Development of the Offender Personality Disorder Pathway: A summary of the underpinning evidence

AuthorCarine Lewis,Sarah Skett
Date01 June 2019
Published date01 June 2019
Subject MatterArticles
PRB832370 167..180
The Journal of Community and Criminal Justice
Probation Journal
2019, Vol. 66(2) 167–180
ª The Author(s) 2019
of the Offender
Article reuse guidelines:
DOI: 10.1177/0264550519832370
Personality Disorder
Pathway: A summary
of the underpinning
Sarah Skett
NHS England, UK
Carine Lewis
Her Majesty’s Prison and Probation Service, UK
The Offender Personality Disorder Pathway programme is a jointly commissioned
initiative between NHS England and Her Majesty’s Prison & Probation Service
(HMPPS), the aim of which is to provide a pathway of psychologically informed ser-
vices for offenders who are likely to be diagnosed with personality disorder. This
paper aims to describe the underpinning evidence behind the principles and expec-
tations of services that make up the OPD pathway programme. Evidence of personality
disorder treatments from mental health settings, as well as the evidence base from the
criminal justice system and the Ministry of Justice’s ‘What Works?’ literature, is con-
sidered and draws together the evidence underlying critical elements of the pro-
gramme. Research shows that there is no one treatment shown to be successful for the
treatment of personality disorder. As such, a holistic approach is taken, with key
components including trauma-informed approaches, a focus on relationship building,
early identification and sentence planning, and the importance of workforce devel-
opment and relationships.
Corresponding Author:
Carine Lewis, Her Majesty’s Prison and Probation Service, 102 Petty France, London, SW1H 9EX, UK.

Probation Journal 66(2)
personality disorder, offenders, prisoners, evidenced-based practice, relationships,
high risk, pathway, psychologically informed
The prevalence of personality disorder in community and prison offender cohorts
has not been examined for many years, yet it is estimated that between 60 and
70 per cent of the prison population meets the criteria for at least one form of
personality disorder (Singleton et al., 1997; Fazel and Danesh, 2002). A small-
scale study in Lincolnshire (Brooker et al., 2012) suggested that this was 50 per cent
of the probation caseload, prior to the split between the National Probation Service
(NPS) and Community Rehabilitation Companies (CRCs).
The Offender Personality Disorder (OPD) pathway programme was initiated in
2011 to meet the joint strategic aims of the Ministry of Justice (MoJ) and the
Department of Health (DH), and their respective agencies (Joseph and Benefield,
2012). It grew out of the Dangerous and Severe Personality Disorder (DSPD) pro-
gramme where money was made available by the then Coalition government to put
in place services to help manage and treat offenders who were seen as high risk, but
also exhibited complex interpersonal problems that might be diagnosable as per-
sonality disorder or psychopathy. This followed a well-publicised case where
Michael Stone, a person with mental health problems, was convicted of the murders
of Lyn and Megan Russell.
After evaluations of the DSPD programme and the Bradley Review (2009) into
mental health provision in the Criminal Justice System, the OPD programme
attempted to address identified concerns and limitations, including a better way of
describing a pathway of care, providing services to more offenders, and putting in
place early identification of the target population.
The overall aims and outcomes of the OPD programme are to improve public
protection via a reduction of repeat offending, and to improve the psychological
health, wellbeing and relational skills of offenders likely to be diagnosed with a
personality disorder. This is driven by the workforce, where the pathway therefore
aims to improve the confidence, competence and attitudes of staff working with
complex offenders. Finally, the pathway aims to be efficient and cost-effective,
through developing a comprehensive and high-quality pathway of services for
this complex and difficult to manage offender population. The pathway focuses on
offenders managed by the NPS; for men, they must present a high likelihood of
violent or sexual offence repetition as well as a high or very high risk of serious harm
to others. For women, the criteria are the same except the level of risk is not spec-
ified. There are 33,087 offenders who are currently screened into the pathway and
therefore satisfy the above criteria, of whom 31,090 are men and 1996 are women
(OPD data return, December 2017).
The pathway programme is unique in that it is a true partnership between the
National Probation Service (NPS), Her Majesty’s Prison Service (HMPS) and the

Skett and Lewis
National Health Service (NHS) England; there is shared recognition and under-
standing that this cohort of people cannot be managed by either agency alone. The
pathway is underpinned by a set of principles that are seen as integral to the success
of the pathway; the whole pathway is also seen as additive, in that it overlays on top
of standard provision in probation, prisons and healthcare settings. It is not meant to
replace what would normally be provided.
The principles were derived using an evidence-based approach or, where there
was no evidence base, by professional consensus. There are 12 principles in total,
which have been agreed between HMPPS and the NHS:
There is shared ownership, joint responsibility and operations, and partner-
ship working (between health and criminal justice).
There is a whole system, community-to-community pathway.
Service users (offenders) are primarily managed through the criminal justice
system, with the lead role held by Offender Managers.
Treatment and management is informed by a bio-psychosocial approach, in
which individuals’ development is understood.
All services adopt a relational approach.
Staff have shared understanding and clarity of approach.
The pathway is sensitive and responsive to individual needs, including gen-
der, protected and offence characteristics.
Service users, where directly engaged on the pathway, have clarity of approach.
There is meaningful service user involvement, in design, delivery, review,
performance management and evaluation of services.
Ruptures and setbacks should be anticipated, understood and responded to
as part of a formulation-based approach.
There is shared learning across the pathway, involving staff and service users.
Services will be developed in line with the model and using an evidence-
based approach, where evaluation continually informs services.
One major criticism of the DSPD programme was that services were only in the
highest security settings (either high or medium secure hospitals or high security
prisons) and did not provide, or conceptualise, a pathway of care and, in particu-
lar, what needed to be in place in the community. The new OPD programme starts in
the community at the earliest point after sentence, with identification of those meet-
ing criteria using a combination of OASys variables, actuarial and dynamic risk
factors, and other information from case files including childhood difficulties, history
of mental health problems, current risk to staff, and current disruptive behaviour.
This early identification then allows Offender Managers to seek psychological con-
sultancy where needed with regard to the interplay between risk of harm and
complex psychological and interpersonal problems. Furthermore, the use of psy-
chological formulation allows a pathway plan to be developed that is psychologi-
cally informed. The aim is for better understanding of risk and need, better sentence
planning, and through workforce development and training, offender managers
who feel more confident and competent to manage their respective offenders.

Probation Journal 66(2)
Steve Johnson-Proctor, Director of Probation for South East and Eastern, has said:
The Offender Personality Disorder pathway has been one of the most successful and
effective practice developments within Probation in recent years. It has significantly
improved the skill base of our staff group, provided access to expert advice in our
offices and improved links with local community mental health providers across Eng-
land and Wales.
The OPD pathway focuses on early identification being key to meeting complex
needs. As such, offenders are screened-in to the pathway at the earliest point
possible. The next step is to carry out a consultation and formulation (if required)
which is used to inform sentence and treatment plans (as opposed to relying on
diagnosis). For a small number of people, additional interventions may be recom-
mended, such as a...

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