women and personality disorder (or why women aren’t just funny shaped men)

focus on women who are harmful to themselves and/or others most likely because of personality difficulties

women with personality disorder what’s different about women? what’s different about working with women? the offender PD pathway and the rivendell service

what’s different … about women with personality disorder

1.gender has an influence on the behaviour of others, and on our expectations about their behaviour

men competitiveassertivedominantindependent women nurturingsensitiveexpressive identification with the other Paris (2007) Rosenfield (2000) greater identification with peers greater identification with intimates

2.the harmful behaviour of men is broadly consistent with our expectations 3.the harmful behaviour of women is more complex …

men agencyresponsibility aggression expected toxic masculinity women innocencevictimisedpowerless harm potential minimised Adshead (2011)

men agencyresponsibility aggression expected toxic masculinity women innocencevictimisedpowerless harm potential minimised Adshead (2011) held accountable, without question responsibility ‘neutralised’

women later onset of criminality fewer convictions fewer convictions for violence fewer women in prison & secure hospital less physically harmful more likely to be victims of violence men a frequent cause of criminality more mental health problems more likely to retain parenting responsibilities

“it appears self-evident that the power one holds in the domain in which one holds it will influence the method used to abuse that power to the detriment of others” Logan, C. & Weizmann-Henelius, G. (2012). Psychopathy in women: Presentation, assessment and management. In H. Häkkänen-Nyholm & J.O. Nyholm (Eds), Psychopathy and Law. Chichester: Wiley Blackwell.

4.the harmfulness of women is different from that of men 5.to treat women like (funny shaped) men is to risk overlooking information of importance to interventions

targets of their harmits functionsand its nature and severity

6.to treat women like you would treat men – as if they were interchangeable – runs the risk of underestimating harm potential because that potential is either misunderstood, neutralised (e.g., she’s mentally ill, she’s a victim) or minimised (e.g., low risk of physical harm)

7.therefore, assessments and interventions that reflect the behaviour of men (e.g., the PCL-R) – one’s expectations about men – and underplay the social context of harmful behaviour, will have limited utility with women

8.gender influences the expression of the same underlying traits

FFMASPDNPDBPDAvPDOCPDSPD N +++ E -- O + A --- C -- +

FFM disinhibdissocial NA detachedanankastic N + E - O A - C - +

19 “mirror image disorders” (Paris 1997): “… similar traits in men and women can have different behavioural expression. The same underlying dimensions could lead to different forms of psychopathology in the two genders … impulsivity in men is more likely to be expressed through exploitation of others, whereas impulsivity in women is more likely to be expressed in self-destructive behaviours.”

what’s different … about working with women with personality disorder

essentials focus on the problems, experiences, and responses of women – as opposed to those of men reliance upon a practitioner group (a) dedicated to and (b) experienced in working with (c) women with personality disturbance implementing treatment and management practices developed for women – as opposed to adapting those developed for men

essentials relationships paramount – individual (peer, professional) – group (peer, professional) – the ‘scurvey behaviour of women’ Atwood (1984) therefore, focus on relational security

essentials a practitioner group that is informed about women and personality disorder – for whom individual and group supervision are essential rather than a luxury clarity of purpose good – containing, validating, empathic and supportive – leadership

interventions support to find, manage, and maintain suitable accommodation financial security understanding obstacles to change (inc. reintegration after detention) faced by women – and working to reduce these as far as possible

interventions pro-social modelling and positive staff interactions stabilisation of drug and alcohol, and co- occurring mental health problems improved literacy, numeracy, and other essential life skills facilitating family contact for women in detention

interventions cognitive skills programmes to address impulsivity and poor problem solving for women at greater risk of harmful behaviour – address criminogenic need

interventions for those, at greatest risk, multi-modal programmes, integrating CBT interventions addressing problem-solving, emotional management, assertiveness, and negotiation combined with practical help in terms of money and time management, parenting, negotiation and employment skills, and so on a higher ‘dose’ of treatment

targets poor self-awareness and lack of a sense of identity inability to ‘read’ other people or think about (‘mentalize’) others’ wishes, beliefs and intentions – a tendency to respond to them as if they are abusive, cruel and exploitative figures from the past

targets chronically high levels of anxiety and arousal that cannot be easily managed extreme sensitivity to rejection, experiences of shame, and perceived humiliation little sense of being able to influence the direction of their own lives, which then become experienced as fragmented and lacking in purpose or meaning

THE RIVENDELL SERVICE and the Offender Personality Disorder Pathway for women

offender personality disorder strategy 2011 on successor to the DSPD Programme Nick Joseph and Nick Benefield establishment of pathways of variable ‘dose’ interventions and support across prison and probation services that addresses the needs of high risk men and women with personality disorder

offender personality disorder strategy for offenders who … – have a current offence of serious harm and are likely to be serving determinate sentences – are likely to have a severe form of personality disorder – are assessed as presenting a high risk of committing a further serious offence – there is a clinically justifiable link between personality functioning and future risk

improved offender wellbeing better informed workforce reduced re- offending offender personality disorder strategy higher level outcomes

the rivendell service a pathway service for women HMP New Hall, West Yorkshire focus on helping women to manage safely and in a prosocial way strong feelings and beliefs about themselves and others arising from early distressing experiences and relationships training and staff support is geared towards quality of relationships and relational security

primrose HMP new hall & rivendell PIPE approved premises probation mentoring and advocacy (TWP) the pathway

GMW HMP New Hall Rivendell Service staff selection and training education (W-KUF) outreach multi- disciplinar y working networking shared aims

the clinical model

STRUCTURED LESS STRUCTURED safety containment control + regulation exploration + change integration + synthesis

safety & containment practical skills (control & regulation) practical skills (control & regulation) beliefs & attitudes (exploration & change) beliefs & attitudes (exploration & change) lifestyle & resettlement (integration & synthesis) lifestyle & resettlement (integration & synthesis) motivation & engagement life goals gender sensitive assessment & (re)formulation

safety & containment practical skills (control & regulation) practical skills (control & regulation) beliefs & attitudes (exploration & change) beliefs & attitudes (exploration & change) lifestyle & resettlement (integration & synthesis) lifestyle & resettlement (integration & synthesis) motivation & engagement life goals gender sensitive assessment & (re)formulation especially self-harm and violence

safety & containment practical skills (control & regulation) practical skills (control & regulation) beliefs & attitudes (exploration & change) beliefs & attitudes (exploration & change) lifestyle & resettlement (integration & synthesis) lifestyle & resettlement (integration & synthesis) motivation & engagement life goals gender sensitive assessment & (re)formulation

practical skills emotion management/regulation tolerating strong & cycling emotions understanding triggers emotions interpersonal problem solving skills critical reasoning responsible sensation-seeking goal-setting impulse control assertiveness

safety & containment practical skills (control & regulation) practical skills (control & regulation) beliefs & attitudes (exploration & change) beliefs & attitudes (exploration & change) lifestyle & resettlement (integration & synthesis) lifestyle & resettlement (integration & synthesis) motivation & engagement life goals gender sensitive assessment & (re)formulation integrated therapy

safety & containment practical skills (control & regulation) practical skills (control & regulation) beliefs & attitudes (exploration & change) beliefs & attitudes (exploration & change) lifestyle & resettlement (integration & synthesis) lifestyle & resettlement (integration & synthesis) motivation & engagement life goals gender sensitive assessment & (re)formulation family, home, finance, stability

16 beds at base range of integrated interventions high level relational activity workforce development outreach CARE Programme Together Women Project

service user involvement recruitment mentoring & advocacy community meetings Oversight Group training compliments & complaints design, implementation & evaluation

women with personality disorder what’s different about women? what’s different about working with women? the offender PD pathway and the rivendell service

women and personality disorder (or why women aren’t just funny shaped men)