Interventions to Improve Social Outcomes in Offenders With Personality Disorders

Among individuals with a history of criminal convictions, personality disorders (PD) are highly prevalent. For example, up to 78% of adult male prisoners and half of adult female prisoners in the United Kingdom have been found to meet the diagnostic criteria for at least 1 PD.¹ In addition, PDs have been noted in as many as half of individuals on probation and in 57% to 77% of male patients confined to high-security psychiatric facilities.^2,3

Personality disordered offenders (PDOs), “are a group whose difficulties come at a considerable cost to themselves, potential victims, the communities in which they live and return, and to society as [a] whole, who must meet the costs of service provision,” wrote the authors of a review published in BMC Psychiatry.⁴ “PDOs experience worse physical and mental health, poorer quality of life, reoffend at higher rates, and are overrepresented in the commission of serious further [offenses], indicating existing approaches may be overlooking important factors.”

One aim of support services for offenders is to improve social outcomes, which are typically poor in this population. Social outcomes result from participation in activities that reflect effective functioning in society, including employment, independent living, and family responsibilities. Thus, the current paper conceptualizes social outcomes as participation.

Engagement in such meaningful and prosocial tasks by PDOs is essential, as these activities are closely linked with health, functioning, and social outcomes in general, and a decreased risk for recidivism in the offender population specifically. “Conversely, offenders who do not participate in prosocial activities (eg, those who remain unemployed or who lack prosocial relationships) or [who] participate in antisocial activities (gang affiliation, substance use) are at higher risk of reoffending.”⁵

Noting the dearth of findings regarding interventions aimed at improving social outcomes in PDOs, researchers at the University of Warwick and Brunel University London conducted a systematic review of studies that examined such endeavors.

Only 5 studies both met inclusion criteria and contained extractable data. The risk for bias was deemed high in all but one of the studies (in which the risk for bias was deemed moderate), and none were considered high quality. Treatment approaches included cognitive behavioral therapy, multimodal treatment with a psychosocial counseling component, multidisciplinary community-based services, integrative psychotherapy, and a psychological intervention called the Good Life Model.

The 2 studies that included social functioning as an outcome found no significant differences following intervention. Studies that included employment as an outcome did show an increase in employment following intervention — from 22% at baseline to 69% at 7-year follow-up in 1 study, for example, and from 41% to 71% over a 2-year period in another investigation.⁶ However, limitations in the design of the studies precluded conclusions regarding the effectiveness of the interventions examined.

The potential mechanisms by which the interventions may influence the outcomes include the following:

• Training in emotional, social, and practical skills that are proposed to affect social participation among PDOs. Although such training is common within criminal justice institutions, it is unknown whether the learned skills generalize to the “real-world” setting once offenders are released.
• Encouraging change in identity and values by supporting and validating offenders’ efforts toward prosocial goals. This approach frames offending as a barrier to the attainment of such goals. It is proposed that mastery of new prosocial activities leads to “volitional realignment” toward these goals. The effectiveness of this approach has not yet been proven.
• Practical assistance to help offenders overcome individual difficulties in “real-world” employment or social settings, similar to the Individual Placement and Support model for individuals with serious mental illness.⁸ “Whilst this has an immediate effect, it does not impart a change in the individual him or herself, and thus may not support continued participation on a long-term basis” in the PDO population, according to the present review.

Further research with a well-designed, clearly operationalized approach is needed to assess these and other potential mechanisms of change adequately. “The heterogeneity of the studies in this review indicate that a theoretically-informed exploration of the factors influencing participation is required before systematic development and evaluation of interventions that are likely to be effective can be conducted,” the authors concluded.

They note that the Theory of Human Occupation is based on universal principles and explains, “how participation is achieved, experienced, maintained, and changed, and has valid and reliable measures for associated and influencing factors.”⁹ This model is currently used in forensic research and practice, and may provide a solid starting point for exploring factors and mechanisms of change that should be targeted through intervention in the PDO population.

References

1. Singleton N, Meltzer H, Gatward R. Psychiatric Morbidity Among Prisoners in England and Wales. London, UK: Office for National Statistics; 1998.
2. Brooker C, Sirdifield C, Blizard R, Denney D, Pluck G. Probation and mental illness. J Forensic Psychiatry Psychol. 2012;23(4):522-537.
3. Blackburn R, Logan C, Donnelly J, Renwick S. Personality disorders, psychopathy and other mental disorders: co-morbidity among patients at English and Scottish high-security hospitals. J Forensic Psychiatry Psychol. 2003;14(1):111-137.
4. Connell C, Furtado V, McKay EA, Singh SP. How effective are interventions to improve social outcomes among offenders with personality disorder: a systematic review. BMC Psychiatry. 2017;17:368.
5. Andrews DA, Bonta J. The Psychology of Criminal Conduct. 5th ed. New York, NY: Routledge; 2010.