Cabinet Office Social Exclusion Taskforce
Last updated: 09 November 2008
Mental health problems in prisoners are extremely common: one study found that 90% of UK prisoners showed signs of one mental disorder and 80% showed signs of two disorders. Self harm, a symptom of distress or underlying mental illness, is common in prisoners, and can lead to completed suicide. Reducing the rates of suicide in prisoners is a government objective. Women prisoners are 18 times more likely than their male counterparts to self harm in custody. Many of these women have borderline personality disorder (BPD), a condition characterised by emotional lability, poor interpersonal skills and recurrent self harm. The prevalence of BPD in women prisoners is around 20% as opposed to 2% in the general population. Women with BPD present a severe management problem in prison and are more likely to be convicted of serious and violent crimes. It is therefore a high priority for prison services to address the problems of this group.
Dialectical behaviour therapy (DBT) was developed as a treatment for borderline personality disorder to improve quality of life and reduce self harm. It was the first treatment to achieve an evidence base in this group in a randomised controlled trial. A further six randomised controlled trials have demonstrated the effectiveness of DBT across a variety of locations and patient groups in reducing self harming behaviour and improving patient retention in treatment. In summary, BPD is common in women prisoners and underlies much self harm and difficult to manage behaviour. DBT has proven efficacy as a treatment for BPD and self harm.
In March 2007, The Home Office published Baroness Corston's review of service provision within the prison estate for women “with particular vulnerabilities”. The report called for a radical change in the way that women are treated by the criminal justice system. As part of the resettlement programme the report calls for training in “life skills” and also makes an explicit link between women's disturbed relationships, poor education and their offending behaviour. It praises the prison estate's efforts to improve education but bemoans the lack of what it describes as developing emotional literacy. It also describes a number of “prisons without walls”: women focussed centres where female offenders can access support at the same time as receiving their punishment. Much mention is made of the high rates of psychiatric morbidity, including self harm, within women's prisons, and the lack of integrated approaches to the problem. This follows earlier policy work on approaches to personality disorder and self harm amongst prisoners Finally the report discusses the needs of staff dealing with recurrent self harm for increased support and training.
In the light of the Corston report Holloway Healthcare developed a partnership with Counselling in Prison, a registered charity. Together we succeeded in bidding for funding from the Cabinet Office as a pilot site in the “Adults Facing Chronic Social Exclusion” (ACE). Our bid proposed a modular, shortened programme of DBT called Holloway Skills Therapy (HOST). Open to all women with BPD in the prison, including those on remand, the service aims specifically to address issues raised in the Corston Report by increasing emotional literacy, developing life skills and moving towards a “Prison Without Walls” model.
Eligibility
Women prisoners in Holloway womens' prison with borderline personality disorder.
Inclusion criteria
Female prisoners on remand and convicted at HMP Holloway
Diagnosis of borderline personality disorder, age 18 and above.
Time remaining, prior to release or court hearing, greater than 10 weeks at therapy start.
Exclusion criteria
Lifetime diagnosis of schizophrenia or bipolar affective disorder
Current symptoms of active mental illness, including severe depression.
Inability to communicate in English, evident at screening interview
Cognitive impairment, evident at screening interview.
Medical or social issues which will impair ability to attend a 10 week therapy course (Eg: impending transfer, pregnancy, severe physical illness.)
Clients will not be excluded on the basis of a history of drug or alcohol misuse or dependence.
Recruitment will be on a wing by wing basis as we anticipate high levels of interest and do not want to approach the entire prison at once. An education session for prisoners will be accompanied by a similar session for wing officers. Leaflets and posters will be distributed. Prisoners can self refer or be referred by officers or the prison in reach team. Recruitment is expected to start in Spring 2008.
This will comprise a structured clinical interview to review personality traits. This will be performed by trained assessors. Screened women will be discussed at the weekly team meeting and their eligibility for inclusion agreed based on this interview.
Screening will also include a brief introduction to the aims and expectations of the programme to ensure women are aware of the intensity of the treatment and can give informed consent to be included.
New cases of psychiatric illness uncovered during the screening process will be referred to the prison in-reach team for assessment and treatment.
The Holloway skills training (HOST) programme has two components, individual psychotherapy and group skills training.
The subjects will receive one hour a week of individual psychotherapy to address self harming behaviour, difficulties in using therapy and quality of life damaging behaviours. These sessions will be delivered by honorary practitioners employed by Counselling in prison. This work will be traditional psychotherapy but with an element of DBT. This may include the use of diary cards or behaviour chain analyses as advocated in Linehan's model. The individual work can continue beyond the group programme for up to one year. It can also continue after release from prison if this occurs during that time.
This comprises two group sessions a week each lasting 90 minutes. The full programme is 16 weeks of groups with a one week break at week 9. This will allow new entrants to join from the waiting list if clients have left the group.
There will be no more than 8 clients in the group and it is a closed format once each 8 week session has started. The first 8 weeks covers core mindfulness, distress tolerance, and emotional regulation. The second 10 weeks covers core mindfulness, interpersonal effectiveness and offending behaviour.