women and personality disorder

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

caroline.logan@gmw.nhs.uk

focuson 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

Paris (2007)Rosenfield (2000)

greateridentification

with peers

greateridentification

with intimates

2. the harmful behaviour of men is broadly consistent with our expectations

3. the harmful behaviour of women is more complex …

Adshead (2011)

Adshead (2011)

held accountable,

withoutquestion

responsibility‘neutralised’

“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

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

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

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

mentoring and advocacy (TWP)

the pathway

the clinical model

STRUCTURED

LESSSTRUCTURED

safety

containment

control + regulation

exploration + change

integration + synthesis

safety & containment

practical skills(control & regulation)

beliefs & attitudes(exploration & change)

lifestyle & resettlement(integration & synthesis)

gender sensitive

assessment &

(re)formulation

safety & containment

practical skills(control & regulation)

beliefs & attitudes(exploration & change)

lifestyle & resettlement(integration & synthesis)

gender sensitive

assessment &

(re)formulation

especially self-harm

and violence

safety & containment

practical skills(control & regulation)

beliefs & attitudes(exploration & change)

lifestyle & resettlement(integration & synthesis)

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)

beliefs & attitudes(exploration & change)

lifestyle & resettlement(integration & synthesis)

gender sensitive

assessment &

(re)formulation

integrated

therapy

safety & containment

practical skills(control & regulation)

beliefs & attitudes(exploration & change)

lifestyle & resettlement(integration & synthesis)

gender sensitive

assessment &

(re)formulation

family, home,

finance, stability

CARE Programme

Together Women Project

service user

involvement

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)

caroline.logan@gmw.nhs.uk