Case studies

Here are a few examples that illustrate the work of a speech and language therapist in the criminal justice setting. [All names were changed to protect the individuals' identity.]

John (18) was serving a 10-month detention and training order. He often fought with his peers and confronted prison officers. He was referred for speech and language therapy to develop his awareness of non-verbal communication, such as eye contact, facial expressions, and personal space in order to avoid getting into fights.

John received 12 individual therapy sessions making good progress. He was able to successfully address his offending behaviour and develop empathy and the ability to interpret non-verbal communication. There was a decrease in aggressive incidents and staff commented he was more able to stop and think before reacting. As a result of the decrease in aggressive behaviour and incidents, he was perceived more positively by others. This helped to raise his self-esteem and for him to establish relationships with others.

Mark (16) has a history of sexual offences. He has schizophrenia which is now well controlled. When first in contact with mental health services, his language skills were extremely limited by the positive and negative symptoms of his mental illness. But even when these stabilised, his understanding was extremely concrete based and limited to two-key-word level.

Group and individual language therapies increased these language levels very gradually but it was a number of years before he became able to engage in sex offender treatment. During this time, Mark developed skills in group language therapy which he did not previously have, but which would be central to his accessing sex offender treatment e.g. how to role play, how to use sequencing pictures. His progress with sex offender treatment was predictably very slow.

The speech and language therapist (SLT) advised the nurse consultant on ways of adapting material and identifying concepts which may be problematic for Mark to understand, such as “responsibility”. The SLT was asked to supervise a staff nurse undertaking further mental health awareness work with Mark.

Paul (18) is convicted of manslaughter and transferred first to high secure and then to medium secure psychiatric facility. He has not been here long. The speech and language therapist conducted a preliminary assessment of his preferred communication style on admission and provided a summary of this to staff.  She then carried out a more in-depth language assessment to inform other therapies. For example, Paul struggled greatly with rating the strength of his own emotions and regulating them. Information around his understanding of emotional concepts which has arisen during SLT sessions were highly relevant to his anger management work. The SLT also explored his general understanding of concepts such as “revenge”, which are relevant to his offence work. Paul is reported to remain quite isolated on the ward and a social skills group was established with the occupational therapist in which he will be involved.

Daniel (28) was referred for speech and language therapy by his prison doctor for his stammer, which he had since childhood.

Daniel expressed a high level of anxiety relating to his stammer, which resulted in him avoiding classes and groups, both educational and therapeutic, which he was obliged to attend in order to progress towards release.  He would avoid talking to prison officers if other people were present. This was often misconstrued as rudeness. His other coping strategy was to try and force the words out which would often be perceived as aggressive by officers and other prisoners.  Daniel would therefore become frustrated and angry when he stammered, which would worsen the problem.

As part of Daniel’s speech and language therapy, all staff working with him were informed of his communication difficulties and taught simple strategies on how to help him.  A disability officer was allocated to work with Daniel’s speech and language therapist and support Daniel between sessions.  A meeting with prison staff to discuss Daniel’s poor attendance at classes also enabled his speech and language therapist to explain his communication difficulties and their impact.

Since receiving speech and language therapy, Daniel has made significant progress including improved listening, turn-taking, eye contact and less repetition of information. The disability officer gained a good understanding of the nature of the communication problems and was able to explain these to other staff and discuss whether adjustments could be made to his classes because of his disability.

Tom (20s) had a history of offending behaviour and struggled with impulsivity. He was assessed by a speech and language therapist and treated first at an open mental health unit, from which he absconded, and then within a secure setting.

His speech and language therapy assessment found him to have poor language skills and limited insight into how he interacts with others, and the reduced ability to manage his own communicative behaviour. He required staff to provide constant and consistent support to help him to minimise his problematic behaviour.

Tom would sometimes answer questions with unrelated information or would fabricate responses, interrupt others impulsively and ask questions repeatedly.  He could also agree too readily with others without understanding what he was agreeing to or sabotage interactions with immature behaviour.

Tom’s speech and language therapist worked extensively with him in group settings to gauge his capacity to manage his social interaction with others. Staff working with Tom were provided with information and strategies to support his speech and language therapy. This included removing distracting stimuli from his immediate environment, explaining the consequences of his actions and helping him approach complex tasks by guiding him through a series of stages. Staff were also advised to avoid broad open-ended questions where possible, as well as vague, ambiguous or abstract language.

As a result, Tom developed strategies to manage his communication difficulties. A care plan was developed for use on the prison ward. This allowed staff to recognise and manage Tom’s understanding of interactional behaviour, which led to a reduction in hostile conduct.

Sarah (30s) has psychopathic disorder, mental impairment and has been offending since she was nine years old. She was transferred to a high security hospital following remand to prison. She made a number of verbal and physical assaults on others and regularly engaged in self-harming behaviour.

Sarah received a speech and language therapy assessment, which identified she has difficulty understanding complex information, a lack of emotional vocabulary and limited awareness of the effect of her behaviour.

She received regular speech and language therapy over a three-year period, delivered through a combination of one-to-one and group sessions to support her with her communication difficulties and also enable her to access other therapies. The speech and language therapy also aimed to facilitate Sarah’s transfer to a medium secure setting by training staff on her communication skills and difficulties while providing them with strategies for supporting her.

All of these aims were achieved and reassessment of Sarah demonstrated an overall increase in both receptive and expressive language skills. Speech and language therapy concentrated on the development of Sarah’s ability to reflect on, and ultimately change, her communicative behaviour and interaction with others. There was also a reduction in risk to herself and others which enabled a successful transfer from a high secure to a medium secure environment.

Mary (22), a patient at a special hospital, had psychopathic disorder, motor difficulties and reduced hearing. She had reasonable language skills but had considerable difficulty with use of vocabulary and poor social skills.

Mary was referred for speech and language therapy to help her access other health services, such as personal construct therapy and cognitive behaviour therapy. She received three sessions each week to slow down speech, work on complex sound production, language skills and her awareness in relation to her immediate environment. She was also fitted with a hearing aid.

Improvement was seen after three months. As a result of her speech and language therapy, Mary was able to engage in regular joint sessions with primary nurses. This also enabled her to engage in ward-based interventions to help reduce her verbal aggression and asking repetitive questions.