Offender Personality Disorder Pathway Research Articles

The Offender Personality Disorder (OPD) Pathway for Men in England and Wales: A Qualitative Study of Pathway User Views About Services, Perceived Impact on Psychological Wellbeing, and Implications for Desistance

The offender personality disorder (OPD) Pathway is a network of services across prison, health and community settings in England and Wales providing psychological support for high-risk people who have offended and are thought to have a personality disorder. As part of a national evaluation of the Pathway, semi-structured interviews were carried out with 36 Pathway users to determine their views about their experiences in these services; and whether and how these impacted on their psychological wellbeing. Framework analysis was used to analyze the data. Participants reported positive therapeutic relationships with staff; improved psychological wellbeing; and for some, a shift away from antisocial toward more pro-social identities. They also described a negative impact of staff turnover and uncertainty about the role of prison officers and psychologists within prison services. Pathway services are able to engage individuals who have not previously engaged with services. Constancy of staff is fundamental to the Pathway.

The effectiveness of the offender personality disorder pathway: a propensity score-matched analysis

ABSTRACT Offenders with severe personality pathology are at significantly increased risk of serious and violent offending. In England and Wales, offenders who are likely to meet criteria for a diagnosis of personality disorder are managed within a network of ‘Offender Personality Disorder Pathway’ services. We conducted a retrospective cohort study over 6 years, using linked routine datasets, to examine the effectiveness of these services on male offenders (n = 28,321). We compared the outcomes of those who received a simple case formulation and had not been referred to Pathway services (the ‘Comparison group’), with a group of offenders who had received a complex case formulation and been referred to Pathway services (the ‘Treatment group’). Over time, significant improvements occurred in re-offending risk scores, and lower rates of behavioural disturbance among both Treatment and Comparison groups of offenders. However, no statistically significant differences were detected in the rates of improvement between Treatment and Comparison groups. Offending rates in both groups significantly increased over time, although there was no significant difference in the increase in offending rates between the Treatment and Comparison groups. Currently, there is no statistical evidence that the Pathway is associated with changes in offender behaviour.

Forensic Case Formulation: Exploring the Knowledge, Opinions, and Training Experiences of Staff Working Within the Offender Personality Disorder Pathway.

Forensic case formulation (FCF) is a key activity within the Offender Personality Disorder Pathway (OPDP), performed by OPDP specialist offender managers (OMs) and psychologists. Although FCF training is provided to OMs, there are a number of questions about the adequacy and effectiveness of this training. Furthermore, it is unclear whether psychologists receive sufficient support to keep their FCF skills relevant and effective over time. This study aimed to investigate the FCF training experiences of OPDP staff, to assess staff satisfaction with this training, to identify ways of improving this training, and to explore the value of FCF from a staff perspective. To meet these aims, OPDP staff were asked to complete an online Qualtrics survey disseminated nationally. Results reveal a lack of standardized FCF training across the OPDP, contributing to poor staff satisfaction and confidence. These results highlight a need for FCF training improvement within the OPDP.

A demographic and clinical profile of prisoners accessing an assessment and treatment service within the offender personality disorder pathway

ABSTRACT The Offender Personality Disorder (OPD) pathway enables men and women likely to have personality disorder to be identified and treated in prisons, secure hospitals and the community. The treatment services forming part of the OPD pathway aim to improve the psychological health, wellbeing, and relational skills of its target population. However, there is very little literature on the population that fall within the scope of the OPD pathway. This paper examines the clinical and risk profile of a cohort of male prisoners participating in a long term, high secure prison-based assessment and treatment service, the Beacon, which forms part of the national OPD pathway. Demographic information, psychiatric and offending history, personality disorder diagnosis, and details on trauma symptomatology was collected from a cohort of prisoners participating in the Beacon service. The paper considers the personality traits and mental health needs present in the population alongside key trauma-related difficulties. This paper demonstrates that the present cohort of the Beacon prisoners show evidence of complex emotional and interpersonal needs. Their experiences with trauma and associated symptoms were common, especially related to posttraumatic stress. Limitations are discussed.

“The People Who Leave Here Are Not the People Who Arrived.”: A Qualitative Analysis of the Therapeutic Process and Identity Transition in the Offender Personality Disorder Pathway

Individuals with personality disorder are often construed as difficult to treat, and sometimes even “untreatable.” In this study, 24 men who had completed treatment on the offender personality disorder treatment pathway participated in focus groups at a high-security prison in the United Kingdom. The results of the data analysis revealed three superordinate themes that captured the impact and experience of the therapeutic process. The three themes were “A self-reconstructed,” which focused on the reconstruing and reconstructions of participants’ identity and how intervention assisted with a coherent narrative of self. The second superordinate theme, “Relational resilience and dealing with abandonment,” relates to the attachment to therapists and the negotiation of relational boundaries and resilience. The third theme, “Reimagining and re-experiencing trauma,” focuses on participants’ exploration and reliving of trauma, and how group processes allowed for shared understanding and a reconstruing of their trauma. Implications for policy and practice are discussed.

Prison-based democratic therapeutic communities, medication, and the power to exclude.

In 1962, the first custodial Democratic Therapeutic Community (DTC) was established in the English prison estate at HMP Grendon. Today, the Category B male prison estate in England and Wales has three DTCs and three 'TC+' units for prisoners with learning disabilities. There is one DTC in the female estate at HMP Send. The services fall under the remit of the Offender Personality Disorder Pathway, a jointly commissioned initiative that aims to provide a pathway of psychologically informed services for a highly complex and challenging group of prisoners who are likely to have a severe personality disorder. Several of these units make clear that prisoners prescribed psychotropic medicines are specifically excluded from entry and participation in the available therapy. This analysis paper explores whether an evidence-based rationale exists for this practice and examines the impact on those whose care pathways may comprise hospitals and prisons.

Investigating the effectiveness of forensic case formulation recommendations

ABSTRACT The Offender Personality Disorder Pathway (OPDP) was co-commissioned in 2011 to better manage high-risk offenders likely to have a personality disorder. Within the OPDP, forensic case formulation is used to develop a psychological understanding of each offender’s criminal behaviour, clinical problems, and criminogenic needs. Each formulation concludes with a set of recommendations aimed at addressing the problems and needs identified. However, no research has yet investigated the effectiveness of these recommendations. To address this, the present study used a multiple case-study method to investigate the effectiveness of recommendations generated within 10 OPDP formulations. Two sets of cases were examined: 5 with positive outcomes, and 5 with negative outcomes (known as a ‘two-tailed’ multiple case study). When these two sets of cases were compared, a clear pattern of differences emerged in the relevance, feasibility, utility, and impact of the formulation recommendations made (in favour of cases with positive outcomes). On the basis of these results, a provisional logic model was developed to operationalise the process by which formulation recommendations were hypothesised to have contributed to outcomes in ‘positive’ cases, and where and why this process commonly deteriorated in ‘negative’ cases. Implications of these results and avenues for further study are discussed.

You hear me: The power of a brief intervention service in an Offender Personality Disorder (OPD) community pathway setting

The Lightbulb Service, a brief intervention, provided the opportunity for people who screened into the Offender Personality Disorder (OPD) pathway to access a therapeutic service to increase insight and experience a positive change in their wellbeing. The Service Evaluation used qualitative methods to explore the benefits of this intervention whilst recognising its limitations. Specificall, themes around being listened to; someone interested in them and their story, and improved connection to other professionals were just some of the discoveries made. It provided us with hope that brief interventions within a personality disorder service can make real and positive change for someone, who otherwise would not have accessed help.

Resettle intensive intervention and risk management service (IIRMS): a pathway to desistance?

PurposeThis study aims to explore the demographic and reconviction data of individuals who had engaged in an established Intensive Intervention and Risk Management Service, a community service within the offender personality disorder pathway (OPD).Design/methodology/approachDemographic information and reconviction data from the Police National Computer was accessed for all participants (n = 69) released to the service over a 10-year period (2008– 2018), 45 of who met criteria to be included in the study. Their intervention period spans custody to community, with an expected period of 2 years engagement upon release.FindingsParticipants in the service had experienced significant traumatic histories, with four or more adverse childhood experiences. Individuals had a mean of 17 convictions for violent and/or sexual offences and an average of 11 years in custody prior to release. The average length of intervention at Resettle in the community was almost 19 months, with an additional minimum of six months in-reach prior to release. A total of 60% of individuals were recalled back to custody at least once during their intervention, with this being more likely for those who had been convicted of a violent rather than sexual offence. Within the group who were reconvicted, the reconvictions were for less serious offences than the index offence, with only 16% being convicted of an indictable offence. Almost two-thirds (64.4%) did not receive a further conviction post-intervention in the follow-up period.Research limitations/implicationsThis follow-up study focused upon demographic and reconviction data from one established IIRMS. Although findings are not necessarily generalisable to other IIRMS and OPD pathway services, the demographic and reconviction data has important learning for how services may reflect upon engaging with individuals whose needs and risks had not previously been adequately met and managed upon release. This data are useful learning, for what may help individuals with complex needs upon release into the community after long sentences and how to best meet their needs. There are aspects of the Resettle IIRMS approach which could be applied to non-specialist services to encourage a holistic, compassionate and relational approach to reaching those with complex needs who pose significant risks to others.Practical implicationsThis follow-up study has provided access to participants’ engagement with an established IIRMS. Although participants “opt in” to the service whilst in custody, engagement on release becomes a probation licence condition; a fixed boundary regarding attendance and engagement which, although enables robust risk management and reduces the likelihood of drop-out, also raises consideration about choice and control. The four day per week service provides an intensive intervention, for those with complex needs and limited prior experience of living safely (with minimal risk to self or others) in the community. Participants were previously offered little hope of release or effective support because of their risk, need, complexity and, in some cases, concern about whether their risk could be effectively managed. Although not a panacea for all, the results are suggestive of a service that is navigating the boundary between “care and control” to good effect for future resettlement and desistance.Originality/valueThe findings are important for service providers, commissioners and the public purse. The results are useful for the national development of IIRMS. The findings are also important for prisoners and people on probation to inform their decision-making regarding intervention choices and hope for what may be achievable.

Service user experiences of a psychologically enhanced resettlement service [PERS] in an English open prison

PurposeThe purpose of this study is to investigate the experiences of adult male prisoners presenting with personality difficulties in an open (Category D) prison in the UK and their experience of a pilot offender personality disorder (OPD) pathway Psychologically Enhanced Resettlement Service (PERS) in the prison.Design/methodology/approachThirteen participants who had engaged with PERS were interviewed about their experiences of open conditions and the service. The interviews were transcribed verbatim and analysed using thematic analysis.FindingsTwo superordinate themes were identified relating to participants’ experience of open conditions, highlighting the challenges they faced. These were “the impact of institutionalization” and “relational barriers”. Two superordinate themes were identified relating to participants’ experiences of PERS; these were “relationships with staff” and “service structure”. Each superordinate theme had subordinate themes.Research limitations/implicationsAnalysis is based on a small number of interviews in one male prison, and only qualitative data were collected. A mixed-methods approach would enable the triangulation of results.Practical implicationsClinical importance for the pilot service is established, and there should be consideration for the rollout of PERS to other open establishments.Originality/valueTo the best of the authors’ knowledge, this study is the first to explore the experiences of Category D prisoners within the open estate engaging with a pilot OPD pathway service. Findings illustrate the difficulties OPD service users encounter managing the transition into open prison conditions and highlight elements of the PERS model that can support this process. Clinical and research implications are identified.

Drumming, singing and ceremony within a psychologically informed planned environment for women on the offender personality disorder pathway

PurposeThe offender personality disorder (OPD) pathway provides services to people with histories of offending and traits of personality disorder (PD) who are at high risk of violent re-offending. The residential provisions have been developed as psychologically informed planned environments (PIPE), in which socially creative activities form an integral part. Ryan et al. (2018) suggest that social and creative activities offer individuals experiences to increase their understanding of themselves and others. The purpose of this study is to complete a service evaluation exploring how people who live on an OPD PIPE in a woman’s prison make sense of their experiences of a drumming, singing and ceremony group, which was offered to them as part of their provision PIPE.Design/methodology/approachSemi-structured interviews were conducted with six service users (between 19 and 42 years old).FindingsThematic analysis identified three themes: emotional regulation, belonging and connectedness and humanising spaces.Research limitations/implicationsThis study used a small sample (n = 6), and all participants were accessing the same OPD provision PIPE. Further, participation was voluntary, and results found may relate to possible biases in a self-selecting sample. The interviewer knew the participants through their clinical work, and despite being informed that participation in this research project would have no bearing on their treatment pathway, some may have participated as a way to demonstrate their compliance with the overall programme. A further limitation relates to the group being evaluated on its own without a comparison group.Practical implicationsThis study has important implications for treatment delivery in prisons, as it demonstrates the therapeutic merit of social creative activities for one of the most complex, high-risk and challenging offender groups. The findings show that the specific combination of the physical act of drumming and the social act of drumming together may create an environment that allows people to heal and overcome both physical and emotional disconnections that have been caused by their trauma.Social implicationsThis study’s findings provide further understanding of the experience of people who have survived trauma.Originality/valueFindings suggest that the group provides therapeutic value, offering an alternative to traditional therapy and targets specific difficulties particularly associated with emotionally unstable and antisocial PDs. We suggest that socially creative activities form an important part of the rehabilitation process of complex, high-risk groups. Future research would benefit from focusing on the extent to which experiential learning through socially creative group participation can impact on lasting behavioural change.

Intensive intervention and risk management services (IIRMS) three years on: what we need to do better in the offender personality disorder pathway

Purpose This is a discussion paper describing the reflections of clinical leads within well-established intensive intervention and risk management services (IIRMS). IIRMS has developed in the past five years, with a small number of services leading in the development of a psychologically informed case management approach to working with individuals released from prison on probation licence, who have a history of high risk, high harm violent convictions linked to pervasive psychological and interpersonal problems. Design/methodology/approach Clinical leads of three services considered a period of 23 months up to December 2019, in which the outcomes for all individuals on their caseload at that time were reviewed. Reflections on the themes included the reasons for a premature return to prison and emerging themes for those who appeared to be successfully resettled. Findings Approximately one-third of the individuals were returned to prison, and for most, this occurred within the first 18 months of release. There was considerable unanimity between clinical leads regarding the themes, and problems with relative youth, substance misuse, relationship difficulties, managing transitions and complacency featured. There were four themes identified in those who appeared to have settled successfully in the community. Practical implications The identified themes provide key learning that will be enshrined in an updated version of the guidance for all IIRMS, with the overall aim of reaching out and engaging with a group of individuals who are most at risk of exclusion from services. Originality/value Although there are limitations associated with the informal approach of this paper, the reflections of the clinical leads have provided a valuable addition to the very limited empirical literature in this field.

Offenders With Personality Disorder Who Fail to Progress: A Case-Control Study Using Partial Least Squares Structural Equation Modeling Path Analysis.

Offenders with personality disorder can be challenging to engage and retain in treatment. The UK Offender Personality Disorder (OPD) pathway aims to proactively and responsively identify and engage offenders with personality disorder. However, a subpopulation of offenders on the pathway have been found to not be accepted into any OPD service and therefore fail to progress. This study aims to identify and describe offenders on the OPD pathway who fail to progress and to understand the causal drivers by which individuals fail to progress in the pathway. A sample of 50 offenders on the OPD pathway who had been refused from at least two OPD services (nonprogression group) were compared to 100 offenders accepted into OPD services (control group). Partial least squares structural equation modeling was used to model the causal factors involved in not being accepted into OPD services. The path coefficients in the structural model showed that the most influential factor in nonprogression was attitude toward treatment (β=.41; P<.001; f2=0.25) alongside those with psychopathology (β=.41; P<.001; f2=0.25), specifically, psychopathy, psychosis, and co-occurring personality disorder. The findings of the study provide a basis of how to work with this population in the future to increase the likelihood of acceptance into OPD services.

“Everyone Needs to Be Cared For”: Exploring Care from the Perspective of Prison Officers Working with Young Adult Offenders

ABSTRACT The purpose of the current study was to explore the care related experiences of prison officers working on an Offender Personality Disorder (OPD) Pathway service, located within a prison for young adults. Due to the exploratory nature of the study, a qualitative, grounded theory approach was utilized. Individual semi-structured interviews were conducted with twelve officers. The data were analyzed in accordance with constructionist grounded theory methodology. The results identified the core category of relationships and two additional categories: impact of caring and development of officers’ caring approach. These categories were integrated into a model of care. Officers reported caring to be both rewarding and challenging. They expressed beliefs that providing care to service users increases wellbeing and reduces recidivism. The results demonstrate a reciprocal nature to care, with officers needing to receive care themselves in order to care effectively for service users. Officers’ approach to caring for service users was dependent upon an interaction between their own experiences of care, care related values, their relationship with individual service users and their own emotional state. Individual officers and the OPD Pathway service could benefit from additional support and understanding from the prison system.

“It’s Us Doing It!” The Power of Participatory Action Research in Prison: A Contradiction in Terms? – Phase 1

We describe and reflect upon the process of setting up participatory action research (PAR) with a group of men resident on a personality assessment and treatment service in a medium security prison for male offenders. The service is part of the national offender personality disorder (OPD) pathway, a joint initiative between the National Health Service England and Her Majesty’s Prison & Probation Service set up in 2011. Its aim was to provide a pathway of services for offenders, likely to be diagnosed with a personality disorder, to reduce risk of re-offending and improve psychological health and wellbeing. Consistent with PAR principles, prisoners were trained as co-researchers with the aim of co-producing new knowledge and improving their community. To our knowledge, this is the first PAR project conducted within the OPD pathway. We focus here on initial stages of research design and development. By sharing our experiences, we contribute to the literature on co-production research highlighting key benefits and challenges of PAR in this setting. Key learnings such as the importance of obtaining organizational support, taking time for establishing trust, relationship-building and research training are discussed.

Conceptualising ‘success’ among Imprisonment for Public Protection (IPP) sentenced offenders with personality-related difficulties

This paper explores conceptualisations of ‘ success’ by men on Imprisonment for Public Protection (IPP) sentence licence screened into the Offender Personality Disorder Pathway. ‘ Success’ was defined as a process of having ‘ survived’ the perceived injustices associated with the IPP sentence. Participants’ discussed ‘ internal factors’ enabling them to make use of ‘ external facilitators’ of self-change; ‘ success’ was embedded in the development of interpersonal relationships with professionals. We propose a model of reciprocal anxiety existing within the criminal justice system in relation to the management of individuals on IPP sentence.

Offender personality disorder pathway Intensive Intervention Risk Management Service (IIRMS): Barriers to engagement and a vision for the future

As part of the national Offender Personality Disorder (OPD) pathway, Intensive Intervention Risk Management Services are commissioned to offer the opportunity for some eligible offenders to access individualised intervention to support their treatment needs, upon their transition from custody to the community (Skett and Lewis, 2019). However, it has previously been acknowledged that psychological services often fail to reach offenders due to a range of potential psycho-social reasons (Byng et al., 2012; NOMS, 2014; Skett et al., 2017). The current study aims to explore National Probation Service (NPS) and National Health Service (NHS) staff perceptions of the Intensive Intervention Risk Management Service (IIRMS), within the Cumbria, North and South Tyneside regions, including their perception of potential barriers to service delivery. Further, areas of improvement that may overcome potential barriers to engagement are discussed and comparisons are made to barriers identified to engagement within other NHS/NPS partnerships pathways; specifically the Mental Health Treatment Requirement (MHTR) (NOMS, 2014). Results indicate that the IIRMS is useful. However, a number of staff barriers, service user barriers and barriers within the method and delivery of the service were indicated. Results of the study offer the opportunity for shared learning across the pathway and with other services engaging with the most marginalised offenders within our society.

Listening to women: relational approaches to female offender management

PurposeThe purpose of this paper is to explore women’s experiences of criminal justice systems to inform the development of guidance on working with women.Design/methodology/approachA two-part, independent samples and qualitative study using semi-structured interviews incorporating both interpretive phenomenological analysis and thematic analysis was conducted. In Study 1, semi-structured interviews were conducted with six women on probation in the community and data were analysed using interpretative phenomenological analysis. Interviews in Study 2 were conducted with seven women in custody with data analysed using inductive-deductive thematic analysis. The applicability and expansion of Study 1 themes was then explored.FindingsSeven emergent themes indicated relational approaches to offender management may improve experiences of judicial systems for female offenders and for their probation officers. This approach may help prevent common systemic issues from perpetuating negative interactions between these groups. Specific suggestions for developing relational security and consistency of care within these relationships are provided.Practical implicationsTaking a relational approach to female offender management may help remedy some of the systemic difficulties faced by female offenders and their probation officers.Originality/valueBy focussing on the experiences of women screened in to the offender personality disorder pathway this study provides insight as to how this service can assist in the development of relational security between probation staff and their clients.

Exploring preliminary outcomes of a community treatment programme for men with sexual convictions screened into the offender personality disorder pathway

ABSTRACT This study describes a preliminary evaluation of a community group treatment programme for men with sexual convictions screened into the Offender Personality Disorder (OPD) pathway in London, UK. The Challenge Project has previously been evaluated prior to it being part of the national OPD pathway and the manual being revised. As such, there was a need to explore the outcomes of the new population being treated on the programme. Between April 2015 – April 2019 150 men were referred and 48 men were accepted onto treatment. At the point of referral data was gathered on the individual’s history, psychometric testing and risk assessment were also completed. Outcomes of the men were recorded based on treatment completion and formal failure up until April 2019. In terms of treatment completion, 50% did not complete treatment and had associated higher scores on the Stable 2007. In relation to formal failures, 44% of the men were either recalled to custody or were reconvicted of a further offence. The sexual reconviction rate was 11%, which was comparable to previous evaluations of the challenge project. Those that formally failed had higher scores on the RM2000 and the Stable 2007.

The Offender Personality Disorder Pathway: An exploration of the differences between offenders accessing a prison pathway service and a non-accessing population

ABSTRACT As the Offender Personality Disorder (OPD) pathway continues to expand in Her Majesty’s Prison and Probation Service, the diversity and characteristics of offender populations accessing the pathway becomes an important area of study. This was the first controlled study to investigate the risk, personality, readiness to change and reflective functioning abilities of offenders accessing a range of OPD prison services and make comparisons with offenders from the wider non-OPD-accessing prison population. A total of 105 males participated. OPD-accessing groups included; a Progression Psychologically Informed Planned Environment (PIPE), a Provision PIPE and an OPD Outreach Service (OPD-OS). The study found significant differences between risk, personality pathology, difficulties maintaining change and reflective functioning abilities of offenders accessing the OPD services when compared to the wider prison population. The OPD-OS service caseload emerged as a particularly high risk and needs group. Further implications for service development and future directions are considered.