“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

• Published date: 01 July 2023
• DOI: http://doi.org/10.1177/00938548231165529
• Author: Nicholas Blagden,Jacquie Evans,Lloyd Gould,Naomi Murphy,Laura Hamilton,Chloe Tolley,Kyra Wardle
• Date: 01 July 2023
• Subject Matter: Articles

CRIMINAL JUSTICE AND BEHAVIOR, 2023, Vol. 50, No. 7, July 2023, 1035 –1052.

DOI: https://doi.org/10.1177/00938548231165529

Article reuse guidelines: sagepub.com/journals-permissions

© 2023 International Association for Correctional and Forensic Psychology

1035

“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

NICHOLAS BLAGDEN

University of Derby

JACQUIE EVANS

LLOYD GOULD

HMP Whitemoor, Fens Unit

NAOMI MURPHY

Clinical and Forensic Psychologist

LAURA HAMILTON

University of Ulster

CHLOE TOLLEY

KYRA WARDLE

Nottingham Trent University

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 cap-

tured 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 thera-

pists 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.

Keywords: personality disorder; intervention; treatment; identity

AUTHORS’ NOTE: We have no conflicts of interest to disclose. Correspondence concerning this article

should be addressed to Nicholas Blagden, School of Law and Social Sciences, University of Derby, One

Friargate Square, Derby, DE1 1DZ, UK. e-mail: n.blagden@derby.ac.uk.

1165529CJBXXX10.1177/00938548231165529Criminal Justice and BehaviorBlagden et al. / The People Who Arrived Are Not The Same

research-article2023

1036 CRIMINAL JUSTICE AND BEHAVIOR

Following a series of well-publicized cases of violent and sexual violent offending, the

UK government commissioned the Dangerous & Severe Personality Disorder (DSPD)

pilot service in 1999, to address the “long-standing frustration within government at the

refusal of psychiatrists to admit high-risk individuals with personality disorder to forensic

psychiatric facilities” (Maden, 2007, p. 8; see also Joseph & Benefield, 2010; O’Loughlin,

2019; Ramsay, 2017). The aim was “to deal with the most dangerous offenders of all,

those with a severe personality disorder” (Labour Party, 2001, p. 5). However, despite

some success, the government decommissioned the DSPD initiative in 2011, rebadging it

as the Offender Personality Disorder (OPD) pathway (NOMS, 2015; O’Loughlin, 2019).

The OPD pathway aimed to provide interventions for a greater number of individuals

(NOMS, 2015; O’Loughlin, 2019), incorporating lessons learnt from the DSPD pilots and

guidance from the National Institute for Clinical Excellence (Cooke et al., 2017; Skett

et al., 2017).

The OPD pathway is a joint approach by the then National Offender Management Service

(NOMS) (now Her Majesty’s Prison and Probation Service) and National Health Service

(NHS) England enterprise, with the overall aim of “improving public protection and psy-

chological health of individuals with convictions, through developing a comprehensive and

effective pathway of services for this complex and often difficult to manage population”

(NOMS, 2015). This overall aim is achieved through: (1) reducing serious violent and sex-

ual reoffending, (2) improving psychological health, wellbeing, prosocial behavior and

relational outcomes, (3) improving competence, confidence and attitudes of staff, and (4)

increasing efficiency, cost-effectiveness, and quality of services (NOMS, 2015). A key

objective of the pathway is to “provide a consistent and cohesive process of individuals

transitioning through a range of different criminal justice and perhaps forensic health inter-

ventions from custody to the community” (Cooke et al., 2017, p. 6).

While it has long been recognized that the function of prison should include rehabilita-

tion (e.g., Blagden et al., 2016; Ginn, 2012; Smith & Schweitzer, 2012), individuals with

personality disorder are often construed as difficult to treat, and sometimes even “untreat-

able” (Chakhssi et al., 2010). Such individuals often have complex psychological needs and

are at increased risk of reoffending (NOMS, 2015). It is well established that personality

disorders are prevalent among the prison population, with an estimated 60%–77% of incar-

cerated males meeting the criteria for personality disorder compared with 4%–11% in the

general population (Bennett & Hunter, 2016; Burki, 2017; Joseph & Benefield, 2010;

O’Loughlin, 2019; Singleton et al., 1998; Slade & Forrester, 2013). These figures are simi-

lar to those seen in prisons across the Western world (Puri, 2017) and globally (Fazel &

Danesh, 2002).

However, labels such as “high risk” or “personality disordered” also mask the highly

heterogeneous nature of these groups, who rarely fit neatly into one diagnostic category or

treatment pathway (Saradjian et al., 2010). Often the individuals participating in OPD ser-

vices have multiple comorbid conditions, which may include developmental trauma

(MacIntosh et al., 2015), substance dependency (Sher & Trull, 2002), and mental illness

(Tyrer & Simmonds, 2003). The types of psychological conditions identified among people

in high-secure OPD services involve long-standing patterns of thinking, feeling, behavior,

and ways of relating, that often emerge from, or are exacerbated by, adverse childhood

experiences (ACES) (Saradjian et al., 2013). The presence of ACEs in individuals with

personality disorder is associated with increased prevalence of several health risk