Abstract
Psychologically Informed Planned Environments (PIPEs) have been developed as part of the Offender Personality Disorder Strategy (Department of Health, 2011). The Yorkshire and Humberside Personality Disorder Partnership (YHPDP) supports the delivery of this strategy at a local level, which includes two PIPE Approved Premises (AP). We have found that one of the most challenging and important aspects of running a PIPE AP has been responding to rule-breaking in a psychologically-informed manner. This paper describes a stepped and structured framework which we developed for managing boundary violations that is in line with the PIPE ethos.
Introduction
The Yorkshire and Humberside Personality Disorder Partnership (YHPDP) describes a commissioned relationship between the North East National Probation Service (NPS) and Leeds and York Partnership NHS Foundation Trust. YHPDP supports the delivery of the Offender Personality Disorder Strategy (Ministry of Justice and Department of Health, 2011) which PIPEs are part of. PIPEs, which the strategy identifies as having a central role in the development of pathways for offenders with PD, are defined as ‘specifically designed, contained environments where staff members have additional training to develop an increased psychological understanding of their work’ (DH, 2011). PIPEs operate in prisons and in the community and each PIPE unit has different roles depending on their place in the PD pathway. PIPE Approved Premises focus primarily on ensuring effective community re-integration for the men and women who reside in them, including a reduction in the number of recalls to prison from the community.
PIPEs are designed to have a particular focus on the environment in which they operate, actively recognising the importance and quality of relationships and interactions (Bolger and Turner, 2014). At the core of a PIPE is the concept of an enabling environment. This is a structured approach to the development and maintenance of a quality pro-social environment which has been developed by the Royal College of Psychiatrists. Participation in this process provides the PIPE with a mechanism for considering the relational processes that occur within it, and to consider the involvement of service users and staff when developing a shared ownership of the social environment. This collaborative approach which emphasises relational risk management is key to understanding with this service user group, as we know that people who have had disrupted and abusive early attachments often struggle with boundaries in relationships as adults. The psychological impact on staff of working with this group of service users is also increasingly being recognised. Due to service users’ disrupted attachment styles, they can relate to and seek care from staff in fragmented and hostile ways. This, understandably, can leave staff feeling vulnerable, bewildered and deskilled and invites staff to react and act out in a variety of maladaptive ways a way of managing these feelings.
Approved Premises are tasked by the Ministry of Justice with managing the highest risk service users through the transition from a custodial setting into the community. A PIPE Approved Premises (AP) offers placements to men who screen into the Offender Personality Disorder pathway and who are deemed at high risk of reoffending. Because of their complex personality traits and attachment histories, this resident group often experience interpersonal and emotional challenges upon release which they respond to in unhelpful or harmful ways. They often push against AP rules, as well as their licence conditions, resulting in rule-breaking, violation of AP values and/or increase in risk. Behaviours may include drug use, not engaging with the PIPE regime, verbal aggression, disregarding hostel rules or consistently arriving late to meetings. Such behaviours and breaches of AP rules are typically managed through warning letters and we noticed how unhelpful this approach was. The letters were not individualised or client-centred and often had a very punitive tone to them. They did not facilitate meaningful conversations with residents, who often responded to such letters by putting them straight into the bin unread. It became common practice for warning letters to be used in response to managing breach of curfews despite this being a licence condition which should be enforced by Offender Managers rather than AP staff. We noticed this could be a disjointed approach which did not lend itself to any discussion, collaboration or involvement from the resident.
It was also recognised that staff often struggled to respond to residents’ behaviour in ways that did not repeat unhelpful patterns from the resident’s past, and that this is a challenge, as outlined in the boundary see-saw model (Hamilton, 2010). This model builds upon the boundary literature and uses ideas from cognitive analytic therapy (Ryle, 1997) and dialectical behavioural therapy (Linehan, 1993), to conceptualise the ‘everyday’ boundary roles adopted by staff groups when working with individuals with complex personality difficulties. It reflects the three types of boundary movements discussed in the wider literature – boundary shifts, boundary crossings, boundary violations (i.e. Gutheil, 2005; Zur, 2001). We suggest that this model can help us understand the apparently small incidents that occur between staff and residents in an AP that can have great significance by illuminating the ‘seemingly innocuous variation in policies and practices at a local level…in Approved Premises…in the facilitation or hindrance of constructive supervisory relationships’ (Irwin-Rogers, 2017: 388). The boundary see-saw model suggests that when faced with emotional conflict from residents, staff may feel a ‘pressure’ to re-enact roles which may resonate from past life experiences of residents. These include: Neglectful and disinterested parent: Turning a blind eye or feeling hopeless or scared, which may mean they become ‘neglecting’ to a resident’s needs, struggles and risks; Punitive parent: Enforcing rules through forcing compliance or coercion, which means they may become ‘punitive or abusive’ inadvertently; Indulgent parent: Rescuing residents, meaning staff are become ‘indulgent’ and overlook the fact we all need boundaries to feel safe and to manage risks.
We developed a psychologically-informed framework to help staff feel more confident and competent in managing difficult behaviours and holding a ‘negotiator’ position in response to relational dynamics. This means: Being clear and explicit with residents about how rule-breaking is dealt with from the outset; Consistently noticing the pushing of boundaries, breaking of rules and violating of values in a collaborative way; Maintaining a flexible balance between understating and support (care) with the clear enforcement of rules and boundaries (control).
This framework was also our response to the guidance set out within the 2014 Approved Premises Manual from the National Offender Management Service. This suggests that all APs need to manage their internal warning and sanction system in a way that ensures that any responses are appropriate and justified, and action to issue breach or withdraw a bed does not take place prematurely because of a series of minor transgressions of behavioural expectations, unless there is a clear persistent pattern of failure to follow rules and all options have been pursued.
Framework
The framework we developed is underpinned by a general set of principles but it has been adapted by each of the PIPE APs so that it is responsive to the particular environment and staff and resident group (see Figure 1). Both frameworks are a staged approach to managing boundary violations. Each stage encourages collaborative and thoughtful reflection from staff and residents with the aim that a shared formulation of risk-related behaviour can be held. From this, a management plan can be negotiated, which is clear, realistic, timely and shared with Offender Managers to ensure that thoughtful and inclusive systemic and holistic wider processes are considered. These plans are regularly reviewed to ensure that residents and staff remain involved and thoughtful around risk-related behaviours. The plans have helped both staff and residents feel contained whilst residents have felt supported and validated when talking about risk-related behaviours. We will now discuss each of the stages in more detail, highlighting differences in approach between the hostels where applicable.
Framework of PIPE staged approach of relational risk management.
Stage 1: Notice of concern
A notice of concern is simply ‘noticing’ with a resident, by way of a conversation, any behaviour(s) that are concerning to staff and providing them with an opportunity to reflect on it. Consistent noticing by staff represents an attunement to the service user which is an emotional experience that was likely lacking in their early life. These conversations involve some exploration of why the behaviour is functional for the resident (i.e. Why are they doing it? How does it help meet their needs?), why staff are concerned (i.e. the negative impact / consequences of such behaviour on the resident and others) and how the resident could behave differently. An example of when a notice of concern may be given includes when a resident is starting to disengage and not attend groups or a resident returns late for curfew without a reasonable explanation. A notice of concern can be done by any member of staff. It is recorded on Handover and on nDelius 1 and their Offender Manager is notified. If there is a sense within the staff team that a notice of concern is not sufficient to support the resident’s needs and it needs to be escalated to another stage (i.e. if the resident continues to demonstrate such behaviour, or another behaviour which is concerning), this is raised with the keyworker and the wider team and it is brought to group supervision for discussion on how to proceed. Bringing all decisions back to the group enables reflective and consistent decisions to be made and shared within the team.
Stage 2: Development process and plan
This is a more formal process than Stage 1 and typically occurs when a resident’s concerning behaviour has continued or is more concerning than behaviour that would warrant a Notice of Concern. A Stage 2 development plan might also go hand-in-hand with an Offender Manager issuing a first licence warning. Stage 2 plans are usually completed between the resident and their keyworker. If the keyworker is on leave, senior staff (i.e. PIPE manager, Clinical Lead, PIPE PO) complete this. Each PIPE hostel has their own paperwork for Stage 2 plans but generally they will include a psychological understanding of the rule breaking: An outline of the concerning behaviours and the resident’s thoughts and feelings which may be driving the behaviours, possibly including triggers and wider context; Impact of the behaviour on self and others, including on the relationship between the resident and staff; An outline of the agreed goals; A time frame for achieving the goals; Clear consequences of what will happen if the rule breaking continues (i.e. move onto the next level); A review date.
Development plans are typed up and uploaded on nDelius. A copy is given to the resident and placed in their file. An email is sent to all hostel staff and the resident’s OM to inform them (1) that the resident is on an improvement plan, (2) the reasons why and (3) the agreed goals and timeframes. Any decisions around taking a resident off a Stage 2 or escalating to a higher stage are brought to group supervision and made as a team. The rationale and ethos of the development plans are not dissimilar to the ones underpinning psychologically-informed warning letters (see Harvey and Sefton, 2018), where the use of formulation-based communication can offer understanding, affirm clear limits of unacceptable behaviour and foster joint meaning-making leading to more collaborative risk assessment and management with service users on licence in the community who breach or rule-break.
It was noticed then that residents can sometimes slip back into unhelpful behaviours when they have successfully completed and ‘come off’ a Stage 2 plan. To manage this, a ‘continuity plan’ is developed with each resident, which means the goals are maintained and carried forward as the expected behaviour(s) from the resident whilst at the hostel. This takes the form of a letter, agreed with the resident, written up and given to the resident and Offender Manager.
Stage 3: Management process and plan
A resident is placed on a Stage 3 management plan if the Stage 2 goals have not been met or maintained, or if they engage in behaviour which is considered serious/risky enough to warrant a management plan (i.e. demonstrating aggressive behaviour). Stage 3 plans are facilitated by the Operational PIPE lead (Senior Probation Officer/AP Manager) and the Clinical Lead (PIPE psychologist) who meet with the resident to discuss the behaviour(s). The resident’s keyworker and Offender Manager should attend where possible. In this meeting, staff and the resident explore why the behaviour has happened and/or is continuing (i.e. How is it functional and why is it being maintained? What are the barriers to change?) and what additional support is required in order for them to maintain residing at the PIPE. The resident is explicitly told that if the behaviour(s) continue, they are at risk of being on a Stage 4, which means deselection from the PIPE and potentially a recall to prison. Similar to previous stages, any decisions around taking a resident off a Stage 3 or escalating to deselection stage have to be made as a team and brought to group supervision. The Stage 3 discussions are summarised in a psychologically-informed letter to the resident which includes: A rationale for why the resident is on a Stage 3; A formulation of why and how the behaviours may be functional and protective for the resident, making links with earlier childhood experiences; An outline of the agreed goals and support plans to achieve them; Timeframes and a review date.
This letter is uploaded on nDelius and a copy is given to the resident and placed in their file.
Stage 4: Deselection
This is the final stage and results in the withdrawal of a resident’s bed at the PIPE. A resident is deselected when they have not responded to the previous stages and continue to demonstrate difficult and concerning behaviour and/or when they demonstrate behaviour which is of a significant risk / seriousness that it is necessary to remove them from the PIPE. The resident is informed of this decision in a meeting with the Operational and Clinical Lead. Where possible the Offender Manager attends. In all cases, the Offender Manager is notified in advance of the meeting so an appropriate move or plan can be agreed and developed. This plan might involve a transfer to another hostel; in some cases it results in recall to prison. All decisions around deselection are again made as a team and discussed in group supervision.
Features of the framework
This framework offers a staged, transparent approach to manage boundary violations. It is atheoretical in that it does not rely solely on one therapeutic or risk theory or model and so is accessible and flexible. It provides an opportunity to develop collaborative understandings of behaviours with residents and to co-produce clear, brief formulations and negotiate risk management plans. It also acts as a vehicle to have structured and close links with Offender Managers and regular review periods. For both leaders and teams in AP PIPEs we believe this framework can offer the structure needed to be consistent and explicit about ‘noticing’ rule breaking, to be curious about the purpose of behaviours and to be flexible in striking the balance between support and upholding boundaries and to slow things down for staff, increasing a sense of containment. Through this way of working we have been able to plan responses in a considered manner and avoid the ‘knee jerk’ responses that can inadvertently increase risk.
Embedding relational risk management in the culture of an AP
An important aspect of setting up and using this framework has been embedding it into routine practice and the ‘collective awareness’ of all those in the AP PIPEs, including staff and residents. We have aimed to achieve this in various ways. A diagram of the framework is displayed around the AP and a copy is given to each resident at induction. Feedback from some residents has been that they prefer to know how rule-breaking will be dealt with in advance.
Perhaps more importantly has been how, where and when this framework and rule-breaking is talked about together amongst residents and staff. A weekly house meeting occurs, which forms part of the minimum engagement expectation for all staff on shift and all residents. In this meeting we routinely speak about the notices or plans issued in the previous week. It is not announced by staff which resident has received the notice or plan (although in our experience residents are already often aware of who has broken rules), but the number and type of notices or plans issued the week before. Doing this was an idea generated by the resident group itself and was adopted for various reasons.
Firstly, it has helped modulate some of the frustration that comes from residents (and from residential staff) when they believe that ‘nothing gets done about bad behaviour around here!’. It has allowed us as a staff group (and a leadership team) to be open about action taken to respond to drug use, non-engagement or verbal aggression, for example, leading to a greater sense of safety, trust and containment. Secondly, it has helped the whole group hold in mind the limits and boundaries that are in place and will be upheld when pushed. By encouraging these discussions it has created and supported a common language for boundary violations to be noticed, named and talked about together. We believe that this has helped the group hold in mind that behaviour will not go unnoticed, helping everyone feel safer as a whole – both those who may desire some form of limit to their own rule-breaking (perhaps not wholly within their awareness) for containment and for those who may be potential victims within an AP PIPE.
Finally, and perhaps most helpfully, by referring to the notices and plans that have been issued in the previous week, we have seen an increased openness and discussion involving residents and staff about rule-breaking. Men have sometimes spoken openly about their rule-breaking behaviours and some of the reasons for this – such as struggling to cope in the community after long periods in custody or feeling frustrated living with others. They have at times expressed their frustrations of feeling let down or ignored by staff and this has been talked about together. Some men’s behaviour has been challenged by other residents when rule-breaking impacts on other residents (such as smoking Spice, making lots of noise or taking others’ belongings) and the group has had moments, all be them brief, of ‘self-governing’.
The ongoing struggles and the importance of wider support
To avoid occupying an idealised, unrealistic position we are keen to be open about our struggles, anxieties, frustrations and the limitations we have found in developing and using this framework at the frontline of this work. Despite the framework, it is still challenging to engage more evasive or detached residents. Residents have at times voiced their opinion that the system is unfair and applied inconsistently. We always listen and validate such concerns and discuss the differences of opinions with residents, with the aim of trying to encourage and model ways of doing this in safe, pro-social ways. At others times we have come to realise we have struggled to be as consistent as we would like amongst the emotional and relational tangle in which we find ourselves working in this setting. The thoughtful, non-reactive approach has at times meant that it can be difficult to be as responsive as we would like, especially if staff would like to decide how to respond in group supervision which can, at times, be five or more days away, for example. When we talk about the number and types of notices or plans issued in the house meeting there are times that this has been met with stony silence or angry withdrawal in the house meeting from the residents, as opposed to any engaged responses and dialogues that we would hope for.
A key consideration is that unhelpful, knee-jerk responses may well occur ‘within’ the framework, and it is of course possible (if not highly likely) that the framework itself comes to be used in punitive, indulgent or neglectful ways if not embedded within wider psychological thinking. As such, we believe that it is not the framework alone per se that allows the psychologically-informed management of boundary violations, but the way that it is used in conjunction with the wider support, processes and structures that surround it.
It is necessary to remember that this framework, which has been embedded in two AP’s PIPEs, forms part of a range of structures and practices that contribute to and uphold relational risk management in the hostel. Part of the PIPE model includes plenty of opportunities for relationship building and learning in structured groups and creative social activities for residents. Each AP has a senior psychologist or psychotherapist who works four days a week in partnership with the AP manager. Each AP is therefore led in a psychologically-informed manner. The psychologist/psychotherapist provides a weekly group supervision session and a monthly individual clinical session which are to be attended by all staff. This means that support is available for writing psychologically-informed development plans or for managing psychologically-informed one-to-one sessions discussing rule-breaking. The psychologist/psychotherapist themselves also have access to clinical supervision and support from highly experienced clinicians. There is a half-time assistant psychologist to assist in evaluation. There is a range of training available for staff as well as support and governance arrangements available from the wider NHS and NPS partnership. Having all this in place means that the framework is located within robust agreements and arrangements between the NHS and NPS, which we believe has been key in its meaningful, thoughtful implementation.
A case study
Jamie was 34 and had a history of violent offences, including robbery and domestic violence. The majority of his violent behaviour had occurred in the context of having consumed alcohol. He was on a determinate sentence and had been recalled on one occasion previously for having had contact with a female partner and concealing this from his Offender Manager. He had completed intervention programmes, including Enhanced Thinking Skills (ETS) and Controlling Anger and Learning to Manage it (CALM).
Jamie had been in the PIPE for a week. He missed one house meeting and one structured group in the second week without speaking to a member of staff about his absence. His Offender Manager was notified and the process and plan explained to her. In his key worker session, an attempt was made to understand together what had led to him to miss these important aspects of the regime without notifying staff. Jamie attributed this to appointments with his Offender Manager and the benefits office, which he said was more important. Jamie was issued with a notice of concern and the framework was explained to him. He told his keyworker that he was angry and left the session before quickly returning to say that he accepted the notice of concern.
Following this there was a period of settled behaviour with Jamie engaging well with the regime and his key-worker. However, ten days later he missed a house meeting without notifying staff. He returned to the AP that night under the influence of alcohol and he was very verbally abusive to a relatively new and inexperienced member of staff. The following day Jamie presented as anxious and worried about recall. He contacted the local substance misuses service to seek an appointment. Staff offered reassurance and told him that the team planned to have a think about how best to respond to his rule-breaking and aggressive behaviour and would let him know by the end of the day. He was reassured that he was unlikely to have his ‘bed pulled’ as he had not been through the management process of rule-breaking. He was offered time with staff informally throughout the day and through these conversations it came to light that the day before Jamie got drunk, he had been notified by Social Services that he could not have letter contact with his daughter, which he had requested.
In group supervision, facilitated by the PIPE Clinical Lead and attended by the AP PIPE manager, varying opinions were discussed as a team. Some members felt that he should be given a Notice of Concern as it was his first major transgression in the AP and it was in response to some difficult news. Others felt that it was utterly unacceptable to be verbally aggressive, especially to inexperienced staff, and so wanted him to have a level three warning or a deselection from the PIPE. With support, staff were able to explore their emotional reactions and the differences between them (i.e. feeling the pull to rescue him and relinquish him of responsibility for his behaviour or feeling the pull to protect colleagues and staff regardless of proportionate risk management or what that meant for Jamie). Through these psychologically-informed discussions, the team decided that the risk could be safely managed in the AP and that a level 2 development plan was a healthy middle ground and the best way forward. The plan consisted of the following:
The behaviour that has led to this development plan is…
Missing a house meeting without speaking to staff Being under the influence of alcohol Being verbally aggressive to a member of staff
My concerns are….
Feeling stressed being back in the community Not allowed any contact with my daughter
These concerns make me feel…
Upset, anxious, angry
And so I behave in these ways….
Drink alcohol
Lash out verbally at others
Stop engaging with people who might support me
The impact on me of behaving in these ways is….
I end up getting in trouble and feel more ‘controlled’
Feeling anxious about being recalled
Feeling embarrassed afterwards
When I behave in these ways other people….
Might feel scared and withdraw
Might not realise that I am struggling with stuff and so not offer help
My action points are….
Attend all house meetings from now on
Attend key work sessions and try to speak to key worker about my worries
Attend appointment with substance misuse services next week
Follow AP rules, including about alcohol use
Attend my review meeting about this plan
What will happen if I don’t carry out the action points at the review point?
I will move to a level 3 development plan – this will mean I am closer to being deselected
Actions points for staff are:
Offer me regular one-to-one times weekly
Ask me if I am worried about being in the community in one to one sessions
Come with me to my first appointment with substance misuse services
Give me some space if I ask for it
Attend my review meeting about this plan
Carry out the breath testing as we agreed
Things that are going well are…
I have contacted substance misuse services
I have engaged in the development of this plan
Although I have been angry about this plan, I have managed this emotion well and it has not led to aggressive behaviour
My review meeting will be attended by me, my key worker and my Offender Manager on 15 September 2018 at 3 pm.
The Offender Manager was notified and invited to the meeting to develop the plan together. Jamie was notified by his key worker. He was relieved that he was not getting ‘deselected’ increasing the chance of recall and agreed to attend the meeting to develop the plan together. It was also decided that the member of staff involved in the altercation would receive some time individually to think about what had happened and access support.
Conclusion
We have developed this framework to manage boundary violations and escalations in risk for men whose risk potential in relationships is rooted within their own early life trauma and the risky ways in which they have come to cope with the emotional impact of this. We have found it has helped us as leaders, and as teams, be clearer, more consistent, more collaborative and more thoughtful than trying to manage boundaries without it. We do not offer it as a panacea, but as a piece of practice development which we hope may provoke thought and curiosity in our colleagues also involved in this work. We would encourage our colleagues to adopt, adapt and improve the framework for their work settings and would be interested to hear about the successes and challenges of doing so. We would also be interested to hear about the changes that need to be made for the framework to be effective in non-PIPE APs or in custodial settings for example. We are particularly interested in disseminating an evaluation of the impact of the framework and hope to do so in the future. Evaluation ideas so far have been focused around recall rates for PIPE residents, looking at how this framework might reduce recall, hold residents for longer, support them to be more psychologically aware, increase their capacity for feedback and overall to have had a ‘good enough’ experience of PIPE. This would involve mixed methods of analysis to include semi-structured interviews with recalled and non-recall residents who have experienced this framework.
Footnotes
Acknowledgements
The learning and framework outlined here is the result of over three years’ hard work of many colleagues and residents. Special recognition should go to Jodie Woodward-Loft (Counselling Psychologist) and Christine Wright (Senior Probation Officer), both of whom were key in its development and implementation from its inception. Thanks also go to Claire Cooper, who supported its use in consistent and thoughtful ways from the outset. We would also like to thank all the staff at Southview and Holbeck House Approved Premises who have worked compassionately, thoughtfully and skilfully in this very challenging area of work. Final thanks go to all the men who have passed through both AP PIPEs who have engaged with us, often in diverse ways, and helped us continue to learn about this very important aspect of our work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
