Some general thoughts about treatment for personality disordered offenders

Different treatment approaches

The types of treatment can be thought of as lying on a continuum from behavioural to psychoanalytically-informed interventions. At the behavioural end the treatments target more concrete observable difficulties (e.g. actions) and as we move to the more analytical end, the treatments focus on more abstract and less easily observed difficulties (e.g. mental representations). This is detailed below:

In general, therapies for personality disorder are gravitating to the middle, incorporating both psychoanalytic and behavioural elements into one package. That is, there is an emphasis on an attachment based formulation of the offender’s difficulties, with interventions which include an element of psycho-education, skills development, and the development of a capacity for reflection and self-awareness. Some of the evidence-based treatments include cognitive behaviour treatment (CBT), dialectical behaviour therapy (DBT), mentalisation based therapy (MBT), schema therapy, cognitive analytic therapy (CAT), transference-focused psychotherapy and therapeutic communities (non-forensic). A review of the evidence base for personality disorder treatments can be found in Bateman, A., & Tyrer, P. (2004). Psychological Treatments for Personality. Advances in Psychiatric Treatment, 10, 378-388.

Treatment targets different areas

When you are referring someone for treatment, it is worth considering the reason for the intervention, which can address four separate areas. These are:

• the underlying personality disorder itself
• treating symptoms and behaviours associated with the disorder (e.g. impulsivity and aggression)
• treating problems which commonly co-exist with the disorder (e.g. substance misuse or depression)
• addressing offending behaviours.

Think about which aspect you are interested in targeting, as this will partly dictate whether you refer, and where you refer the person to.

For the two most commonly encountered personality disorders (Borderline Personality Disorder (BPD) and Antisocial Personality Disorder (ASPD), there are national guidelines on the type of treatment that should be provided (National Institute of Clinical Excellence – NICE. http://www.nice.org.uk). It is acknowledged that probation services manage a high number of individuals who would meet criteria for ASPD. These people should not be excluded from NHS treatment services on the basis of their diagnosis or history of offending behaviour, although the NHS may be limited in the interventions it can offer. It is important for probation to be aware of this as a potential diagnosis and where it is suspected as present, the individual is seeking help, and probation cannot meet his/her needs alone, consider referring to a forensic mental health service. Where there is co-existing disorder (e.g. anxiety or depression) consider referring to general mental health services (e.g. the local community mental health team) and where the treatment directly relates to the personality disorder, the individual should be referred to a forensic or specialist personality disorder service).

Treatment sequencing

There has been a good deal written about the importance of delivering interventions in the right order. Generally, the following sequence is agreed:

1. Proactive development of contingency plans to anticipate crises and to determine the limits of confidentiality
2. Establishing a working relationship, and dealing with immediate problems (such as panic attacks or depression)
3. Learning to develop skills in controlling feelings and impulses
4. Delving beneath the surface to explore, process and potentially resolve longstanding psychological issues.

Treatment effectiveness

There is a growing body of literature reporting on treatment effectiveness for personality disorder, offender rehabilitation and personality disordered offenders. For a detailed account, recommended reading is provided at the end of this chapter. As a general guideline treatment effectiveness can be subdivided according to the level of risk. Interventions for low risk cases may make offenders worse (although exactly why this is the case is not fully understood); for medium to high risk cases the effectiveness is better.

Treatment completion is important, and there are consistent findings that those offenders who drop out of treatment – whether in prison or the community – reoffend at significantly higher rates, more so than those who refuse to commence treatment at all. Given that personality disorder is linked to a greater likelihood of treatment non-completion, you will need to pay particular attention to this issue. PD offenders are likely to respond to encouragement, contact outside treatment sessions, help with attending, reminders about failed appointments, and so on. In other words, PD offenders may need more not less attention when they are attending a programme.

Is psychopathy treatable? Research would generally suggest that there are some grounds for optimism in thinking about interventions for psychopathic offenders. In particular, a mixed approach of individual, group and family work, delivered by a confident and well supervised staff team, may offer a chance of success. Interventions most likely to be effective are those which focus on ‘self interest’ – that is, what the offender wants to get out of life – and works with them to develop the skills to get those things in a pro-social rather than antisocial way.

Factors associated with treatment effectiveness generally are summarised below.

Summarising successful treatments:

• Combining group and individual treatments works best
• Consider additional family work & telephone contact outside planned sessions
• Treatment completion is crucial
• Target high risk groups, and expect at least 10-15% reduction in offending
• Treatment programmes lasting at least one year
• A cohesive team approach and philosophy of care, which is understood by the offender.