Personality disorder: prison vs community

[Dr Sue Wheatcroft]

This is a blog I wrote for CLINKS in May 2019. The exact link appears at the bottom of this blog.

Personality disorder: prison vs community

It is a sad and worrying fact that, as it stands, the best place in Derbyshire to get help for someone with a personality disorder (PD) is in HMP & YOI Foston Hall. Since 2013, the prison’s CAMEO unit has provided intervention and treatment pathways for women in prison, with all types of PD, in a therapeutic environment (Coping with complex needs, Aiming for a better understanding of self through Motivation to change, Engaging with others, and Optimism for the future). However, strict criteria mean that only those who have at least two years left on their sentence (meaning that they must have received a sentence of four years or more) can be admitted to the unit. For others, with a less serious offence, treatment must come from the over-stretched In-Reach team, who deal with the rest of the prison population. In the community, programmes exist in Approved Premises. For those who have not offended, however, specialised help for people with a PD is virtually non-existent.

Prison (specialist services)
The CAMEO service is part of the Offender Personality Disorder (OPD) Pathway, which is co-commissioned and managed by NHS England and Her Majesty’s Prison and Probation Service in response to the knowledge that approximately two-thirds of prisoners meet the criteria for at least one type of personality disorder. As well as initiatives such as the CAMEO unit, various courses have been established around the secure estate to help people in prison, including those with a PD, to interact with others in a safe and productive way. This includes the various hostels in the community, operating as Approved Premises. The Pathway Press, the newsletter of the OPD programme, offers more information.

Prison (without specialist support)
There is a serious lack of training for prison staff in the symptoms of PD. Too often, those with a personality disorder are seen as attention-seekers and/or trouble-makers. It is very often the case that an individual with a PD spends a longer time than normal locked in their cell and, as was my experience, this could be in segregation, alone for up to twenty-three hours a day. This exacerbates the condition, leading to even more time in segregation. For those lucky enough to be referred to In-Reach, there is inevitably a long waiting list and even then, treatments for personality disorders, outside the specific units, are difficult to source.

With a lack of resources, members of In-Reach face an uphill struggle to cope with the number of prisoners with a PD. In addition, making a diagnosis whilst in custody can be unreliable because the individual is away from their usual environment. People very often act differently in prison; they may be putting on a brave face or become anti-social. With regard to triggers, those in the community will merely be replaced with new or similar ones in prison. For example, a common symptom of Borderline Personality Disorder is the fear of sudden endings. This can be relationships, such as with a therapist, or situations. In prison, relocating an individual into another cell without prior knowledge can be immensely traumatic.

In-Reach may not be able to offer a tailor-made service and the individual may be left despondent, angry and potentially dangerous. However, being in a secure environment, they are more likely to see a member of the same team than if in the community.

Arguably, one of the most effective systems in prison is the Assessment, Care in Custody, and Treatment (ACCT) book. Once an individual is seen as having a mental health condition which could lead to self-harm or suicide attempts, they are supported with the ACCT book, which offers on-going monitoring during and after any treatment. Significantly, the book will not be closed until a team of healthcare professionals, prison officers and the individuals themselves agree that it should.

The Derbyshire community
As an expert by experience (I have Borderline Personality Disorder and have spent 18 months in prison) and the founder of the Derbyshire Borderline Personality Disorder Support Group, I was asked by my local NHS Clinical Commissioning Group to set up a focus group to inform and advise on the soon-to-be-established Derbyshire Personality Disorder Pathway. The pathway will be a long time in the making, and we have to be patient, but we believe it will be worth the wait because we must get it right. With one-in-ten people with Borderline Personality Disorder ending their own lives, and many more regularly self-harming and/or spending time in secure estates, lives are at stake. People in Derbyshire, and probably in other counties, have been badly let down by health services in the past. This is largely due to a lack of understanding of the disorders on the part of health and social care professionals, and this is why we need a proper community pathway.

It is not realistic to expect a service such as the CAMEO unit to be available to everyone with a PD in the community. However, at the moment, there are many out there who are subject to a poor, or even non-existent, service. PDs continue to be misunderstood and highly stigmatised. Consequently, people are more at risk of offending, and those in prison are more at risk of re-offending once released. The proposed Derbyshire Personality Disorder Pathway model addresses the issue of education and training, with the recommendation that it should include people with lived experience. It also suggests methods of assessment, referral and re-referral, treatment, and follow-up, and warns against excluding those with complex needs, who may be thought to be a potential danger to themselves or others. It focuses on bringing awareness to all professionals who are likely to come into contact with someone with a PD, with a particular emphasis on eliminating offensive terminology. Finally, it highlights the importance of a person-centred care/treatment plan and the inclusion of long-term follow-up. For more details on the proposed pathway, please email Sue at [e-mail]

And finally
It is, perhaps, ironic that although diagnosed with Borderline Personality Disorder in the community, the only help I received was in prison. It was refused in the community on the basis that my symptoms were too complex. However, receiving a sentence under four years meant that I could not access the services of a PD unit and I, like many others, was forced to rely on the over-stretched In-Reach team.

Nevertheless, we still felt that we were better off than those in the community, especially in Derbyshire. For this to change, it is vital that a community pathway is established.

I would like to finish this blog with a few questions for you to consider:

How much do you know about personality disorders?
Do you know anyone with a personality disorder?
What services does your county offer for people with a personality disorder?
Does this blog leave you with a need to discover more about personality disorders?

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