By Nick Benefield
Personality difficulties, their developmental nature, and their often pervasive and enduring impact are at the heart of the different but closely related tasks of mental health, social care, substance misuse and criminal justice services. The relationship between professional intervention and lives in crisis will always be complex and often problematic. Political vision, policy formulation and practice development have not always achieved a coherent approach to the relationship between the presenting problem and the dynamic nature of psychosocial life. There is nothing new in this – I suspect it will always be thus as, in seeking answers to complex problems, we are confronting the unending desire for uncomplicated solutions. However, there is common cause here, shared between psychotherapeutic work and political objectives, to improve outcomes for individuals that pose a challenge to supportive intervention. This is particularly the case in offender populations where the prevalence of personality disorder (PD) is high.
The National Personality Disorder Programme (DSPD) began with a focus on the most severe and complex end of the spectrum of personality difficulties – those offenders who pose the highest risk of harm to others. The programme was an initiative to begin the difficult task of mobilising practice and research expertise to answer the question, ‘What might we do different or better to improve the psychological health of offenders, and protect the public from those whose risk can be functionally linked to their personality disorder?’
There was no strong evidence to guide interventions for those with the most complex needs to reduce risk and improve public protection. The approach taken was to use the best available knowledge to encourage a range of psychological models and novel and innovative programmes of investigation into what works. Treatment of this population, primarily men but also a small cohort of women, has proved challenging, and whilst it has produced much practical learning there is as yet no substantively clearer evidence. In terms of the complex nature of the problems involved this should be no surprise.
Four major issues remain central to the next phase of development.
1. Personality Disorder as a diagnosis is troubled and troublesome. For many, the arrival at a diagnosis is seen as a solution in itself. In reality, a diagnosis of PD offers only a starting point and even then can create a straitjacket to formulation and a treatment/intervention. An intervention plan, based on a well-researched life narrative, contextualised to the environment, is essential for effective engagement with those with poor experience of help.
2. Lack of therapeutic optimism represents the legacy of medical psychiatry and historical prejudice towards those diagnosed with PD. It also reflects that many professional groups working in this field are not adequately trained, experienced and supported to work effectively and safely with complex psychological disorders of this nature.
3. Evidence on efficacy remains elusive and incomplete. The level of good quality international evidence is just too weak and the need for stronger evidence must be seen as a long term goal.
4. The primacy of relational working is still seen as too messy and imprecise an input in a world of tightening specification and a pressure to do only what can be counted. Like Foster Wallace’s ‘water’ anecdote, the significance of the environment in this context is often not recognised.
This final point, to recognise that the dynamic nature of relational work as environment is at the heart of a common cause shared by psychotherapy, social, health and criminal justice care. It has simply been ignored for too long. To ‘do environment better’ must now take centre stage. The quality of inter-relational work needed is inseparably linked to the professional capability of the practitioner, their personal attributes and life experience.
Establishing environments (settings) where the psychological can be modelled, be learnt and flourish is paramount to support the development of specific psychological treatment interventions that will come from a sustained research into effectiveness.
One example to test this hypothesis is the development in criminal justice settings of an environmental model of living, management and care known as Psychologically Informed Planned Environments – PIPES. Related directly to Donald Winnicott’s conceptualisation of the ‘good enough’, these enabling and facilitating environments aim to support emotional and character development. Whilst not treatments in themselves, they provide support to sustain and reinforce the insight and learning gained from specific treatment interventions.
The hypothesis that underpins the concept of a PIPE is:
If the environment through which offenders/patients progress is considered holistically as a setting in which organisation, behaviour, decisions, actions and culture can be informed and planned on the basis of psychological thinking, it will create better social conditions for relating and will improve psychosocial outcomes by supporting post-treatment interventions. It will support intra-psychic stability, and emotional and social development.
Requires that the training, skills and experience of staff groups, and their way of thinking about the meaning of behaviour and relationships, is focused on understanding of the interactive nature of emotional and psychological life in which the individual, the other person, and the group all play a part. Attention to all aspects of relational exchange is crucial.
‘The environment’ includes all the external conditions, covering both individual and social relations, which we are required to adapt to or manage. This can be more or less supportive of positive emotional management of ourselves and others. In the context of institutional or group life we can plan how the environment operates so that it facilitates learning and growth, rather than reinforces emotionally destructive behaviours.
In the context of a pathway of treatment and rehabilitation, enabling environments will provide the following features:
- consistent and reliable relationships: to support the principle of secure attachment in people for whom this capacity is generally fragile.
- support for managing the appropriate development of psychosocial skills: to sustain new consciousness of emotional and cognitive learning.
- reflective interactions and responses: to enable the emotional and psychological processing of experience.
- protection from unreasonable levels of impingement: to protect against prolonged or high levels of anxiety beyond the capacity of the individual to manage.
- facilitation of the capacity for reflection: thinking and action as opposed to feeling and reaction.
- living arrangements and activities: that are supportive of individual wellbeing and pro-social living.
- Non-institutional structures and expectations: to support thinking and emotional management in patients/offenders and the staff groups.
- a setting in which actions are informed by conscious psychological thought in planning and acting in the environment: thereby establishing ‘smoother’ management of psychological/emotional life.
- support for challenge to any lack of ‘fit’ between contextual realities and therapeutic need: to support reality testing and acknowledgement of the limitations of institutional living.
- conscious, active and authoritative leadership: to protect the boundary from the disruptive impingement of the conditions for psychological thinking.
Whilst these environmental conditions are comprehensive, only a ‘good enough’ situation is required to create the experience that the environment (relationship with staff and the setting) is facilitative and enabling rather than lacking in emotional understanding, or is being actively destructive. In effect, what is sought is a sense of good enough ‘fit’ between the person and their world.
There is nothing new here other than the mobilisation and location of the right skill in the right place. With public sector financial pressures, the criminal justice system is under particular economic constraint. The role the NHS can have in supporting these vital areas of work needs a shared strategy by health and criminal justice services to provide the conditions necessary for individual and social change. The essential role psychotherapy must play in developing and supporting these conditions is now more important than ever
Nick Benefield is Head of National Personality Disorder Programme, Care Pathways Branch, Mental Health Division, in the Social Care, Local Government and Care Partnerships Directorate of the Department of Health