The Westgate Service and Related Referral,Assessment,and Treatment Processes

Abstract

The formerly named “Dangerous and Severe Personality Disorder” (DSPD) units are no longer standalone services within the criminal justice system in England and Wales. These sites now provide personality disorder treatment services in the high-security prison estate as part of the new national Offender Personality Disorder (OPD) Pathway Strategy. The OPD Pathway intends to take responsibility for the assessment, treatment, and management of offenders who are likely to have a personality disorder and who present a high risk of re-offending (men and women) and serious harm to others (men). Further PD treatment and progression services are being commissioned in lower security prisons and in the community as part of the new PD Strategy. While the suitability criteria for the two male high-security PD treatment sites are the same, the individual units have their own assessment and treatment methods. This article aims to communicate the referral, assessment, and treatment methods employed within the prison-based Westgate Personality Disorder Treatment Service, HMP Frankland.

Keywords

personality disorder psychopathy assessment treatment

The Treatment of Personality Disorder and Psychopathy

Effectively treating personality disordered offenders is challenging. Service providers are tasked with developing service-users’ skills to appropriately manage dysfunctional aspects of their personality whilst targeting dynamic criminogenic needs that contribute to offending behaviour (Howells, Krishnan, & Daffern, 2007). A major barrier to achieving this aim is that high-risk personality disordered offenders have a propensity for low treatment “readiness.” This can be due to low motivation to engage within therapy, resistance toward treatment (Howells & Day, 2007), mistrust of others, paranoia, and dominant interpersonal styles (Sheldon & Tennant, 2011). These factors have led to this population being considered “untreatable” due to their historical behaviour leading to either (a) them not being offered mainstream offending behaviour programmes on the basis that they were considered unable to benefit, (b) treatment failing to result in clinically meaningful change, or (c) inability to fully engage with treatment and/or attrition (Howells & Tennant, 2010).

The literature base relating to “what works” within this population is still developing meaning that it is still unknown as to which specific treatments are effective (Vollm & Konappa, 2012). Given that it will take time for treatment completers to be released into the community for a sufficient amount of time to evaluate the impact of treatment, it is currently difficult to identify which treatment processes can significantly impact upon recidivism rates. Despite the challenges of treating this population, the surrounding literature of “what works” with high-risk offenders with personality disorders is developing. The literature suggests that an “eclectic array” of treatment delivered in an integrated, systematic, coordinated way to provide a structure of generic therapy supported by specific interventions intended to target specific problems. Using phased treatment enables the focus of that treatment to change systematically through such a model (Livesley, 2007). Livesley’s proposed structure has been incorporated into the treatment of psychopathic offenders (Wong, Gordon, Gu, Lewis, & Olver, 2012). This study presents treatment for psychopathic offenders comprising two components targeting interpersonal factors and criminogenic factors, reflecting Factor 1 and Factor 2 traits assessed with Hare’s Psychopathy Checklist–Revised (PCL-R). Findings from this study provide evidence to suggest that this model provided positive treatment outcomes, supporting the notion of treatment efficacy for this population. Skeem, Polaschek, Patrick, & Lilienfel (2012) discuss what psychopathy is, its development, impact upon offending, and treatment outcomes. This review provides evidence to suggest that criminal behaviour can reduce as a result of treatment that adheres to the risk, need, and responsivity principle. In other words, appropriate treatment is intense to suitably match this high-risk population, targets criminogenic need, and is delivered in a format that maximises treatment engagement (Skeem et al., 2012).

Dangerous and Severe Personality Disorder (DSPD) Services

DSPD services were developed in England and Wales as a result of the Government taking responsibility for high-risk offenders previously considered to be untreatable and posing a high risk to the public. Four DSPD treatment units (two within high secure prisons and two within high-security hospitals) were subsequently developed with the intentions to target the following outcomes (Dangerous and Severe Personality Disorder Programme, 2008):

Improved public protection,

Provision of new treatment services improving mental health outcomes and reducing risk, and

Better understanding of what works in the treatment and management of those who meet the DSPD criteria.

There have been a number of changes and restructuring to this service since the completion of its pilot phase (Department of Health & National Offender Management Service Offender Personality Disorder Team, 2011) and the introduction of the Offender Personality Disorder Pathway (Joseph & Benefield, 2012). This has included the decommissioning of DSPD services in hospital settings. In addition, “DSPD” is now redundant as a title. It has never been considered to be a clinical diagnosis and the negative connotations attached to the labelling of “dangerousness” were felt to be counterproductive to the service aims. This led to Westgate no longer being referred to as a DSPD unit and more appropriately being referred to as a Personality Disorder Treatment Service.

The Development of the Westgate Personality Disorder Treatment Service and Its Multidisciplinary Staff Team

The Westgate Service opened in 2004 and is a purpose built treatment unit located within HMP Frankland, Durham. HMP Frankland is one of eight establishments within the high secure estate located within the H.M. Prison Service in England and Wales. The Westgate Service provides a non-collusive regime (i.e., both violent and sexual offenders reside on the same unit). HMP Frankland was selected over other establishments as it had space to build a standalone unit large enough to house 80 prisoners. An expert advisory group (made up of forensic psychologists and psychiatrists) was consulted throughout the planning stages of the Westgate Service’s treatment framework. Developers faced initial clinical opposition for a range of reasons. This was the first time that a treatment service of this kind had been developed in the United Kingdom after other services developed abroad were considered to have been unsuccessful. Given the infancy of the literature base regarding the treatment of personality disordered offenders, contrasting schools of thought were held both within the advisory group and between the advisory group and service developers. This required the Westgate Service’s developers to present their evidence-based proposed model of treatment (including supporting theory based in Cognitive Behavioural Therapy [CBT] and Dialectical Behavioural Therapy [DBT]) to those allocating the service’s funding.

A number of challenges were faced by the team of staff implementing the Westgate Treatment Service. Initially, operational pressures were experienced with initial low levels of occupancy. Despite the staff to prisoner ratio being high at this time, staff were tasked with developing treatment components and processes on the unit. Other historical and future challenges within referral, assessment, and treatment processes are detailed within relevant sections throughout the remainder of this article.

Treatment is supported by a structured regime comprising education, horticulture, and physical education sessions. The rationale for providing a varied regime that complements therapy are as follows: a varied regime would limit boredom susceptibility (a feature within psychopathy), audit requirements limiting treatment dosage, and the need to complement formal treatment (i.e., allowing opportunities to practice skills and explore learning within other environments). This mixed regime is delivered within an ethos based on the Good Lives Model (Ward & Brown, 2004), the Conditions of Success and Strategy of Choices. Prisoners are asked to adhere to the Conditions of Success during their time on the Westgate Service which is a strategy used as a way of setting expectations and boundaries to encourage meaningful engagement across the regime. The Conditions of Success are to constructively participate within the regime, two-way communication, and to be respectful at all times. The Strategy of Choices intends to encourage offenders to consider treatment as an “enhancement” as opposed to a “restriction” on their autonomy by using their need for “control and choice as a way of promoting self-responsibility and self-management.” Potential participants are asked to choose to accept the conditions or choose not to participate (Harris, Attrill, & Bush, 2005).

Multidisciplinary working is at the heart of Westgate’s regime meaning that assessment/treatment teams include psychologists, prison officers, nurses, therapists, and physical education instructors. A significant amount of resources were invested in the staff and training models employed at the Westgate Service. This was to ensure that appropriately skilled and trained staff were employed to develop and run the service in the most appropriate way. As well as expressions of interest being considered, potential staff are interviewed to ascertain whether the Westgate Service is an appropriate working environment. Westgate employees are expected to become involved with clinical work on the unit, with opportunities provided within all aspects of the service (referrals, assessment, treatment, and treatment supporting services). The unit’s assessment and treatment processes are presented in Figure 1. An “Assessment and Development Centre” was developed for new staff to complete assessing skills through exercises in group work, report writing, communication, and during a semi-structured interview. This is how management identify appropriate staff to work with this challenging population as well as their individual areas of strength and development. This information informs recommendations regarding appropriate aspects of the clinical framework that staff can have the opportunity to become involved in. All staff are subsequently trained to work with this population either within treatment or the wider regime (such as within referrals, assessments, or supporting services on the unit). Training offered by the Westgate Service includes “Working With Psychopathic Offenders,” “Conditioning and Manipulation Training,” “Personality Disorder Awareness,” “Attachment Styles Awareness,” “Westgate Service/Chromis Treatment Awareness,” and “Group Processes Awareness". Communication and information sharing is of paramount importance and encouraged by the recording of information within prisoners’ electronic case note entries and multidisciplinary attendance at staff briefings (which occur three times a day).

Figure 1.

The Westgate service’s assessment and treatment processes.

The Westgate Service is currently undergoing assessment for status as an “Enabling Environment”, an award overseen by the Royal College of Psychiatrists. This initiative identifies key elements in a setting that can establish “a sense of connected belonging” (Johnson & Haigh, 2011) and involves 10 standards (belonging, boundaries, communication, development, involvement, safety, structure, empowerment, leadership, and openness).

Referral Process

The Westgate Service considers referrals from staff, typically Offender Supervisors; prisoners who wish to self refer are directed to do so through their Offender Supervisor. When the Westgate Service first opened, a number of unsuitable referrals were received, possibly due to the service being seen as a transfer option for prisoners residing in Segregation Units or displaying challenging/violent behaviour within custody. Referrals staff limited this issue through processes both internal and external to Westgate. Externally (as funding allowed at the time), Westgate staff promoted the unit and its services by conducting outreach work with both staff and prisoners across the prison estate. This provided awareness of this population to prison staff and informed them how to appropriately refer potential referrals. Internally, a referrals process was developed to ascertain suitability for admission. A standardised referral form is completed by the referrer and sent to the Westgate Service’s multidisciplinary referral team and used as part of the screening process. This helps to help ascertain offence-related risk; the likely presence of personality disorder and psychopathy, and ultimately indications regarding the suitability of Westgate’s treatment framework for the individual concerned. Sources of information can include: offending history, treatment reports, risk assessments, assessments of intelligence, security information, adjudications, and behavioural observations. This information is reviewed at a monthly multidisciplinary referral panel where the decision is made whether to accept or reject referrals (or seek additional evidence if required). In addition to the above information, the panel take into consideration the offender’s stage in sentence, tariff length, treatment compliance, motivation, and relevant security information. The referrals process intends to limit the number of receptions for whom Westgate is unlikely to meet their needs. With this, decisions made by the panel take into account the importance of offering appropriate services to individuals, the limited places available on the Westgate Unit, and the cost-effectiveness of the service.

The introduction of the Offender PD Pathway (Joseph & Benefield, 2012) led to part of the Westgate Unit to be re-rolled into a Category A Psychologically Informed Planned Environment (PIPE) in 2012, reducing the Westgate Service’s capacity to 65. The Offender PD Pathway also increased treatment options for offenders likely to be diagnosed with a personality disorder which will impact on the referrals received by the Westgate Service. It is anticipated that offenders monitored under the Managing Challenging Behaviour Strategy (MCBS); and located within Closed Supervision Centres (CSCs); Category A establishments; and Segregation Units will become an increased source of referrals for the Westgate Service. This is due to the Westgate Service being appropriately placed to provide treatment services for high-risk offenders. This is anticipated to change the future population residing on the Westgate Service, including prisoners with longer tariffs.

Given the reduced levels of resources within the Prison Service, the Referrals Department has faced a number of challenges in encouraging the levels and suitability of referrals. Reduced funding has meant that outreach work carried out by Westgate staff has decreased. This includes work appropriately advertising the service, motivational work, and the administration of personality disorder assessment tools. This means that the referrals to the Westgate Service have required an increased level of information from the referring establishment including requests for the referring establishment to administer personality disorder assessments where possible. This has impacted on referrals received to the Westgate Service in two ways. First, referring establishments can become deterred from making referrals due to the increased work involved. Second, referrals with limited information require follow-up work from Westgate staff, resulting in offenders staying in the referral process for a longer period of time. To account for this, the Westgate Service has commenced joint referral panels run in collaboration with CSC sites with the intention of most appropriately identifying potential admissions.

The “Living” Phase

On arrival, prisoners commence the “living” phase on the Westgate Service and a unit induction is completed (similar to other prison establishments). The following “living” phase focuses on participation in what is referred to as the “complementary regime” and acts as a period of adjustment for the prisoner. The “complementary regime” comprises of non-treatment activities (e.g., education, horticulture, physical education). The rationale behind this aspect of the regime is to develop prisoners’ life skills by encouraging personal development, interpersonal skills, and engagement in a structured regime as well as provide purposeful activity across a range of domains. The “living” phase is a valuable opportunity for prisoners to develop working relationships with staff. This is with the aim of increasing sources of support for prisoners to maximise meaningful engagement within assessment and treatment processes. During the prisoner’s induction (completed within 5 working days of him arriving on the unit), he meets his allocated clinical case manager. This is a clinician (either a Forensic Psychologist in Training or a Therapist) who is the prisoner’s first point of contact should he have queries regarding the clinical framework. Clinical case managers complete reports for the parole or Category A board process and are consistently invited to attend any reviews and case conference related to the prisoner.

Behavioural Monitoring

From the “living” phase onwards, staff observations are integral to assessment and treatment processes on the Westgate Service. Observations in all areas of the regime can provide evidence of the presence/absence of personality traits (relevant to assessment) and the presence/absence of skills generalisation (relevant to treatment). On arrival to the Westgate Service, an individualised Key Indicator Profile (KIP) sheet is developed for the prisoner, including problematic behaviours that he has historically displayed. This is completed by members of the referrals team as they have transferable skills in identifying relevant problematic risk and personality-related observations from collating information in preparation for referral panels. The KIP sheet is available to all Westgate staff, which they reference when recording case note entries (should such behaviours be observed). Behavioural Monitoring contributes to the “observation” part of the triangulated approach towards assessment that is used on the Westgate Service. Measures are taken to limit the amount of discordant and subjective information recorded within staff observations. Staff training has been implemented to maximise objectivity within observations. In addition, Supervising Officers are responsible for weekly monitoring of the quality of case notes recorded by staff.

Assessment and Treatment Needs Analysis (ATNA)

The assessment process has been refined during the time that the Westgate Service has been running. To limit repetition, assessment teams use a “combined interview” schedule alongside the International Personality Disorder Examination (IPDE) interview. This elicits information required to administer the PCL-R and risk assessments utilised by the unit. This has reduced the assessment period used at Westgate. The detailed assessment of suitability for the unit starts after the “living” phase and is referred to as the ATNA. There are two aims of the ATNA process. These are (a) to assess for suitability for the Westgate Service and (b) identify relevant treatment needs. These are achieved within one merged process. This leads to a more efficient way of working, ensuring that a full and comprehensive risk assessment and treatment need analysis is communicated to future treatment teams (either at the Westgate Service or at another establishment if the prisoner does not meet criteria). The criteria for the Westgate Service comprises of the following three factors (Dangerous and Severe Personality Disorder Programme, 2008):

A significant/high risk of re-offending;

The presence of a “severe” personality disorder (evidenced by either: a PCL-R score of 30 [95.8th percentile] and above; a PCL-R score of between 25 and 29 [85.2th-94.4th percentile] combined with at least one PD other than antisocial PD; or two or more PDs [regardless of the PCL-R score]); and

The presence of a “functional link” between the disorder and the risk of re-offending.

Risk of violent recidivism is assessed with the Historical, Clinical, Risk Management - 20 (HCR-20): Assessing Risk of Violence (Webster, Douglas, Eaves, & Hart, 1997) and Violence Risk Scale (VRS; Wong & Gordon, 2000). Risk of sexual recidivism is assessed with the Violence Risk Scale: Sex Offender Version (VRS-SO; Wong, Olver, Nicholaichuk, & Gordon, 2003), Static 99 (Nunes, Firestone, Bradford, Greenberg, & Broom, 2002), and Risk Matrix 2000 (Thornton et al., 2003). Personality disorder is assessed using the IPDE (World Health Organization [WHO], 1997) and the PCL-R (Hare, 2003). The PCL-R is not used as a tool to assess risk. Treatment starters are subsequently “severely” personality disordered or psychopathic, and by default tend to have pervasive and persistent offending behaviour and therefore considered to be chronic or “life course persistent” offenders (Moffitt, 1993). Despite the above criteria identifying a specific population, there can be differences within this population. For example, the ATNA process can identify individuals suitable for the Westgate Service that are high scoring psychopaths but without personality disorders outside of the diagnosis of antisocial personality disorder. Conversely, suitable individuals can be severely personality disordered but not have excessively high levels of psychopathy. Personality disorder diagnoses and descriptions (according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV; American Psychiatric Association, 1994) are provided within Table 1 below, divided into three clusters.

Table 1.

Personality Disorder Diagnoses.

Cluster A (odd/eccentric)	Cluster B (dramatic/erratic)	Cluster C (anxious/fearful)
Paranoid Distrusting and suspicious interpretation of the motives of others	Antisocial Disregard for and violation of the rights of others	Avoidant Socially inhibited feelings of inadequacy, hypersensitivity to negative evaluation
Schizoid Social detachment and restricted emotional expression	Borderline Unstable relationships, self-image, affects and impulsivity	Dependant Submissive behaviour, need to be taken care of
Schizotypal Social discomfort, cognitive distortions, behavioural eccentricities	Histrionic Excessive emotionality and attention seeking	Obsessive-compulsive Preoccupation with orderliness, perfectionism, and control
	NarcissisticGrandiosity, need for admiration, lack of empathy

The treatment needs analysis aspect of ATNA is derived on a narrative case formulation, resulting in the identification of motivators, destabilisers and disinhibitors for up to three significant offences within the prisoner’s convictions. The rationale for using case formulation within the ATNA process is in line with the current literature base. This suggests that case formulation is increasingly being used with the personality disordered forensic population to provide understanding about the client’s functioning and shape understanding of why offences were committed (Jones, 2010). Varying models of case formation are discussed within the literature with “situation level formulation” (Jones, 2010) being the format implemented within ATNA by conducting between one and three case formulations focusing on specific offences (including the index offence).

The case formulation process provides insight into the functional link between identified personality disorder traits and risk. The “functional link” has previously been criticised for not being sufficiently defined within the developing literature base relating to personality disorder assessment. Suggestions have included that the functional link is (a) a “causal connection” that exists between the severity of the personality disorder, resulting in an increased risk of violence or (b) the covariation between the personality disorder and dangerousness (Duggan & Howard, 2009). The new Offender Personality Disorder Pathway requires “a clinically justifiable link between the personality disorder and the risk” (Joseph & Benefield, 2012; p. 213). Understanding of the functional link between personality disorder and risk informs subsequent treatment recommendations. Identified criminogenic treatment needs are consequently grouped into the domains of self-management, social and interpersonal, and offence interests/thinking processes. The evidence used to inform a prisoner’s suitability is accrued by a triangulated approach including prisoner self-report and responses to psychometric tests, collateral, and staff observations (including Behavioural Monitoring). This ensures that a thorough review of available evidence is conducted, increasing the reliability and defensibility of the assessment process.

Psychopathy and personality disorder traits can manifest themselves in the form of treatment interfering behaviours which can impact upon treatment readiness and engagement (Howells & Tennant, 2010). The complexity of psychopathy and its co-morbidity with mental disorder and criminogenic need means that psychopathic offenders are difficult to motivate and engage within treatment. This results in disruptive behaviour being observed regularly within this population (Hemphill & Hart, 2002). Psychopathic offenders are also less likely than non-psychopathic offenders to remain in treatment (Hemphill & Hart, 2002) indicating that this issue extends further than merely encouraging this population to commence treatment. The Westgate Service refers to these treatment interfering behaviours as “Responsivity Issues” (McGuire, 2001). Responsivity issues act as barriers to either physical attendance or meaningful engagement in treatment. Responsivity issues encountered with this population can be linked to emotional dysregulation, interpersonal problems, unhelpful thinking styles, attachment problems, impulsivity and sensation seeking, and symptoms of trauma. The previously described heterogeneity of this population emphasise the importance of managing responsivity within this population. Examples of responsivity issues linked to personality disorder and psychopathy traits experienced with this population are presented in Table 2.

Table 2.

Example Responsivity Issues and Associated Personality Traits.

Responsivity issue	Impact on engagement	Associated personality traits (from IPDE or PCL-R)
Self-harming behaviour	Limited attendance due to seeking medical treatment	Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour (Borderline PD)
Mistrust of others	Limited disclosures within sessions	Doubts about the loyalty or trustworthiness of others frequently expects, without sufficient basis, to be exploited, harmed, or deceived by others (Paranoid PD)
Boredom susceptibility	Limited attention within sessions	Prone to boredom (PCL-R)
Belief that treatment is beneath them	Superficial engagement in treatment	Grandiose sense of self-worth (PCL-R)Believes that he or she is “special” and unique and can only be understood by special or high-status people (Narcissistic PD)
Refusal to take responsibility for offending/changing future behaviour	Lack of skills generalisation, blaming others	Failure to accept responsibility (PCL-R)

Note. IPDE = international personality disorder examination; PCL-R = Psychopathy Checklist–Revised; PD = personality disorder.

ATNA identifies relevant responsivity issues as well as methods that the prisoner and future staff can use to manage these behaviours with the intention of maximising treatment engagement. This information informs an individualised Responsivity Plan which is reviewed and amended (as required) during the prisoner’s progress through the treatment framework (Wood, in press). For some significant responsivity issues (e.g., significant self-harm or experience of trauma), a referral can be made to the Imminent Needs Service (described below).

Within the Westgate Service’s wider regime, multidisciplinary case conferences are held on a monthly basis and can be requested on an ad hoc basis if required. This is a minuted forum where formal decision-making regarding prisoners’ engagement and management are made. Prisoners are usually raised at case conference to discuss assessment outcomes and recommendations, applications to leave the unit as well as management/clinical concerns impacting on engagement with treatment or the wider regime. The Westgate Service does not use a specific clinical tool to assess motivation to engage within clinical processes on the unit. Instead, any concerns about decreased motivation (at any time) trigger inclusion within a case conference where concerns and management strategies are discussed.

The Westgate Population

Considering all prisoners that have met the above suitability criteria and commenced treatment (between May 2004 and January 2014), the following breakdown of personality disorder and risk assessments represent this sample (n = 118). The average total PCL-R (Hare, 2003) score was 29.73 (range = 14.70-40.00; SD = 11.67). The average HCR-20 (Douglas & Webster, 1999) score was 31.68 (range = 23-40; SD = 11.30). The average number of definite PD diagnoses (as assessed by the IPDE; WHO, 1997) was 1.89 (with 29.55% being diagnosed with one PD, 40.91% diagnosed with 2 PDs, 18.18% diagnosed with 3 PDs, and 7.95% diagnosed with 4 PDs).

Good Lives and Development (GLAD)

GLAD is a scheme based on the Good Lives Model (Ward & Brown, 2004) and runs alongside treatment on the Westgate Service. The Good Lives Model suggests that individuals universally desire the same primary “human goods” attained via individually chosen methods (referred to as secondary goods). The GLAD scheme intends to encourage participants to set and achieve relevant treatment-related targets to promote the use of socially acceptable secondary goods. This scheme has historically been coordinated by Prison Officers working alongside clinical staff to identify personally relevant treatment-related targets. The GLAD scheme is currently being reviewed (following changes in staffing levels on the unit) with the intention of re-rolling a revised system. The aims of the system will remain the same but it is anticipated that the format that it will follow will alter to adapt with organisational changes. Historically, when a prisoner commenced treatment on the Westgate Service, an initial GLAD plan was developed. The GLAD plan detailed relevant treatment-related targets including skills the prisoner could generalise to achieve these goals. Similar to Behavioural Monitoring sheets, all staff had access to GLAD plans, enabling them to make reference to skills they have observed when recording case notes. GLAD plans were reviewed quarterly and targets reviewed and refined as a result of the prisoner’s ability to generalise relevant skills.

A clinician and an appointed programmes manager have consulted prisoners residing at the Westgate Service to identify appropriate solutions to revise the system whilst incorporating service-user involvement. These contributions intend to maximise willingness to engage in the finalised process as well as encourage prisoners to contribute to and take responsibility for aspects of their environment, in line with the Enabling Environments standards (Johnson & Haigh, 2011). The new system intends to have consistent intentions with the initial system but intends to adapt to staffing alterations in the service and respond to prisoners’ suggestions for the system.

Treatment

If an offender meets criteria and Westgate is considered to be the most appropriate treatment option, it will be recommended that he remains on the unit to commence his individual treatment pathway. The Westgate Service offers a treatment framework (see Table 3) and associated supporting services. There has historically been call for the treatment providers of specific forensic populations (including psychopathic offenders) to prioritise the development of treatment components to effectively reduce offending within these populations (Polascheck, 2012). The Westgate Service treatment framework takes into consideration psychopathic and personality disorder traits, resulting in subtle differences when compared with mainstream prison treatment. Treatment groups are smaller (approximately five prisoners), sessions are shorter (1 hr), and supporting services and imminent need services encourage meaningful treatment engagement. The majority of formal treatment is based on the Risk Need Responsivity (RNR) model (Andrews & Bonta, 2010), incorporating multimodal, skills-based, cognitive behavioural methods. Treatment takes a mixed format of both group and individual sessions. Some treatment components form part of the Chromis programme (as presented by Tew & Atkinson, 2013), which is designed to reduce the risk of violence in psychopathic offenders. The Westgate Service was being planned and developed at the same time as the national Offending Behaviour Programme Unit was commissioning the development of a cognitive behavioural treatment programme targeting psychopathic offenders. Subsequent co-working between Chromis developers and Westgate Service developers resulted in the subsequent Chromis components. Chromis components were developed alongside other aspects of the Westgate Service, ensuring they were complimented within the finalised treatment framework. This explains why aspects of Chromis are mirrored within other areas of the Westgate Service. The Chromis programme was accredited by the Correctional Services Accreditation Panel (now known as Correctional Services Accreditation and Advice Panel [CSAAP]) in 2005. Chromis was initially meant to be run in three of the four original DSPD sites but was only introduced at the Westgate Service (Burns et al., 2011). Other treatment components have been developed and adapted by Westgate clinicians. The length of time in treatment varies across participants and is dependent on individual treatment need requirements and responsivity issues. Westgate’s treatment framework is delivered by multidisciplinary staff teams and although psychologically driven, is not solely facilitated by psychologists. This was an important factor within Westgate’s treatment model and has proven to be successful in developing staff/prisoner relationships as well as developing a highly skilled pool of staff. This pool of staff includes discipline officers regarded as skilled facilitators and treatment managers.

Table 3.

The Westgate Service’s Treatment Framework.

Motivation and engagement	Psycho-education domain	Self-management domain	Social and interpersonal domain	Offence interests/ thinking processes	Progression domain
Chromis Motivation and Engagement	Psycho-Education	Iceberg (Substance Misuse)	Social CompetenceRelationship and Intimacy Skills	Chromis Schema Therapy	Progression and Maintenance Programme
		Emotion Modulation		Healthy Sex Programme
		Chromis Creative Thinking
		Chromis Problem Solving
		Chromis Handling Conflict

The literature base recognises that the sequencing of the treatment of offenders should be considered within responsivity, particularly as “one size does not fit all” (Stephenson, Harkins, & Woodhams, 2013, p. 450). This literature also highlights the importance of motivational work being completed at the outset of treatment to maximise subsequent treatment engagement. The above treatment framework is not strictly completed in the above order but the treatment pathway has some sequencing requirements. The non-risk focused Chromis Motivation and Engagement and Psycho-education components are consistently completed at the start of prisoners’ treatment pathways as they act as foundations for subsequent risk-focused treatment. This is to motivate prisoners to meaningfully engage in treatment, to educate them about their personality traits and risk, increase awareness of appropriate boundaries and structure their expectations about the Westgate Service’s treatment framework. Following this, the appropriate sequence for treatment is established, according to individual need with the Progression Domain always ending individual treatment pathways. Members of the Clinical Management Team meet on a monthly basis to plot and review profiled assessment and treatment for the Westgate Service. This process allocates both prisoners and staff teams/leads to aspects of the clinical framework. Factors taken into consideration are staff availability/training as well as group dynamics and recommendations regarding the sequencing of the prisoner’s treatment pathway (from the prisoner’s assessment team or clinical case manager).

Chromis Motivation and Engagement

Chromis Motivation and Engagement is delivered individually and aims to motivate prisoners to constructively engage in treatment and the wider regime provided by the Westgate Service. This is the rationale for why this component is completed early on in prisoners’ treatment pathways. By using the Good Lives Model (Ward & Brown, 2004), facilitators are able to elicit what factors the prisoner cares about and how he tried to attain/achieve these historically. Personal relevance is encouraged with the aim that participants choose personally relevant change over compliance. In addition, the skill of objectivity is facilitated with the intention of encouraging meaningful engagement and a more objective overview of their concerns, motivators, and goals (Tew & Atkinson, 2013).

Psycho-Education

Research has suggested that psycho-education informing personality disordered individuals about their traits can help to increase understanding about an individual’s disorder and does not impact upon the therapeutic alliance within the treatment setting (Banerjee, Duggan, Huband, & Watson, 2006). This understanding was considered important prior to risk focused treatment being completed for participants to link personality traits to offending behaviour and criminogenic risk. Psycho-education was developed by Westgate clinicians to educate prisoners about personality disorder, risk, the Westgate Service’s treatment framework and to set appropriate boundaries within treatment. Psycho-education is delivered in a group setting and comprises the following four modules:

Introduction to Treatment: This provides an overview of treatment approaches on the Westgate Service. It aims to increase awareness of the skills employed by facilitators (Socratic questioning, reinforcement, modelling, respect, listening, and collaborative working).

Boundary Setting Awareness: This explores previous boundary testing behaviour and its impact on goal attainment. It aims to increase prisoners’ success in Westgate’s treatment framework by understanding what a range of different boundaries are.

Risk Assessment Awareness: This explains static and dynamic risk and explores prisoners’ risk factors relevant to their treatment needs.

Personality Disorder Awareness: Personality disorder and psychopathy traits are explained to prisoners who are then asked to link their own traits to their offending behaviour.

Self-Management Domain

The Self-Management Domain comprises treatment components delivered in a mixed group/individual session format and is designed to develop effective cognitive and self-management skills.

The Chromis Cognitive Skills components (Creative Thinking, Problem Solving, Handling Conflict) aim to develop thinking processes, more appropriately manage interpersonal conflict and lay foundations for future schema therapy work. The rationale for this is so that personally meaningful goals can be attained by prisoners without the use of verbal or physical violence. Creative Thinking introduces skills to make sense of and solve problems, attain goals, and limit boredom. Problem Solving aims to develop critical reasoning, problem definition and resolution. Handling Conflict explores ways of making sense of, avoiding and resolving interpersonal conflict. This includes a “Life Map” where prisoners identify past key events and how their interpretations of these developed their views of themselves, others and life in general. This work informs subsequent schema therapy (Tew & Atkinson, 2013).

Iceberg is aimed at substance-related offending. This component introduces Prochaska and DiClemente’s (1983) transtheoretical model of behavioural change to participants and Iceberg’s format mirrors this “Stages of Change” model. Iceberg does this by exploring how to increase/maintain motivation to be substance free (cognitive change), identifying relapse prevention strategies (behavioural change) and necessary lifestyle modifications (long-term behavioural change) required to be substance free.

Emotion Modulation aims to increase participants’ ability to appropriately manage emotions by encouraging skills to adjust or regulate how intense emotions are and how long they last. This includes increasing the ability to recognise emotions and their links to offending; education regarding the adaptive, healthy functions of emotions; exploring problematic emotions as a result of over-controlling and under-controlling emotions.

Social and Interpersonal Domain

This domain includes the Social Competence and Relationship and Intimacy Skills components. The Social Competence component is completed prior to the Relationships and Intimacy Skills component due to the former exploring skills that inform the latter. This means that social skills can be further explored and applied to intimate relationships.

Social Competence is designed to increase and develop the level of social skills. This is with the intention of interacting with others in a positive, pro-social way. This includes the following skills:

To identify and monitor personal patterns of social behaviour.

To enhance participants’ competence in perceiving the social environment.

To enhance participants’ competence in social problem solving through accurate processing of social information.

To enhance participants’ ability to demonstrate and reflect on socially competent behaviour.

To increase participants’ self-esteem and self-confidence in social situations as a result of enhancing aspects of their social and interpersonal competence.

Relationships and Intimacy Skills aims to develop a range of skills required to develop and maintain healthy intimate relationships and friendships. These skills include the following:

The ability to identify, monitor, and modify thinking patterns and related feelings and behaviours experienced within relationships;

Appropriate ways to express feelings, perspective taking, negotiation, support seeking, and conflict management;

Managing interpersonal difficulties within relationships; and

Increasing confidence and self-esteem in relation to the formation, maintenance, and potential termination of relationships.

Thinking Processes and Offence Interests

The preliminary identification of schemas within the Chromis Cognitive Skills components informs the Chromis Schema Therapy component. This component is split into three phases. Phase one (delivered individually) identifies unhelpful schemas held by the prisoner via a case formulation approach. Mind maps and thought records help to explore how schemas developed in the past and how they are maintained in the present. This formulation informs phase two of the component (delivered in a group format) where behavioural experiments are designed and implemented to test out the validity of unhelpful beliefs as well as newly constructed beliefs. Phase three aims to prepare the prisoner for progression by consolidating learnt skills and encourage ongoing schema testing (Tew & Atkinson, 2013).

As the Chromis programme was designed to reduce the risk of violence within psychopathic offenders, sexual offending treatment needs have not historically been addressed by this treatment domain. Prisoners who have completed Westgate’s treatment pathway with ongoing treatment needs in sexual offending have been recommended to complete work specifically addressing this need area after they have progressed from the Westgate Service. The Westgate Service piloted the Healthy Sexual Functioning Programme which has since been revised into the Healthy Sex Programme (HSP). Across the custodial setting, HSP aims to be completed following treatment needs in cognitive distortions, minimisation and pro-criminal attitudes have been addressed. HSP involves individually delivered behavioural modification which aims to change residual deviant sexual interests that can be present for some offenders after these other sexual offending treatment need areas have been addressed. Lessons learnt from the implementation and pilot of this treatment have included the adjustment of delivering 1.5-hr sessions within the Westgate Service’s regime. In addition, some manualised session content has been found to replicate other aspects of the Westgate Service treatment framework. For example, exercises relating to developing skills in problem solving, relationships and attitudes may not be necessary to complete if the prisoner is considered to have made meaningful progress within these treatment need areas within other aspects of the Westgate Service’s treatment framework. Facilitators have therefore tailored exercises to be as meaningful as possible to participants.

Progression and Maintenance Programme

Given that no set progression pathway was initially developed for DSPD programme completers, the developers of the Westgate Service included a Progression Domain within the proposed treatment framework. This component is consistently delivered at the end of a prisoner’s treatment pathway on the Westgate Service. The Progression and Maintenance Programme explores issues related to resettlement and “step down” from the high-security estate. This encompasses support processes such as parole conditions, vocational training, and community networks. Relapse prevention plans are developed within the component which focus on personally relevant high-risk situations.

Treatment Supporting Services

Imminent Need Services

Due to the complex nature of personality disordered offenders, responsivity issues can interfere with treatment engagement. The Imminent Needs Services provide voluntary treatment designed to support participants in managing their responsivity issues to maximise treatment benefits. These therapies can be run alongside the other treatment components discussed above. Referrals for these services are discussed within Imminent Need Services meetings attended by psychologists, therapists and mental health nurses trained in the available treatments offered by the Westgate Service. This means that the most appropriate service is matched to the participant on a case-by-case basis. The following treatments are included within the Imminent Need Service.

CBT

CBT was introduced on the unit with the aim to reduce individuals’ emotional distress by helping them to identify, examine, and modify the distorted and maladaptive thinking underlying the distress. CBT intends to target Axis I disorders so prisoners can appropriately manage difficult emotions/unhelpful beliefs which act as barriers to treatment that inhibit engagement. CBT is delivered individually and prisoners are allocated to specifically trained clinicians. An assessment period is negotiated between the prisoner and clinician and treatment sessions follow this targeting specific problems working towards collaboratively identified goals.

Challenges experienced by CBT therapists on the Westgate Service have included the increased level of time required to resolve difficulties targeted in treatment in comparison with community-based CBT services which would aim to run over a set number of sessions. The extended amount of treatment at the Westgate Service leads to a concern that prisoners could become dependent on clinicians to solve encountered problems. Clinicians manage this by being time bound and goal specific within treatment. Observed difficulties about implementing this treatment with this population is that it can be challenging to differentiate between target behaviours and the manifestation of personality disorder traits, highlighting the complexity of personality disorders.

DBT

DBT is designed for individuals diagnosed with borderline personality disorder (Linehan, 1993) which manifests itself within personality traits likely to have three consequences: (a) threaten life, (b) manifest as treatment interfering behaviours, or (c) threaten quality of life. The DBT team is made up of specially trained clinicians and discipline officers. DBT is delivered via individual and group sessions. Prisoners attending DBT sessions are asked to complete diary cards on a weekly basis which record any situations where their behavioural responses have threatened life, treatment engagement, or quality of life. Individual sessions are facilitated by an allocated clinician and discipline officer. These sessions are guided by any unhelpful behaviours recorded within diary cards. Facilitators then encourage prisoners to identify solutions and generalise skills in response to these situations. Group sessions are facilitated by any two members of the DBT team and intend to provide a supportive, “validating” environment for prisoners. These sessions aim to facilitate and generalise skills for regulating emotions, tolerating distress, being successful in relationships, and being mindful (self-aware).

The DBT team have faced challenges implementing this service within a custodial environment. Within the community, DBT clients would have the option to have 24-hr access to their therapist should an emergency situation arise. This is referred to as “crisis intervention.” Applying this theoretical aim of DBT to the practical secure setting is not possible given the physical restrictions of the environment. DBT guidelines recommend that clients do not have contact with their therapist for 24 hr after an incident of self-harming behaviour. This is difficult to uphold within custody as H.M. Prison Service Safer Custody requirements are to assess and have subsequent interactions to manage prisoners’ self-harming behaviours. In addition, aside from borderline personality disorder, prisoners attending DBT can be diagnosed with other personality disorders and psychopathy traits. As this client group has a range of functions of self-harming behaviour including interpersonal influence, status seeking and sensation seeking (Bennett & Moss, 2013), conditioning and manipulation can feature within behaviours that would be otherwise be considered as triggering a crisis. This means that the function of crisis intervention for some prisoners could contravene its aims. DBT therapists have managed this issue by agreeing with prisoners that they can request crisis intervention support for a maximum of 1 hr per week which is solely aimed at resolving the crisis that the prisoner is experiencing. The restrictive nature of prison and its regime can limit which skills prisoners can implement in prison which would not be problematic in the community setting. This can make some crises particularly distressing for prisoners.

Eye Movement Desensitisation and Reprocessing (EMDR)

EMDR is an innovative treatment developed for individuals who suffer from posttraumatic stress disorder (PTSD). It is delivered in an individual format. Trauma can lead to the experience of extreme emotions that can overwhelm the brain and impact on all aspects of life. EMDR assists individuals who have suppressed distressing memories/images associated with past trauma. EMDR provides prisoners with the opportunity to re-process these memories so they have less of an impact on their day-to-day life (Shapiro, 2001). The rationale for including this treatment within the Westgate Service’s treatment framework is to help prisoners improve their focus and engagement in treatment on the unit, which may be asking them to think about their past. Challenges faced by EMDR therapists to date include that some prisoners have developed robust defence mechanisms (also strongly linked to offending behaviour) which have made it challenging to explore past memories.

Mental health team—Care programme approach

Prisoners on the Westgate Service are allocated a named Nurse from the Healthcare team. This service can identify mental health requirements of individual prisoners. This can trigger referrals to relevant treatment services. These can include other imminent need services available on the Westgate Service or support from a psychiatrist.

Skills Rehearsal Group

The Skills Rehearsal Group is a weekly group where participants have the opportunity to further practice skills from treatment within a safe, therapeutic environment. This is with the intention to practice skills that prisoners are finding difficult to master to encourage skills generalisation. Any staff can refer a prisoner to the Skills Rehearsal Group, as well as prisoners self-referring. Attendance however is voluntary as it is viewed as a supportive service to prisoners.

Active Learning

Active Learning differs from group room-based treatment by nature of its experiential learning approach and gym-based setting. The “Introduction to Group Working” sessions are offered to prisoners in the pre-assessment “Living Phase.” Through active participation in practical exercises, participants are introduced to elements of group work which will help to maximise treatment engagement. These elements include communication, personal disclosure, managing group dynamics, problem solving, planning, team work as well as giving and receiving feedback. In addition, the sessions provide participants and staff the opportunity to work together and build positive relationships. The provision of Active Learning is currently under review with the aim to explore whether it could be used effectively at other points during treatment to increase group cohesion.

ATNA Update

ATNA Update acts as a review of progress partway through and at the end of a prisoner’s treatment pathway at the Westgate Service. The timing of the ATNA Update is not identical for all participants due to the individualised treatment pathway but intends to take place approximately halfway through the treatment pathway. The case formulation developed within ATNA is reviewed as well as the dynamic risk items on the VRS and HCR-20 and identified responsivity issues. Again, a triangulated approach using prisoner self-report, responses on psychometric tests, collateral and staff observations (including Behavioural Monitoring and GLAD) is used within this process. This process results in identified areas of progress and ongoing need for prisoners, informing subsequent recommendations with respect to treatment, management and supervision. These recommendations can include the completion of offence specific treatment at a progression site.

Progression

At the outset of the introduction of DSPD services, funding was not allocated to implement progression options dedicated to completers of the DSPD treatment frameworks. Staff at the Westgate Service developed working relationships with staff at HMP Altcourse (a Category B site within the private sector) to develop a progression option for completers of the treatment pathway. This work involved training Altcourse staff to have an increased awareness and understanding of personality disorders and psychopathy as well as the treatment framework completed by prisoners progressed on to their Foinavon Wing. Since this time, the Offender PD Pathway (Joseph & Benefield, 2012) has been introduced offering a range of potential progression sites for Westgate “completers.” Following the introduction of the Offender PD Pathway in England and Wales (Joseph & Benefield, 2012), an increased number of personality disorder services across health and secure settings are being introduced. One of Westgate’s four units was re-rolled into the only Category A PIPE in May 2012. Although this reduced the Westgate Service’s capacity, this change enabled a provision for Category A completers from the Westgate Service and other treatment services within the Prison Service.

Progression options for Westgate Service completers currently include the following: PIPEs based at HMP Frankland (Category A), HMP Garth (Category B, non-sexual offenders), and HMP Hull (Category B, sexual offenders). In addition, progression sites have included the Foinavon Wing at HMP Altcourse as well as mainstream prison sites to address outstanding treatment needs within the domain of offence-related interests. Treatment “completers” engage in progression planning prior to transferring to progression sites to maximise their ability to generalise learnt skills from treatment.

Research and Evaluation

The impact of what was referred to as DSPD services on long-term rates of re-offending is unknown given the limited number of treatment completions released into the community environment. It is also (realistically) considered that long-term evaluation impact of DSPD services will take time (Department of Health & National Offender Management Service Offender Personality Disorder Team, 2011). The lack of completions residing in the community means that reconviction data are not available to evaluate service effectiveness at this time. At the time of writing, the Westgate Service’s treatment completions totalled 25. This increasing sample has allowed scope for small scale initial evaluation. As completers have progressed on to other settings, this has allowed initial short-term evaluation of treatment services at the Westgate Service which will be summarised here.

A case study exploring initial Chromis completions who had transferred to progression sites has been conducted (Tew, Dixon, Harkins, & Bennett, 2012). This study aimed to evaluate changes in anger and aggression within a sample of five completers. Self-report (psychological test) information, documented staff observations and adjudication information was used within this evaluation. This case study found evidence to suggest that after progressing from the Westgate Service, participants experienced a decline in self-reported anger as measured by the Novaco Anger Scales and Provocation Inventory (NAS-PI; Novaco, 1994). Expected rates of violence (calculated by using the frequency of historical violent incidents and time located at the Westgate Service) were compared with actual rates of violence. Participants were found to be involved in fewer incidents of physical aggression than expected but higher than expected levels of verbal aggression (Tew et al., 2012). Further research is ongoing with the same cohort of five participants to qualitatively explore engagement and the lived experience of Chromis treatment. A study intending to explore the functions of self-harming behaviour on the unit also found evidence to suggest that treatment on the unit led to an ability to verbalise insight into their self-harming behaviour. It was considered that this was either to insight being increased as a result of treatment or treatment assisting prisoners in disclosing this information (Bennett, 2013).

Research has also explored treatment dropout at the Westgate Service (Bennett, in press) given that personality disordered and psychopathic prisoners can be challenging to engage in treatment. This study identified that a diagnosis of narcissistic personality disorder was (just) significantly related to treatment dropout. No other personality disorder diagnoses, PCL-R total or factor scores were related to treatment dropout. This was considered to provide evidence to suggest that the Westgate Service can engage individuals with a range of personality disordered diagnoses in treatment, supporting the use of responsivity planning and management on the unit. Given the small sample sizes available, qualitative research may be considered a valuable research methodology within this population, particularly as it has been observed that sensitive subjects can be explored with this population in an ethically appropriate way whilst providing detailed insight of participants (Bennett, 2013).

Up until January 2014, 25 prisoners had completed the Westgate Service’s treatment framework. Twenty of these completers had reduced their risk as assessed by the HCR-20 (Douglas & Webster, 1999), with an average reduction of 2.28 across all 25 completers. Eight of the 25 completers had experienced reductions in security category. Although none of these reductions were for the Category A completers, they had either been transferred to complete mainstream sexual offending treatment or to a PIPE site to assist their skills generalisation. This provides evidence to suggest that Westgate Service treatment completers can experience reduced risk, which is particularly beneficial given the chronicity of this specific offending population and the impact this has on cost and resources accrued by crime. In addition, treatment completers can attain progression to lower security (and less cost intensive) settings or continuation through the Offender PD Pathway.

The Offender PD Pathway’s research and evaluation strategy is being jointly developed by the Department of Health and the National Offender Management Services. Aside from this, the Westgate Service also hopes to build on the developing literature by exploring the impact of other treatment components. It is hoped that this will increase understanding about “what works” with this challenging population. Given the previously discussed changes to the referrals process and limited scope to complete outreach work, the unit intends to research the referrals process. This is with the aim of increasing knowledge and understanding about which referrals are most likely to meet the service’s criteria and limiting the number of referrals that do not subsequently meet criteria.

Future Directions for the Westgate Service

Given the recession’s influence on Government funding cuts within the Prison Service in England and Wales, a number of changes have impacted upon the regime, staff structure and levels at the Westgate Service and will continue to do to. This has led to decreased staffing levels through staff not in post not being replaced as well as voluntary redundancy packages being accepted by experienced and skilled staff. This means that training and supervision has been required to further develop staff to replace these roles. Education provision is being reduced on the unit. This is due to the unit not being able to guarantee required numbers of prisoners attending set education sessions due to treatment taking priority on the unit. Senior management at the Westgate Service are currently making efforts to agree new terms with education providers and exploring the option of developing structured sessions that can be run by staff on the unit. This would provide opportunity for prisoners to engage in creative work and further develop their skills.

Funding is currently secured for the Westgate Service until 2015, and is therefore likely to be subject to scrutiny and processes such as benchmarking which is being carried out across the Prison Service estate. This means that the service needs to continue to provide value for money and prove cost-effectiveness to individuals allocating funding. Staffing cuts have meant that there no longer was a dedicated department to research the effectiveness of the service. It is still intended for service evaluation to take place however. This will be implemented through a range of ways including: clinical staff who are required to complete research studies as part of their professional training; external researchers; and the Offender PD Pathway’s research and evaluation strategy. It is hoped that developing professional relationships with academic institutions will allow increased opportunities for further research and evaluation to take place. Research priorities for the unit include: the effectiveness of treatment components (particularly those not already explored within Chromis evaluations); the effectiveness of the referrals process; other benefits of treatment on prisoners (e.g., impact on quality of life). Metrics used to explore treatment effectiveness could include proven adjudications, behavioural observations, and self-report (via psychological tests). As previously discussed, it is anticipated that the Westgate Service will experience a change in population as a result of other personality disorder services opening within the Offender Personality Disorder Pathway (Joseph & Benefield, 2012). This means that the service is likely to need to revisit service effectiveness in order to evaluate “what works” with this population.

Footnotes

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.

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