress, viewing

behaviours and symptoms shaped by interpersonal dynamics and cultural
context (Vossler, Squire & Bingham, 2020, p. 224). It has strengths in
exploring how past and present relationships influence patterns of
behaviour and helps enable clients to understand their position within a
broader social system, including issues of power and control (DD310,
Week 19, Section 2.1).

However, systemic therapy presents clear limitations in a prison setting. It

often relies on the involvement of family members or other external social
system resources, which are not readily accessible in most custodial
environments (DD310, Week 19, Section 3.2). Additionally, the
abstract and dialogical nature of systemic approaches may not meet the
immediate needs of individuals in acute emotional distress or at risk of
self-harm (DD310, Week 19, Section 3.2). While systemic thinking can
be helpful for staff training or broader organisational change, its use as a
front-line therapeutic tool within prisons is limited by environmental
constraints.

Mindfulness-based interventions, including Mindfulness-Based Cognitive

Therapy (MBCT) and Dialectical Behaviour Therapy (DBT), have shown
promise in helping people manage emotional distress, reduce self-harm,
and increase self-awareness (Barker and Cooper, 2020, p. 239). These
interventions are particularly accessible in group settings, are relatively
low-cost, and can be delivered by trained facilitators within the prison
(DD310, Week 20, Section 2.2). Mindfulness fosters present-moment
awareness and non-judgmental acceptance, which can be empowering for
individuals who have experienced shame, trauma, and emotional
overwhelm (DD310, Week 20, Section 3.1). It may also enhance
resilience and reduce symptoms of anxiety, depression, and impulsivity—
issues commonly reported by incarcerated women (DD310, Week 23,
Section 2.1).

Nonetheless, mindfulness on its own may not be sufficient for individuals

with complex trauma histories. Without a secure relational context or
psychotherapeutic support, mindfulness practices could potentially trigger
distress or flashbacks, particularly when individuals are asked to “sit with”
overwhelming emotions (Reeves and Taylor, 2020, p. 273). As such,
mindfulness may be better positioned as a supplementary tool within a
broader therapeutic strategy.

Key Issues: Self-Harm, Suicide, and Trauma

Women in prison are disproportionately affected by complex trauma, self-

harming behaviours, and suicide risk. Female prisoners are significantly
more likely than men to have experienced childhood sexual abuse,
domestic violence, and other forms of interpersonal trauma (Richards
and Reid, 2020, p. 127). These experiences may manifest in adulthood
as emotional dysregulation, dissociation, and suicidal ideation—symptoms
that are especially acute in restrictive environments like prison (DD310,
Week 12, Section 1.2).

Self-harm and suicide are often coping strategies for overwhelming

emotional pain, rather than simply indicators of mental illness (Reeves
and Taylor, 2020, p. 269). Self-injury, such as cutting or burning, can
offer a temporary sense of control or relief from emotional numbness,
while suicidal thoughts may reflect a deep sense of hopelessness or
powerlessness. Incarcerated women often report that the prison
environment, with its emphasis on control and discipline, replicates the
dynamics of abuse they experienced in the past, exacerbating these
behaviours (DD310, Week 23, Section 2.3).
Attachment-based therapy is particularly relevant because it addresses
the relational wounds underpinning many self-harming behaviours.
Women with insecure attachment histories may not have learned to
regulate emotions through healthy interpersonal relationships (DD310,
Week 12, Section 1.2). Instead, they may turn to harmful strategies
such as isolation, dissociation, or physical harm to manage distress. ABT
helps these individuals relearn emotional regulation in the context of a
secure, validating therapeutic relationship. It also provides a model for
building trust, a foundational step toward long-term psychological healing
(Haley, 2020, p. 191).

While CBT can challenge negative thinking and reduce impulsive

behaviours, it may fall short when individuals are too dysregulated to
access rational thought processes (Bruce, 2020, p. 208). Although
mindfulness-based interventions can support emotion regulation, they
may retraumatise individuals if introduced without an appropriate
therapeutic foundation (Barker and Cooper, 2020, p. 241).

An additional layer of complexity lies in the fact that many women who
self-harm do not necessarily view themselves as mentally ill, but rather as
coping with intolerable emotions in the only way they know how (DD310,
Week 23, Section 1.1). This highlights the importance of therapies that
do not pathologise these behaviours but offer compassionate
understanding (DD310, Week 23, Section 1.1). ABT supports this
stance by exploring the origins of distress and validating emotional
experiences, rather than seeking to “correct” behaviour (Haley, 2020, p.
191).

Moreover, self-harm and suicidal behaviour are often interlinked with

histories of disempowerment, where the individual has felt unheard,
unsafe, or out of control (Reeves and Taylor, 2020, p. 270). Rebuilding
a sense of safety through therapeutic attunement and empathy is
essential to any sustainable intervention (DD310, Week 24, Section
3.2). This again aligns strongly with the principles of attachment-based
work.
The high prevalence of trauma, self-harm, and suicidality among female
prisoners is well-documented (Richards and Reid, 2020, p. 127). These
patterns of distress highlight the relevance of attachment-based therapy,
which offers a relational and trauma-informed approach that addresses
underlying emotional needs rather than focusing solely on behavioural
symptoms (Haley, 2020, pp. 190–191).

Recommendations

This report has evaluated four therapeutic approaches: attachment-based

therapy (ABT), cognitive behavioural therapy (CBT), systemic therapy, and
mindfulness about the psychological needs of women in prison. While
each approach offers distinct strengths, the evidence supports
attachment-based treatment as the most suitable intervention for this
setting.
Women in custody often present with complex trauma histories, including
childhood abuse, domestic violence, and disrupted caregiving
relationships (Richards and Reid, 2020, p. 127). These patterns are
strongly linked with emotional dysregulation, mistrust, and harmful coping
strategies such as self-harm and substance misuse (DD310, Week 12,
Section 1.2). Attachment-based therapy addresses these difficulties by
supporting emotional regulation and the development of secure relational
bonds (Haley, 2020, p. 190).

In comparison, CBT offers a useful short-term tool but may fall short for
individuals who are too dysregulated to engage with insight-based
methods (Bruce, 2020, p. 208). Similarly, mindfulness approaches may
be less effective or counterproductive when introduced without a secure
therapeutic foundation (Barker and Cooper, 2020, p. 241).

While insightful in broader relational contexts, systemic therapy is limited

by environmental constraints in prison settings. ABT is exceptionally well
aligned with trauma-informed practice, supporting psychological safety
and personal reflection, core values for rehabilitative work with this
population (DD310, Week 17, Section 2.3). These goals also resonate
with the broader rehabilitative aims of the criminal justice system, where
consistent, relationship-focused interventions are often difficult to
implement but critically needed (van Linschoten, 2020, p. 285).

Although ABT requires skilled practitioners and longer-term commitment,

these challenges can be addressed through weekly one-to-one sessions,
supplemented by peer-led support groups and staff training in
attachment-informed care.

While ABT is well-suited to the psychological needs of this population,

implementing it within a prison environment requires careful
consideration. Prisons often operate under resource constraints and a rigid
security-led structure, which can conflict with the consistency and
relational safety that ABT relies on (van Linschoten, 2020, p. 284).
High surveillance and limited confidentiality may also undermine
emotional safety, making it more difficult to build therapeutic trust
(DD310, Week 2, Section 3.1).

To address this, therapy could be delivered through weekly one-to-one

sessions provided by in-house professionals or external therapists with
specialist training in trauma-informed practice (DD310, Week 17,
Section 2.3). Where continuity of care is at risk, relational consistency
could be supported through structured communication and staff handover
protocols (van Linschoten, 2020, p. 285). In addition, peer-led support
groups, facilitated by trained staff or third-sector organisations, could
provide supplementary emotional support and foster a sense of
community among the women (DD310, Week 17, Section 3.1). These
would not replace therapy but offer shared reflection and skill
development space. Embedding ABT within a wider trauma-informed
prison culture would also be essential. Bright, Higgins and Grealish (2022)
argue that staff training in relational safety and trauma awareness can
significantly improve therapeutic outcomes and reduce re-traumatisation
in custodial settings (Bright, Higgins and Grealish, 2022).

This recommendation is further supported by UK-based research. Bright,

Higgins and Grealish (2022) found that women preferred therapeutic
relationships grounded in trust and relational safety. Their review also
found that trauma-focused interventions produced better outcomes than
risk-based models (Bright, Higgins and Grealish, 2022). Bell and
Cornwell (2015) highlighted the value of attachment-focused interventions
in supporting behavioural change and desistance, particularly in
supporting mothers within the criminal justice system (Bell and
Cornwell, 2015).

Similar approaches have shown promising results in UK custodial settings.

For example, the New Beginnings programme, an attachment-based
intervention for mothers in prison, helped maintain or improve parent–
infant bonding and emotional insight. At the same time, participants in
standard care showed decline (Baradon et al., 2011). Though not
identical to the proposed model, it highlights the value of building secure
relationships in therapeutic settings. In addition, trauma-informed group
programmes like Healing Trauma have received positive feedback from
women in prison, who reported a greater understanding of their past
experiences and improved emotional coping strategies (Covington and
Bloom, 2007). Together, these examples demonstrate the broader
effectiveness of trauma-informed, relationship-based interventions in
women’s prison settings. Taken together, the evidence indicates that ABT
is not only suitable but necessary to address the underlying emotional
distress and behavioural difficulties experienced by many women in
prison.

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