‘What’s needed as part of probation practice when working with personality disordered offenders? The importance of avoiding errors of logic’ – A practitioner response

Introduction

The last ten years have seen a quiet revolution begin in the area of personality disorder (PD) within the criminal justice system. What started with the establishment of the Dangerous and Severe Personality Disorder (DSPD) units (Duggan, 2011) has become an initiative to construct a custodial and community pathway, that seeks to improve the outcomes for service users who may meet the diagnostic criteria for personality disorder (Joseph and Benefield, 2012). The article ‘What’s needed as part of probation practice when working with personality disordered offenders? The importance of avoiding errors of logic’ can be understood as a useful contribution to that initiative. The article convincingly argues the case for probation practice to be psychologically informed, and offers a helpful series of practical examples which demonstrate how this would facilitate understanding, so increasing the likelihood of engagement, compliance and risk reduction. In focusing on how the Schema Focused Therapy constructs of Early Maladaptive Schema (EMS) can be used to help address the ‘difficulties in the room’, the authors bring a welcome focus on to the interpersonal crux of probation work. The capacity of the criminal justice system to become more therapeutic, or perhaps sometimes just less damaging, is surely inextricable from the capacity of staff to form and maintain relationships with service users. Ramsden and Lowton’s accessible piece summarizes some of the understanding and skills practitioners could benefit from in cultivating this capacity. However, in responding to this article it seems worthwhile to think about what else is needed: if practitioner skill is one part, what are the other fundamentals? This response is informed by my current roles as a probation officer (recently seconded to prison) and student on the Knowledge and Understanding Framework MSc in Working with Personality Disorder, as well as previous involvement with a personality disorder project in London Probation Trust.

My proposal is that advising officers how to improve their practice is invaluable, but will only go so far, and occasionally will be redundant, without a wider focus on organizational health. As valuable as psychologically informed management is, it is also a challenging relational and emotional endeavour, and if staff are to offer supervision attuned to service users’ particular needs, then the wider system needs to afford opportunity for this work to be both safe and sustainable. So, any move to develop staff needs to be held within a framework which aspires to make it possible for them to maintain a psychologically informed or therapeutic stance. Drawing on the literature concerning the psychodynamics of organizations (Stokoe, 2011; Obholzer, 2006), and especially that from the forensic field (Aiyegbusi and Clarke-Moore, 2009), there is much that probation could learn. As such, this response makes no claim to originality, but is an attempt to paraphrase a particular model of understanding care-giving organizations in a way that relates to a probation context.

Psychologically informed management

Before considering the directions in which the article might usefully be extended it is worth reflecting on the value of what it offers. The emphasis on ensuring staff carry adequate psychological understanding to offer containing and therapeutic relationships is critical. For too long prison and probation systems have acted out unthinkingly against those service users deemed manipulative, unmanageable, and untreatable, and so have replicated histories of abuse, rejection and social exclusion (Department of Health, 2003). Thus, enabling practitioners to understand seemingly obstructive or (self-)destructive behaviours as having a functional aspect, in that they protect an individual from states that were previously experienced as intolerable, means that empathy might be maintained. An example Ramsden and Lowton use is fabrication, suggesting that this might be an individual’s unconscious attempt to stop professionals from getting close; such behaviour may exasperate professionals less if it is understood that this is a way of minimizing the threat of abuse authority figures pose. The practical implications of staff carrying such knowledge are significant. For example, the sizeable cohort of IPP prisoners who are currently over-tariff and stuck in a pernicious cycle of parole knock-backs, failure in open conditions and recalls from the community, are likely to benefit significantly from a workforce that can understand this frustration of progress as something other than a wilful rejection of help offered. Of course, there is another conversation to be had about the relationship between the hopeless nature of the indeterminate sentence and the behaviours which then become understood through the lens of personality disorder. But as Ramsden and Lowton state:

An individualized approach that seeks to understand the protective function of an individual’s behaviour and offending… and link it to a particular aetiological journey is seen as essential for helping criminal justice staff to understand the dynamics particular to a case and for helping them to reflect on their own responses and reactions.

Team and organizational functioning

Ramsden and Lowton describe supervision as essential, whilst this cannot be overstated (and will be discussed shortly), wider team and organizational systems also demand attention. Kahn states that in care-giving organizations resilience is ‘a product of the collective’ (Kahn, 2005: 180). In this Kahn, and the tradition of organizational thinking he inhabits, encourages us to think of workforce development as more complex than an individual practitioner benefiting from more training. At the risk of over-simplification, some broad tenets of this tradition of thought can be summarized in the following way:

Without these conditions, or attempts to achieve them, the avoidance of anxiety will take the place of the primary task, and thus become the defining activity of the team. As Kahn describes:

Many organizations whose members face daily anxiety develop cultures of action, characterized by a manic pace of work, an emphasis on overly demanding or ambitious deadlines, rushed decision-making in the face of incomplete information, and seemingly constant changes in organizational structures and systems… together they create a culture in which organization members are pressed to act rather than reflect. (Kahn, 2005: 193)

Essentially, ‘thinking is at risk in helping institutions’ (Griffiths and Hinshelwood, 2001: 31), as a pressure to act can stall the capacity to reflect. It is a ‘culture of enquiry’ that allows reflective thought to be kept alive, keeping at bay dehumanized and reactive practices, best understood as social defence systems (Menzies-Lyth, 1959). Containment ‘involves the creation of a relational and mental space that helps in the toleration of ambiguity, uncertainty and anxiety’ (Simpson and French, 2005: 294). An example might be a reflective practice forum in which I can discuss my concerns about a service user’s engagement in supervision and compliance with licence conditions; this space equips me to manage the situation safely and proportionately by affording opportunity for anxiety to be translated into understanding of what may be causing de-stabilization.

Application of this model to probation raises a series of questions. For example, the difficulty of establishing a single primary task in a probation context is unavoidable, given the care and control or need and risk dichotomies that characterize practice. This reality cannot be removed or avoided, and so perhaps the negotiation of these polarities needs to be acknowledged as, in fact, being the primary task, rather than an obstacle to some idealized practice. This is especially the case in working with personality disorder, in which the invitation to rescue or punish can be keenly felt as patterns of insecure attachment play out. For example, working in the community I struggled to remain consistent with a probationer who fluctuated between rejecting contact all together and intense bursts of over-commitment. In a chaotic attempt to remove anxiety, I hopped between being caring and punitive, under- and over-emphasizing risk respectively. Possible risks were ignored as I tried to use supervision to somehow salvage desperate situations, whilst at other times enforcing breaches inconsistently and with hostility. In Ramsden and Lowton’s terms, my reactive practice confirmed an expectation that those in authority will be inconsistent, at once claustrophobic and rejecting. Thus the system needs to engineer itself so that practitioners can safely try to engage with this challenge, rather than avoid it through a myriad of defences. The article makes a valuable point in stating that ‘the most important factor will be the supervisors’ capacity to enter the “logical world” of the client so that they have a capacity to interpret what is happening and bring meaning to the interaction for the client’. In some senses, the organization needs to offer the same capacity to its staff. If we understand the interactions between practitioners and service users as a microcosm of the organization as a whole, then the macro-structures need to mirror what is asked of practitioners in delivering effective supervision. The capacity of practitioners to reflect on their own responses and reactions cannot be expected to occur without the cultivation of a reflective ethos.

Clinical supervision

Towards the end of the article the authors state that the use of supervision is essential. As my practice benefits from the recent arrival of clinical supervision in London Probation Trust, I am coming to understand that it is support and opportunity for reflection that enables understanding to emerge and be translated into empathetic engagement. For example, my inclination to dismiss a service user’s chronic suicidality as somehow false has become unpacked so that I can use it to understand what it tells me about his state of mind, and so work more effectively with him to think about what might help. Just as we are encouraged to understand that destructive behaviours serve a protective function for service users, so staff perspectives that condemn, avoid and simplify emotional distress, whether explicit or hidden, also serve a function. The avoidance of relational work needs to be understood as a means of protection. Without containing structures through which the work can be digested and made sense of its difficulty will remain avoided, in an inevitably doomed attempt to make it less so. Crucially, any intellectual understanding that staff have of complex difficulties risks being lost in practice if adequate containment is not provided.

Potential risks

Given the scale of the challenge it is naive to propose the availability of reflective forums and clinical supervision as the answer; panaceas are not to be trusted. Like the guidance on schemas offered in the article, these structures are only part of the picture, and indeed risk being rejected if not properly integrated. The systemic workforce development Milligan and Gordon describe at Rampton Hospital emphasizes a whole systems approach, integrating education, supervision and culture (Milligan and Gordon, 2010). Critically, it also emphasizes that progress is a measured journey, and any search for a speedy transformation will flounder. Without patience, and attention being paid to education, supervision and culture in probation, it seems useful to sound a note of caution about the way the vexed label of personality disorder risks being used. The article presents something of a split between professionals and service users, creating a binary between the logic of the practitioner’s world and the illogical world of the service user:

… what constitutes psychological well-being for someone with a personality disorder cannot be necessarily determined through reference to our own logical position.

Involvement

The final part of the answer to ‘What else might be needed in probation practice with personality disorder?’ is service user involvement. Arguably, without meaningful involvement, any claim to be delivering an ethical and responsive service will ring hollow. The challenges of involvement with a population convicted of serious sexual and violent offending are multiple, but emerging initiatives (East London NHS Foundation Trust, 2013) disprove any inclination to say that it is not possible. Again, the lessons from the health sector are multiple (for example, Sheldon and Harding, 2010). However, in constructing involvement initiatives it is important that probation does not simply seek to import what has been done elsewhere, but constructs frameworks specific to its role. As such, lessons from desistance research might provide a useful base from which ethical, just and user-led structures can develop. Current emphasis on offender engagement tells us how far we are from full involvement (World Health Organization, 2002), but the progressive direction of travel can perhaps be sustained by a willingness to discover what is possible.

Conclusion

Pickard highlights that unlike other mental disorders, certain types of personality disorder are diagnosed via ‘characteristics or traits that count as failures of morality or virtue’ (Pickard, 2011: 183). Leaving aside the implications of this for psychiatric classifications, this characteristic of personality disorder explains the need for health and criminal justice perspectives to cooperate. Indeed, it invites the importation of health frameworks, such as Early Maladaptive Schema, into probation practice, just as it necessitates a dialogue about responsibility and blame in health settings. As such, Ramsden and Lowton’s direct application of psychological theory to the probation activities of supervision, risk management and enforcement is not only necessary, but also hopefully symptomatic of wider changes being initiated by the Offender Personality Disorder Pathway (Joseph and Benefield, 2012). The potential value of these frameworks is significant, but so is the need to ensure that they are not lost in translation. Paying attention to factors that promote organizational functioning could allow these concepts to be effectively used by probation practitioners to work alongside service users. Further, the adaptation of these frameworks to support probation’s primary tasks could also ensure that in its work with personality disorder, the probation service remains primarily concerned with the promotion of justice.