Development of the Offender Personality Disorder Pathway: A summary of the underpinning evidence

Introduction

The prevalence of personality disorder in community and prison offender cohorts has not been examined for many years, yet it is estimated that between 60 and 70 per cent of the prison population meets the criteria for at least one form of personality disorder (Singleton et al., 1997; Fazel and Danesh, 2002). A small-scale study in Lincolnshire (Brooker et al., 2012) suggested that this was 50 per cent of the probation caseload, prior to the split between the National Probation Service (NPS) and Community Rehabilitation Companies (CRCs).

The Offender Personality Disorder (OPD) pathway programme was initiated in 2011 to meet the joint strategic aims of the Ministry of Justice (MoJ) and the Department of Health (DH), and their respective agencies (Joseph and Benefield, 2012). It grew out of the Dangerous and Severe Personality Disorder (DSPD) programme where money was made available by the then Coalition government to put in place services to help manage and treat offenders who were seen as high risk, but also exhibited complex interpersonal problems that might be diagnosable as personality disorder or psychopathy. This followed a well-publicised case where Michael Stone, a person with mental health problems, was convicted of the murders of Lyn and Megan Russell.

After evaluations of the DSPD programme and the Bradley Review (2009) into mental health provision in the Criminal Justice System, the OPD programme attempted to address identified concerns and limitations, including a better way of describing a pathway of care, providing services to more offenders, and putting in place early identification of the target population.

The overall aims and outcomes of the OPD programme are to improve public protection via a reduction of repeat offending, and to improve the psychological health, wellbeing and relational skills of offenders likely to be diagnosed with a personality disorder. This is driven by the workforce, where the pathway therefore aims to improve the confidence, competence and attitudes of staff working with complex offenders. Finally, the pathway aims to be efficient and cost-effective, through developing a comprehensive and high-quality pathway of services for this complex and difficult to manage offender population. The pathway focuses on offenders managed by the NPS; for men, they must present a high likelihood of violent or sexual offence repetition as well as a high or very high risk of serious harm to others. For women, the criteria are the same except the level of risk is not specified. There are 33,087 offenders who are currently screened into the pathway and therefore satisfy the above criteria, of whom 31,090 are men and 1996 are women (OPD data return, December 2017).

The pathway programme is unique in that it is a true partnership between the National Probation Service (NPS), Her Majesty's Prison Service (HMPS) and the National Health Service (NHS) England; there is shared recognition and understanding that this cohort of people cannot be managed by either agency alone. The pathway is underpinned by a set of principles that are seen as integral to the success of the pathway; the whole pathway is also seen as additive, in that it overlays on top of standard provision in probation, prisons and healthcare settings. It is not meant to replace what would normally be provided.

The principles were derived using an evidence-based approach or, where there was no evidence base, by professional consensus. There are 12 principles in total, which have been agreed between HMPPS and the NHS:

There is shared ownership, joint responsibility and operations, and partnership working (between health and criminal justice).

One major criticism of the DSPD programme was that services were only in the highest security settings (either high or medium secure hospitals or high security prisons) and did not provide, or conceptualise, a pathway of care and, in particular, what needed to be in place in the community. The new OPD programme starts in the community at the earliest point after sentence, with identification of those meeting criteria using a combination of OASys variables, actuarial and dynamic risk factors, and other information from case files including childhood difficulties, history of mental health problems, current risk to staff, and current disruptive behaviour. This early identification then allows Offender Managers to seek psychological consultancy where needed with regard to the interplay between risk of harm and complex psychological and interpersonal problems. Furthermore, the use of psychological formulation allows a pathway plan to be developed that is psychologically informed. The aim is for better understanding of risk and need, better sentence planning, and through workforce development and training, offender managers who feel more confident and competent to manage their respective offenders.

Steve Johnson-Proctor, Director of Probation for South East and Eastern, has said:

The Offender Personality Disorder pathway has been one of the most successful and effective practice developments within Probation in recent years. It has significantly improved the skill base of our staff group, provided access to expert advice in our offices and improved links with local community mental health providers across England and Wales.

The problem with the term personality disorder and the role of formulations

The complexity of presentation of offenders with severe psychological and social problems transcends the traditional way of diagnosing mental health problems. Such complexities include comorbidity with psychosis and mental illness, neurodevelopmental disorders such as autism, and acquired brain injury, and the likelihood of professional disagreement over diagnoses. For this reason, when dealing with potentially complex presentations, the OPD pathway adopts a psychologically informed, holistic approach to formulating a person’s needs, which takes into account and describes the interplay and origin of psychological, social and emotional problems, and any physical considerations that may impact (for example any neuro-developmental issues). Via the OPD pathway, personality disorder is most commonly defined by the 3 P’s – that in order to be present a range of psychological, emotional and social issues (such as impulsivity) must be persistent, problematic and pervasive.

There are many problems with the more traditional way of diagnosing personality disorder and the label itself, with symptomatic overlaps with other diagnoses (for example schizoid and autistic spectrum disorders), overlap between the different types of personality disorder (for example impulsivity is included in several categories) and heterogeneity within categories (Tyrer et al., 2015). For example, two people with the same diagnosis can present in very different ways, and two people with different diagnoses can present in the same way. An attempt to improve diagnostic criteria is currently ongoing with a review of the International Classification of Diseases with the intention to define personality disorder on a continuum from mild through to severe (Tyrer, 2017), supported by Clark (2007). Mild is defined as having notable problems in interpersonal and social functioning but the risk of harm to self and others is low; moderate is defined as having a marked degree of problems and there is a risk of harm but not to a degree that causes long-term damage or danger to life; and severe, which is defined as having severe problems including threats to life and limb of either self or others. The latest DSM V criteria, however, failed to review the diagnosis of personality disorder, retaining the categorical approach.

In addition to diagnostic overlap, there is also a groundswell, supported by the British Psychological Society, of anti-diagnosis in mental health services, driven by the perceived inadequacy of this traditional medical approach, and service users’ increasing issue with it. ‘Personality disorder’ is particularly problematic, largely because it has been seen as a diagnosis of exclusion from mental health services. It is seen as blaming the individual for problems that, more often than not, have their origins in child and adolescent development mediated by the impact trauma, abuse, and neglect has on attachment and the development of a ‘social’ brain. An underpinning theory of how personality disorder develops is that the multiple, complex, or one-off catastrophic trauma experiences disrupt early attachment and bonding which, in turn, has a long-term impact on how that individual develops, their core understanding of how the world is, their place within it, and their relationships with others (Ball and Links, 2009; Barnow et al., 2010; Glaser et al., 2010; Berenbaum et al., 2008; Van der Kolk et al., 1994).

A landmark study in the United States described a list of Adverse Childhood Experiences (ACEs) (physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, mother treated violently, household substance misuse, household mental illness, parental separation or divorce, incarcerated household member), and followed a large cohort of the population in a longitudinal design. As the number of self-reported ACEs increased (and particularly for those with four or more), so did the likelihood of a range of health, social and behavioural problems throughout the lifespan, including alcohol and substance dependence, depression and suicide attempts (Felitti et al., 1998). There is now growing evidence of the link between ACEs and mental health, including personality disorder (Afifi et al., 2011; Douglas et al., 2011; Kalkamis and Chandler, 2015), and significant funding towards understanding more about ACEs being carried out by Public Health Wales (Ashton et al., 2016).

Biologically, these early adverse experiences affect the developing brain, impacting both structural development of neural networks and biochemistry (see, for example, Cozolino, 2002) – from an adaptive perspective this makes sense, as it is preparing the child to live in a hostile world. It is important to acknowledge that not everyone with an adverse experience will go on to develop complex psychological and emotional problems, and not everyone diagnosed with personality disorder has a history of such experiences. There are likely to be natural vulnerabilities that differ from person to person, that make it more or less likely that problems will emerge, and that mediate the impact of different events. Secondly, there is increasing evidence that the environment can change the expression of genes (López-Maury et al., 2008), which then has a generational impact leading to imperfect correlations between experiences and later symptomologies.

These ACEs are also significant when examining the early experiences of offenders. A study as part of the Surveying Prisoner Crime Reduction initiative (Cleary et al., 2012) showed that 24 per cent of newly sentenced receptions into prison stated they had been in care, 29 per cent said they had experienced abuse, and 41 per cent had observed violence in the home as a child. Further, those who reported abuse or observed violence were more likely to be reconvicted in the year after release than those who did not. Those with a convicted family member were also more likely to be reconvicted in the year after release. Again, it is important to acknowledge that not all offenders have such experiences, and not all offenders would be likely to satisfy the criteria to be diagnosed with personality disorder. However, the OPD pathway programme approach is to see that both offending and complex psychological and social problems, a likely personality disorder, are underpinned by these similar adverse experiences.

In practice, then, services must have a developmental and trauma focus – ‘what has happened to you?’ – in order to understand current behaviour, rather than ‘what is wrong with you?’ (Kezelman and Stavropoulos, 2012). This is integral to the novel and unique formulation-based approach of the pathway, as opposed to diagnostic and aligns with the recent Power Threat Meaning Framework (Johnstone et al., 2018) which sees making sense of previous experiences as central rather than a diagnosis.

Evidence for the amelioration of severe psychological, emotional and social problems

Two pools of evidence have been used and combined in order to inform the OPD pathway principles and respective service specifications: the evidence for the treatment of personality disorder, and the ‘What Works?’ literature, coupled with Ministry of Justice publications on reducing reoffending.

With regard to treating personality disorder, the evidence base is both poor and largely limited to the consideration of anti-social and borderline personality disorder. The National Institute for Health and Clinical Excellence (NICE, 2009a, 2009b) has considered the evidence for both of these and concludes that medication is not advised for core features of either, unless to treat co-morbidities. For borderline personality disorder there is no one treatment over another that seems to afford an advantage, and an explicit and integrated theoretical approach, staff supervision, and collaboration with the service user are helpful. For anti-social personality disorder comorbid conditions, particularly substance misuse, should be treated first – cognitive behavioural approaches have the best evidence of efficacy focused on offending behaviours. Of particular importance, both guidelines discuss the need for ‘optimistic and trusting’ relationships, and the need to work on engagement and motivation, using those collaborative relationships.

In a more recent review of personality disorder treatments, Bateman et al. (2015: 735) concluded that:

The essential features of personality disorder, substantial impairment of interpersonal function, identity problems, and recognisable social dysfunction, are all difficult to measure. No convincing evidence exists that these core domains of the diagnosis improve significantly or reliably with treatment.

As stated in the NICE guidance, the importance of developing and fostering relationships seems key. This was implemented in housing services via Psychologically Informed Environments (PIEs). Services run as PIEs attend to the relational, emotional and psychological needs of service users, as well as to specific, practical problems (Johnson and Haigh, 2010), and is much like the way that Psychologically Informed Planned Environments (PIPEs) within the OPD pathway work in the context of Approved Premises. They have demonstrated that running a service in this more flexible, psychologically informed way can have impact both on service users and staff. In a five-year follow-up report, Cockersell (2016) noted that PIEs had improved staff morale, improved levels of mental health and reduced levels of social exclusion. He concluded that:

…PIEs achieve significant positive change for people experiencing multiple exclusion/deprivation and with histories of compound trauma in terms of improved housing outcomes, improved behaviours, improved use of services, and improved mental health. The data and findings also suggest that PIEs achieve more positive outcomes than services not run as PIEs. (Cockersell, 2016: 228)

Workforce development and supervision

We know that this cohort of offenders are challenging for staff, and bring with them particular requirements with regard to workforce development and supervision, including stress, burnout and negative attitudes (Freestone et al., 2015; Newton-Howes et al., 2008). Roth and Pilling (2013) used evidence, professional judgement and consensus to develop a set of core competencies for clinical staff working with people likely to be diagnosed with personality disorder. This work was commissioned by NHS England as part of the Improving Access to Psychological Therapies (IAPT) initiatives which began in 2008. Interventions offered in this area rest on a set of underpinning skills (core and generic therapeutic competencies), as well as a set of assessment and formulation skills, and what they describe as meta-competencies such as how and when to use professional judgement in decision-making rather than inflexibly following rules. The former and latter have relevance to all staff working with such complex individuals, and, in particular, frontline probation staff, prison officers, and clinicians.

They acknowledge that such skill, and specifically the meta-competencies of knowing how to respond in particular circumstances, is not easy to deploy and requires sophisticated knowledge and understanding of the client and their difficulties. This is especially so when working with people who push boundaries and behave in seemingly incomprehensible and unpredictable ways.

Roth and Piling (2013) also noted a common factor of the clinical interventions that have positive outcomes as a result of randomised control trials. Most trials go to great lengths to ensure the associated training and supervision is delivered consistently and rigorously. The observation that interventions once mainstreamed lose their efficacy, they believe, is in part because this rigour falls away once the trial has ceased. The conclusion is that the training and supervision of the delivery of an intervention becomes a critical component of successful delivery. The ‘What Works?’ literature also highlights the requirement for staff to be properly trained and to have a clear theoretical understanding of interventions they may deliver (Bonta and Andrews, 1997).

Training and supervision was therefore incorporated into the key principles and outcomes of the pathway with a specific focus on improved competence, confidence and attitudes towards personality disorder. Reflective supervision is also necessary as an adjunct to good workforce development as this refers to managing difficult interpersonal relationships, boundary infringements, and chaotic behaviour, including self-harm. In addition, the aim is to help staff to acknowledge the impact on their resilience and learn how to better manage this.

Combining the mental health and criminal justice research evidence for reducing serious offending

There is now a longstanding and consistent set of evidence drawn from the early meta-analyses of interventions to reduce reoffending (Andrews et al., 1990) that resulted in the ‘What Works?’ movement in the early 1990s (McGuire, 1995). The Risk Need Responsivity (RNR) principles of Andrews and colleagues are now well accepted and fundamental to most HMPPS interventions. This has been supplemented by more recent evaluations by the Ministry of Justice, whose summary publications highlight the current set of knowledge with regard to activity that is related to reoffending or the reduction of reoffending (Williams et al., 2012). The list of factors that have been shown to be related to reoffending look remarkably similar to some of the criteria of personality disorder outlined, including impulsivity, low self-control and predatory attitudes.

The RNR principles have, however, been criticised for not adopting a holistic approach, raising difficulties for motivating offenders, and the lack of guidance for therapists in which to be able to engage offenders. These criticisms are all considered as key factors for success within the OPD pathway. Secondly, the principles of the Good Lives Model (GLM) (Ward et al., 2007) have been adopted, which include a strength-based perspective, promoting offenders’ goals and meaningful (pro-social) life plans as opposed to focusing on risk, the avoidance of risk, or situations where risk might increase, as you would using if just an RNR framework. Ward et al. argue that we are all goal directed and are set up to seek a number of ‘primary goods’ in order to improve well-being; for example, experiences and activities such as happiness and positive relationships / intimacy / friendships. Using the GLM, goals of major significance are identified, and in particular where offending may be used as a way of achieving those goals. Alternative, meaningful and pro-social methods of achieving those goals are then explored. Of key importance with the GLM is the concept of personal identity. Our lifestyle and daily activities lead to a sense of self and, as a result, it is not enough simply to learn new skills to change behaviour but to adopt pro-social identities, and to view others as benign or benevolent rather than threatening or competitors. Given that people with complex interpersonal problems have, by definition, complex views of self and others, using a GLM framework can help understand and address fundamental beliefs about the self, the world and other people.

The OPD programme also considers desistance theory (Maruna, 2001) which suggests that, to successfully break the cycle of offending, offenders need to make sense of their past lives in specific ways and consider how they can change for the better; identity and beliefs about others again raises a profile. Maruna found that as well as demographic factors such as age, those who were able to desist from crime had higher levels of self-efficacy. They were able to make sense of their past lives and identified pro-social identities for themselves, reporting that they felt like they had retained ambitions and control of their future.

There are clear overlaps in the characteristics of effective interventions for reducing reoffending and for addressing mental health. Specifically, this includes having psychologically informed staff, in a safe and supportive environment where the use of the relationship is the primary method and mode of treatment. Secondly, we require an understanding of how to influence the ‘system’ so it also becomes psychologically informed, helping to provide an empathic but boundaried environment within which to work with offenders.

Democratic Therapeutic Communities

The evidence base for DTCs exists in both health and criminal justice contexts; originally developed in mental health settings, Democratic Therapeutic Communities (DTCs), whether in prison, secure hospitals, or existing as day services in the community, are underpinned by therapeutic relationships and activities to create a living and learning environment that support the delivery of psychotherapy in small groups, and as a whole community. The majority of outcome studies in both health and forensic settings are weak, lacking methodological rigour and limited by sample size (See: Capone et al. (2016), summarising the evidence to date). Conclusions were hampered by limitations in study designs and overall showed there were mixed findings in relation to offending risk. However, there was an improvement in interpersonal outcomes. In addition, studies have shown that, taken as a whole, there is evidence that a DTC approach can reduce reoffending, particularly for personality disorder (Capone et al., 2016; Lees et al., 1999, 2004; Newbury, 2010). More recently, Pearce et al. (2017) conducted a randomised control trial on a day centre DTC for non-forensic patients, concluding that the DTC improved self and other-directed aggression and self-care compared to controls, for both male and female patients diagnosed with ‘personality disorder’.

The OPD pathway programme and implications for probation practice

The OPD pathway programme and its principles were identified using the evidence and theories highlighted throughout this article. There is a need for both the effective management of offenders, and interventions to reduce reoffending. Central to this is understanding both mental health and offending behaviour. Practitioners need to see where there may be a link between the two either directly (e.g. impulsivity and substance misuse) or via historical factors that underpin both the offending and the persistent, and pervasive problems. Neither health nor the criminal justice system alone can attend to these factors, hence the joint responsibility that underpins the OPD pathway.

A holistic method of understanding risk and need is also key, and these links need to be available to offender managers via psychological formulations. There is a need for early identification of offenders who are likely to be diagnosed with a personality disorder, in order to understand the interplay of factors leading to both risk and mental health problems.

As the evidence shows, relationships and understanding between offenders and staff are critical. To be successful, this needs to be trauma informed. Thus, staff training and psychological consultancy to Offender Managers has been made available throughout the pathway in order to improve knowledge, and skills to manage risk and help the OM increase an offender’s ability to engage and address their problems. Offenders need to be managed across a pathway that starts and ends in the community, and which understands that such complex needs will often lead to ruptures and impasses in relationships and management plans. The OPD programme team view workforce development as a core outcome of the programme. There is a ‘Knowledge and Understanding Framework’ set of training materials offered, of which the entry level programme is two days. Training continues to be developed where the team are currently working on providing training materials to new entrant probation staff. Secondly, the Enabling Environments award (RCP) has been adopted across the pathway, where the primary aim is to develop effective relationships. This is soon to be adopted across all Approved Premises to encourage both staff and residents to work together on a supportive ‘relational environment’.

The OPD pathway programme continues to adopt an evidence-based approach to assessing the outcomes that it aims to achieve and, in addition, aims to improve the existing evidence base for personality disorder. The national evaluation of the OPD pathway (males only) will prove an important watershed in terms of learning and the shaping of the pathway and network into the future.