Under the radar - Centre for Mental Health

POLICYUnder the radarWomen with borderlinepersonality disorder in prisonMatt Fossey and Georgia Blacka better way

Centre for Mental Health POLICY PAPER Under the radar2005) (See Box 1). However, this service onlyaccommodates twelve women at a time who aredeemed to be a significant danger to society.Women in other prisons receive treatment thatfalls short of this standard, and receive far lessthan the financial resources given to thosein DSPD services (Barrett et al., 2009). Thispaper gathers evidence from health, prison andpsychiatric research about women with BPD inprisons.Box 1: Women’s DSPD pilotThe Primrose Project, based at HMP/YOI Low Newton, is a collaborative pilotprogramme serving the needs of womenwho primarily pose a risk of seriousharm to the public emanating fromtheir complex clinical presentations.The issues affecting service provisionfor women may be different from thoseof men; therefore, the Department ofHealth states that the project has drawnon best practice to develop a hybridmodel of intervention. Unlike the DSPDprogramme for male offenders, the 12places allocated to the Primrose pilotare housed on the wings and are notsegregated from the rest of the prison(Department of Health, 2006).When considering the provision of services forprisoners with personality disorders, politicaldebate and policy decision making seem tobe disproportionately skewed towards thoseoffenders who pose the greatest risk to society.A recent report by the Centre estimates that upto £60 million is spent annually on containingand treating prisoners in services for Dangerousand Severe Personality Disorder (DSPD) in onlya small number of prisons and high securityhospitals (Rutherford, 2010), yet DSPD is anon diagnostic term without a clinical meaning(Buchanan & Leese, 2001). An economicevaluation argues that these services are morecostly than prisons and result in a deteriorationin outcomes (Barrett et al., 2009).Under 0.5% of prisoners have access to thespecialist interventions offered by DSPD unitsdue to the nature and degree of their condition,yet research suggests that 78% of male remand,64% of male sentenced and 50% of femaleprisoners have a diagnosis of personalitydisorder (Singleton et al., 1998).Although significant resources are directedtowards interventions for male prisoners indangerous and severe personality disorderservices very little resource is used to helpwomen prisoners with debilitating conditionssuch as borderline personality disorder.What is borderline personalitydisorder?The term personality disorder has been usedto describe people who have “an enduringpattern of inner experience and behaviourthat deviates markedly from the expectationsof the individual’s culture” (DSM-IV, 1994).There are twelve different types of personalitydisorder (Sainsbury Centre, 2009a). Borderlinepersonality disorder (BPD) is a diagnosis used todescribe people who show “a pervasive patternof instability of interpersonal relationships,self-image, and affect, and marked impulsivity,beginning by early adulthood and present in avariety of contexts” (DSM-IV, 1994).“It was like as if someone had injected mewith ... I don’t know speed or something, and Iwas just getting out of control. I was told ‘if youdon’t come off the ladder you’re going to fall offthe top, you’re going to run out of rungs’.”Many people with BPD experience a life full ofemotional pain and distress (Perseius et al.,2005). The reality of the symptoms described inthe diagnostic manual is that these difficultiesoften lead to self-harm and self-mutilation,associated with the complexity of expressingdifficult emotions (Nehls, 1999). A systematicreview found that over half of people withBPD also fulfilled criteria for drug or alcoholdependence (Trull et al., 2000).Many people with borderline personalitydisorder have experienced some form ofchildhood trauma, especially physical abuse(71%), sexual abuse (68%), and witnessingserious domestic violence (62%) (Herman etal., 1989). This leads to some of the underlyingcognitions behind borderline personalitydisorder, for instance feeling that the world ishostile (Silk et al., 1995).2

Treatment for BPD in the community haschanged in recent years following publicationof government policy implementation guidance(Department of Health, 2003). This has beenfurther reinforced by new evidence-basedguidelines, recommending longer treatmentcourses, a reduction in medication prescriptionand continuity of care (NICE, 2009).Borderline personality disorderand women in prisonBPD is very common in prison, with a recentestimate at 30% for men and women in the US(Black et al., 2007). A decade before, Jordanet al., (1996) estimated that 28% of femaleprisoners met criteria for BPD in the US,suggesting this figure is stable. BPD has a highco-morbidity with other mental health diagnosesand risk factors such as substance use and selfinjury.Women represent one-twentieth of the prisonpopulation, with the current figure at 4,420(5.4%), of whom one-fifth are on remand (PrisonService, 2010). There was a rapid increase innumbers of women in prison from 1,180 in1992 to 3,340 in 2002 (Councell, 2003) sincewhich time the figure has been relatively stable.There are still concerns that there are too manywomen in custody (Corston, 2007; MoJ, 2007).“... to tell the truth, the first time, I don’t evenremember going into prison, I was so ill. It wasonly … talking to xxx, that she said ‘yeah you’vebeen in prison twice’. I said, Oh!”The female population in custody has differentdemographic characteristics to the malepopulation, with 19% being foreign nationals,and 29% being of an ethnic minority comparedto 13% and 27% respectively for men (PrisonService, 2010). Half the women in prison haveexperienced domestic violence, and women aretwice as likely as men to have experienced someform of mental illness in the year preceding theiradmission to custody (Singleton et al., 1998).Sixty-five per cent of imprisoned women havesubstance use problems, compared to 70%of men (Social Exclusion Task Force, 2009).Worryingly, 83% of women in prison have alongstanding illness, compared with 32% of thegeneral female population, and many are onprescription medication (HM Chief Inspector ofPrisons, 2009).The Corston Report suggested an agendaof radical change to provision for custodialsentences for women. The Governmenthas responded by addressing sentencingrecommendations, alternative custodialarrangements, life skills/learning, hygiene andself-harm programmes (Corston, 2007). Thereport also highlighted that while services in thecommunity are targeting women who are at riskof offending, for instance by providing ‘one stopshops’ (www.justice.gov.uk) and by monitoringthose with mental ill health, that ethos has nottranslated to prisons.The Corston Report did not mention BPD itself,but it included many vignettes about self-harmwithout recognising it as a key indicator of BPD(See Box 2). Despite only representing 5% ofthe custodial population, women represent halfof all self-harming incidents in prison (HomeOffice, 2009).Box 2: Key indicators of borderlinepersonality disorder“If a person presents in primary carewho has repeatedly self-harmed orshown persistent risk-taking behaviouror marked emotional instability,consider referring them to communitymental health services for assessmentfor borderline personality disorder.”(NICE, 2009)In 2009, the Bradley Report raised concernsabout the provision of mental health carein the criminal justice system, particularlyhighlighting that there is no formal provision ofservices for people with personality disorder inprison (Bradley, 2009). This is not equivalentto the community, where specialist services forpersonality disorder have been in developmentsince 2003 (Department of Health, 2003). Thereport recommended that the Department ofHealth, the National Offender ManagementService (NOMS) and the NHS develop a strategyfor managing personality disorder at all levelsof service, from custody to probation and in thecommunity (Bradley, 2009). As the new strategytakes hold (Department of Health, 2009), it isa good time to address borderline personalitydisorder within the general context of femaleoffender mental health.Centre for Mental Health POLICY PAPER Under the radar3

Centre for Mental Health POLICY PAPER Under the radarWhat is the impact of prison onwomen with BPD?It has been recognised that people with BPDhave frequently experienced some form oftrauma during childhood, such as sexual abuse(Herman, et al., 1989). The prison environmentis hostile and punitive, having been designedprimarily for the male prisoner (Corston, 2007).Prisons are predominantly staffed by men, withonly 35% of prison service staff being female(Fawcett Society, 2008).Women who have experienced abuse are morelikely to feel traumatised by routine prisonprocedures such as body searches (Moloneyet al., 2009). This was found in a study of 800male and female prisoners in a US study, wherethe greatest feelings of unsafety in prison wereexpressed by women with depression, anxiety,post traumatic stress disorder (PTSD) or recentvictimisation (Wolff & Shi, 2009).“Well it’s a bloody awful place. It smells likehorse piss as soon as you walk in that healthcare department ... They’ve got so manypsychiatric patients in there ... They just leaveyou in a cell with a hatch open and keep you inthere most of the day ... When you go on theblocks most of them are mentally ill and they’reall on drugs. They’re all trying to nick your drugs.They’re a nightmare. It’s a horrible place.”The reaction of emotionally vulnerable womenin prison may be to re-experience many of thefeatures of childhood sexual abuse, namelytraumatic sexualisation, betrayal, powerlessnessand stigmatisation (Heney & Kristiansen, 1998;Dirks, 2004). This poses a threat to their mentaland physical wellbeing, and may cause themto adopt maladaptive strategies to address thetrauma of being in prison such as substanceuse, violence, self-injury and suicide (Heney &Kristiansen, 1998; Zlotnick, 1997).Avoiding trauma in people with a personalitydisorder is important, as it directly affects theirgeneral and mental health. One study found thatany type of recent victimisation was significantlyassociated with serious mental disorder for48.1% of male prisoners and 47.2% of femaleprisoners (Wolff & Shi, 2009). Poorer healthincreases the disruption and ill-effects of prisonfor women with BPD and also raises the cost tothe prison estate. People with BPD cost healthservices three times as much when they developother health problems as those without BPD(Rendu et al., 2002).“I was self-harming quite, quite a lot. Andanybody who self-harms goes straight to thehospital wing, which is horrible ... just sittingthere until somebody opens the cell door …I think that that was where the self-harm gotworse … basically if you didn’t go to work you’dget locked in your cell all day. It goes roundin circles. Because you’d self-harmed as apunishment you’d get locked up, so you selfharmeven more to get out of the cell, but theywon’t have you at work because you’ve selfharmed.”Family issuesWomen’s pathways to custody differ greatlyfrom those of men, as the majority of offencesare non-violent or property related and as suchrarely pose a threat to public safety (Moloney etal., 2009). Women’s offending patterns are morelikely to be directly affected by their families,with property crimes such as petty theft beingassociated with family poverty (Taylor, 2004).“Didn’t see my son and daughter for sixmonths which broke my heart and killed me.”When mothers are imprisoned the impact ishighly disruptive on their families, as femaleprisoners are often the only carers of theirchildren, frequently resulting in custody beingtaken by grandparents or other female relatives(Caddle & Crisp, 1997; Home Office, 2004).This is not the case for men, whose children areusually cared for by their female partners duringtheir incarceration (Taylor, 2004). Fathers takecustody of female prisoners’ children in just 9%of cases in the UK, only marginally higher thanthe number taken into care, at 8% (Caddle &Crisp, 1997). Around two-thirds of women inprison have dependent children under 18, and40% of those are children under 10 years.Women with BPD have potentially difficultfamily situations. This may be dependent onthe severity of BPD symptoms, as men andwomen with increasingly severe symptomsexperience more marital distress, commit moredomestic violence and have more disruptionin their marriages (Whisman & Schonbrun,2009). Imprisoned women with more antisocialand borderline traits also show greater4

Centre for Mental Health POLICY PAPER Under the radarto substance use and involvement in thesex trade. These factors contribute to thelikelihood of criminal behaviour.5. Associated stigma: Children of incarceratedparents suffer the stigma of criminality, withstaff in the criminal justice system beingprone to bias in decision making about thechild. Some may believe that “the apple doesnot fall far from the tree” and impose highersanctions for criminal behaviour, rather thangiving them community or social serviceprovision.The potential economic burden of theseintergenerational effects could be mitigatedby effective early intervention and parentingprogrammes. A recent report (SainsburyCentre, 2009b) estimates that the total cost ofcrime attributable to people who had conductproblems in childhood is approximately £60billion a year in England and Wales.Strategies for interventionIn order to tackle a complex mental healthproblem, it first needs to be identified in a timelyfashion, and then treated appropriately, for aneffective period of time. In the criminal justicesystem, mental health diagnoses are identifiedeither at the arrest, court or prison receptionstage, but many mental health problems aremissed due to inadequate screening procedures(Shaw & Humber, 2007). Black et al. (2007)conclude that correctional facilities need tosystematically screen for BPD specifically, suchis the impact of the diagnosis on other mentalhealth needs in prison.The Corston Report recommended increasedattention to health care, mental health andself-harm, but the report does not specificallyaddress BPD. Programmes such as Carousel,which combines group therapy with individualcounselling and other activities, werementioned. The Government has subsequentlyimplemented the CARE (choices, actions,relationships and emotions) programme forself-harm at HMP Downview with the intentionof widespread use. However, these programmesare inconsistent with NICE guidelines for BPD.Simple additions to prison procedure, such ascare in transition periods, could greatly reducethe risk for women prisoners with BPD. Thecurrent lack of specific provision for BPD meansthat evidence-based practice for women with thisdiagnosis is ignored, despite the high prevalencein the prison population. The followinginterventions would help to tackle this problem.ScreeningThe aim of prison mental health services isto screen for mental health problems at alllevels of the system: from reception screeningand induction or ‘first night’ centres onwards(Department of Health, 2005). The earlydetection stage is extremely important as thisdetermines the level of care provided in prison.Screening tools used at reception have beencriticised, with many instances of psychiatricmorbidity being missed (Birmingham, 1997). Thissuggests that comprehensive screening at thecourt stage would make a dramatic difference(Shaw et al., 1999; Bradley, 2009).A screening programme for BPD at the stage ofcourt trial would be able to target the 57,875women who were charged with indictableoffences in 2008 (Home Office, 2010). Of these,14.8% are found guilty, leading to 16,440 womenstarting a period in custody (Home Office, 2010).Of these, 12,676 are first receptions into prison,suggesting that a high number of those screenedat reception will not have been screened before.This may benefit women who have not beendiagnosed outside the criminal justice systemand therefore have not previously received anysupport for their diagnosis and mental healthneeds. In this way, the prison service can play amajor role in increasing the number of womenreceiving help for BPD.In order to screen and treat women with BPDappropriately, prison health care staff shouldnot be exempt from NICE guidelines, which statethat “mental health professionals working insecondary care services, including communitybasedservices and teams, CAMHS and inpatientservices, should be trained to diagnoseborderline personality disorder, assess risk andneed, and provide treatment and management inaccordance with this guideline” (NICE, 2009).Staff training and recruitmentIt has been widely recognised that lookingafter people with a personality disorder can bedifficult, and some people are better suited to itthan others (Bowers et al., 2003). By providingspecialist training and setting up a supportive6

system for staff, most will find it easier tocope with and will be able to provide a betterservice. This will also save money in staffingcosts, as positive attitudes towards people withpersonality disorder lead to improved generalhealth and job performance, decreased burnout,and favourable perception of managers in prisonstaff (Bowers et al., 2006).There are already programmes designedto train staff who are working with peoplewith personality disorders. For example, theUniversity of East London provides a part-timepostgraduate certificate entitled Working withPeople with Personality Disorders which isaimed at staff working in statutory or voluntarysector mental health services.The provision of support for staff workingwith individuals with a personality disorder isrecommended to include the following (Duff,2003):1. Specialised induction2. Mentorship3. Personal development plans and teachingprogrammes linked to organisationaldevelopmental plans4. Support and supervision systems5. DebriefingIn addition, Duff (2003) recommended thatstaff increase their self-awareness of theirvulnerabilities and blind-spots. They shouldalso be more aware of people with a personalitydisorder diagnosis, of their perspectives andpositive attributes, and be able to build on theirexisting skills. It is important for staff to haveawareness of potential complications withinthe team due to the difficulties of working withpeople who have a diagnosis of personalitydisorder.TransitionsTransition periods in prison custody are highrisk, with increased likelihood of suicide forall prisoners (Shaw & Humber, 2007). Prisonsprotect new prisoners from harm by theuse of a ‘first night’ centre and an inductionwing which are designed to ease transitionalperiods. Care is still lacking in transitions backto the community, however, especially forprisoners with mental health difficulties. Rapidengagement with community mental healthservices significantly reduces risk during thisperiod (Shaw & Humber, 2007).Equally, a specific NICE target for treatment ofBPD is to take added care in transition periods.NICE guidelines say that extra care should betaken when a person with BPD has to make atransition between different sources of care dueto the incurred emotional difficulty with thisprocess. The guidelines recommend that:1. Such changes are discussed carefullybeforehand with the person (and their familyor carers if appropriate) and are structuredand phased.2. The care plan supports effective collaborationwith other care providers during endings andtransitions, and includes the opportunity toaccess services in times of crisis.3. When referring a person for assessment inother services (including for psychologicaltreatment), they are supported during thereferral period and arrangements for supportare agreed beforehand with them (NICE,2009).We suggest that these detailed arrangementsare made for women with BPD, in addition to themeasures already taken as part of prison policy.Therapeutic interventions in prisonTreatment programmes for BPD should bebased on psychotherapeutic principles. Thereis a list of suggested therapeutic approaches inthe NICE guidelines which includes dialecticaland cognitive behavioural therapy-basedprogrammes, mentalisation-based therapy andpart hospitalisation, cognitive analytical therapyand psychodynamic therapies (NICE, 2009).Dialectical behavioural therapy, which focuseson acceptance and behaviour change, is the onlytreatment that has shown consistent benefitsfor people with a borderline personality disorderdiagnosis, according to a Cochrane systematicreview (Binks et al., 2006).In the Carousel programme, group therapy iscombined with individual counselling, physicalexercise, relaxation, educational activity and arttherapy. Some of this programme conforms tothe guideline and therefore may be beneficial,but it is currently lacking an evidence base. NICEguidelines also suggest that psychotherapeuticinterventions are embedded within a programmeof strategies for associated co-morbidities suchas substance use and eating disorders (NICE,2009). It is also stipulated in the guidelinesthat therapy should last for not less than threeCentre for Mental Health POLICY PAPER Under the radar7

Centre for Mental Health POLICY PAPER Under the radarmonths. In remand prisons and with shortsentences this may be difficult (theaverage sentence is just 9.6 months), requiringin-reach/bridge services to continue treatmentin the community.Women with BPD frequently have co-morbidmental health problems, including eatingdisorders or substance use issues, andaccording to NICE guidelines these should betreated under the same umbrella as BPD. Apractical strategy is to have a care co-ordinatorfacilitating access to BPD treatment in a way thatcomplements substance use programmes. Thisstrategy needs to be introduced into prisonsto enable women to address multiple needsaffecting their mental health.Alternatives to prisonBy diverting women with BPD from custody,the problem of inadequate mental health careprovision in prison may be avoided. There areseveral different schemes that enable women,specifically, to be diverted at any point inthe criminal justice process. This can includediverting women with a severe mental illnessto hospital under the Mental Health Act (1983)rather than keeping them in the criminal justicesystem.There are also broader schemes supportingprisoners with a variety of mental healthproblems and linking them to communityservices. A review of existing diversion schemesfound that only 2-3% of female offenderscoming through the criminal justice systemwere being diverted (Hunter et al., 2005), whichgrossly excludes the 50% of female prisonerswith a personality disorder diagnosis.The Primrose Service is the only servicedesigned specifically for the diversion fromprison of women with a personality disorderdiagnosis. But it has just 12 beds, and it ishoused within the prison system rather than asecure hospital.The Bradley Report recommended that theGovernment should evaluate the existingtreatment options for personality disorder inprison including therapeutic communities, andalso that the DSPD units should be assessedto see if they are adequately addressingprisoners’ needs. It also recommended thatthe Department of Health, NOMS and the NHSshould develop a personality disorder strategythat would cover management from custodial tocommunity services for women who are servingshort sentences (Bradley, 2009).Parenting interventionsGiven the considerable costs of crimeattributable to conduct disorders (SainsburyCentre, 2009b), and the links made betweenmothers with BPD, incarceration andintergenerational risk factors for crime,evidence-based parenting programmesmay be a cost-effective intervention thatcould have longitudinal benefits. The Centre(Sainsbury Centre, 2009b) estimates that theseprogrammes cost as little as £600-£900 perperson for group-based therapies and up to£4,000 per person for individual interventions.The brevity of parenting programmes alsomeans that they could potentially be deliveredfor women who are serving short sentences.RecommendationsRecommendation 1: Where appropriate,alternatives to custody should be sought at allstages of the criminal justice system for womenwith a diagnosis of borderline personalitydisorder.Prison can be especially traumatic for womenwith a diagnosis of borderline personalitydisorder, due to their personal histories of abuseand victimisation.Staff should be vigilant to symptoms of BPDat all stages of the criminal justice pathway,leading to professional assessment anddiversion to appropriate services.Recommendation 2: Prison staff shouldbe aware of self-harm as a key symptomof borderline personality disorder. This isconsistent with the NICE guidelines for thiscondition (NICE, 2009).Prison staff should be given training torecognise the symptoms of borderlinepersonality disorder, and equipped with thebasic understanding and skills to managesensitively those who self-harm.8

Recommendation 3: Where possible,interventions consistent with NICE guidelinesshould be offered to women with BPD in thecriminal justice system.The NICE guidelines recommend that evidencebasedpsychological therapies are used inthe treatment of people with a diagnosis ofborderline personality disorder. The minimumperiod of treatment suggested in the guidelinesis three months.Women with a diagnosis of borderlinepersonality disorder who are servinglong sentences should be given access topsychological therapies to help them to managetheir condition.Where women are on shorter sentences,therapies should still be offered and continuedafter release. Adequately provisioned mentalhealth in-reach services may provide an effectivesolution.Recommendation 4: ‘Meet and greet’ careshould be provided on discharge to improvelinks between prison and community services.People with a borderline personality disorderdiagnosis benefit greatly from well-managedtransitions between different health careproviders. A ‘meet and greet’ procedure wouldavoid disruption in the provision of services.This is often ignored due to the absence ofadequate hand-over procedures betweencommunity mental health teams and prisonhealth care.Prison health care staff should liaise withprisoners’ local community mental health teamsto prepare for release.Recommendation 5: An adequate number oftrained therapists with dialectical behaviouraltherapy (DBT) skills should be commissioned.The Government is committed to deliveringan increase in access to evidence-basedpsychological therapies (Department ofHealth, 2010). Currently, Improving Access toPsychological Therapy (IAPT) services are beingintroduced across England. This roll-out includesthe provision of training for psychologicaltherapists. This training should be expanded toinclude dialectical behavioural therapy.Recommendation 6: More research needs tobe undertaken to understand the impact ofcustody and family separation on women with adiagnosis of borderline personality disorder.The lack of contact with their children andthe uncertainty surrounding their custodyarrangements is a source of great distress to allparents in prison, but particularly for women.There is little specific research available in thecontext of women with this diagnosis.Recommendation 7: Family-based and parentinginterventions should be provided to incarceratedwomen with a borderline personality disorder.Children of incarcerated women with a borderlinepersonality disorder diagnosis are particularlyat risk of conduct problems and future offendingbehaviour.Women with a borderline personality disorderdiagnosis tend to have more disrupted families,and so require greater support to maintain astable family unit.By seeking suitable diversion at an earlier stagewithin the criminal justice pathway, family unitscan be maintained and the risk of disruption tochildren’s lives can be minimised.Where incarceration is the only option, socialservices should be sensitive to the beneficialeffects of family interventions. All options shouldbe sought to maintain the integrity of the familyunit. This may include the provision of parentingand lifestyle interventions both in prison and onrelease into the community.AcknowledgementsThis paper was written by Matt Fossey, Centrefor Mental Health and Georgia Black, Institute ofPsychiatry.The authors would like to thank:The women who agreed to share theirexperiences and stories of living with adiagnosis of borderline personality disorder inprison.All of the professionals who participated inthe drafting of this report and contributedtheir views and experiences. In particular,Michael Parsonage, Dr Chiara Samele, ClaireWarrington, Lorraine Khan, Dr Graham Durcanand Max Rutherford.Centre for Mental Health POLICY PAPER Under the radar9

Centre for Mental Health POLICY PAPER Under the radarReferencesBarnow, S., Spitzer, C. et al. (2006) Individualcharacteristics, familial experience, andpsychopathology in children of mothers withborderline personality disorder. Journal ofAmerican Academy of Child & AdolescentPsychiatry, 45 (8) 965.Barrett, B., Byford, S. et al. (2009) Theassessment of dangerous and severepersonality disorder: service use, cost, andconsequences. Journal of Forensic Psychiatry &Psychology, 20 (1) 120-131.Binks, C. A., Fenton, M., McCarthy, L., Lee, T.,Adams, C.E. & Duggan, C. (2006) Psychologicaltherapies for people with borderline personalitydisorder. Cochrane Database of SystematicReviews (Issue 1), Art. No: CD005652.DOI:10.1002 / 14651858.CD005652.Birmingham L., Mason, D. & Grubin, D. (1997)Health screening at first reception into prison.Journal of Forensic Psychiatry & Psychology, 8(2) 435-439.Birmingham, L., Wilson, S. et al. (2006) Prisonmedicine: ethics and equivalence. The BritishJournal of Psychiatry 188 (1) 4-6.Black, D., Gunter, T. et al. (2007) Borderlinepersonality disorder in male and femaleoffenders newly committed to prison.Comprehensive Psychiatry, 48 (5) 400-405.Bowers, L., Callaghan, P., Nijman, H., Paton, J.,Carr-Walker, P., Allan, T. & Simpson, A. (2003)The Right People for the Job: Choosing staffthat will adjust positively and productively toworking in the new personality disorder (PD)services. Report to the Home Office.Bowers, L., Carr-Walker, P. et al. (2006) Attitudeto personality disorder among prison officersworking in a dangerous and severe personalitydisorder unit. International Journal of Law andPsychiatry, 29 (5) 333-342.Bradley, K. (2009) The Bradley Report: LordBradley’s review of people with mental healthproblems or learning disabilities in the criminaljustice system. London: Ministry of Justice.Buchanan, A. & Leese, M. (2001) Detentionof people with dangerous severe personalitydisorders: a systematic review. The Lancet, 358(9297) 1955-1959.Caddle, D. & Crisp, D. (1997) Imprisoned Womenand Mothers. Home Office Research Study No.162. London: Home Office.Corston, J. (2007) The Corston report: A reviewof women with particular vulnerabilities in thecriminal justice system. London: Home Office.Councell, R. (2003) The Prison Population in2002: A statistical review. Home Office Findings228. London: Home Office.Cunningham, A. & Baker, L. (2004) InvisibleVictims: The children of women in prison.Ontario, Canada: Centre for Children & Familiesin the Justice System.Department of Health (2010) Press Release23 June 2010 Psychological therapies offeredacross the NHS. (http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_116919)Department of Health (2009) Improving Health,Supporting Justice: The national delivery planof the Health and Criminal Justice ProgrammeBoard. London: Department of Health.Department of Health (2006) Planning andDelivery Guide for Women’s DSPD Services(Primrose Programme). Home Office DSPDprogramme. London: Department of Health andHM Prison Service.Department of Health (2005) Offender MentalHealth Care Pathway. London: Department ofHealth.Department of Health (2003) PersonalityDisorder: No longer a diagnosis of exclusion– policy implementation guidance for thedevelopment of services for people withpersonality disorder. London: Department ofHealth.Dirks, D. (2004) Sexual revictimization andretraumatization of women in prison. Women’sStudies Quarterly, 32 (3) 102-115.Douglas, N. & Plugge, E. (2006) A HealthNeeds Assessment for Young Women in YoungOffender Institutions. London: Youth JusticeBoard/University of Oxford.DSM-IV (1994) DSM-IV: Diagnostic andstatistical manual of mental disorders. ArlingtonVA: American Psychiatric Association.Duff, A. (2003) Managing personality disorders:making positive connections. NursingManagement (Harrow), 10 (3) 27-30.10

Fawcett Society (2008) Women and the CriminalJustice System: The facts. London: FawcettSociety.Feldman, R., Zelkowitz, P. et al. (1995) Acomparison of the families of mothers withborderline and non-borderline personalitydisorders. Comprehensive Psychiatry, 36 (2)157-163.Greene, S., Haney, C. et al. (2000) Cycles of pain:risk factors in the lives of incarcerated mothersand their children. The Prison Journal, 80 (1) 3.Heney, J. & Kristiansen, C. (1998) An analysisof the impact of prison on women survivors ofchildhood sexual abuse. Women and therapy,20 (4) 29-44.Herman, J., Perry, J. et al. (1989) Childhoodtrauma in borderline personality disorder.American Journal of Psychiatry, 146 (4) 490.HM Chief Inspector of Prisons (2009) RaceRelations in Prison: Responding to adult womenfrom black and minority ethnic backgrounds.London: HM Inspectorate of Prisons.Hobson, R. P., Patrick, M. et al. (2005) Personalrelatedness and attachment in infants ofmothers with borderline personality disorder.Development and Psychopathology, 17 (02)329-347.Home Office (2010) Statistics on Women andthe Criminal Justice System: A Ministry of Justicepublication under Section 95 of the CriminalJustice Act 1991. London: Ministry of Justice.Home Office (2009) Statistics on Women and theCriminal Justice System. London: Home Office.Home Office (2004) Women’s OffendingReduction Programme (WORP) Action Plan.London: Home Office.Hunter, G., Boyce, I. & Smith, L. (2005) CriminalJustice Liaison and Diversion Schemes: A focuson women offenders. Mental Health Briefing.NACRO. London: NACRO.Jordan, B.K., Schlenger, W.E., Fairbank, J.A. &Caddell, J.M. (1996) Prevalence of psychiatricdisorders among incarcerated women part II.Convicted felons entering prison. Arch GenPsychiatry, 53 (6) 513-519.Lyons-Ruth, K. (1996) Attachment relationshipsamong children with aggressive behaviorproblems: The role of disorganized earlyattachment patterns. Journal of Consulting andClinical Psychology, 64 (1) 64-72.Ministry of Justice (2007) Monthly Bulletin: April2007. Population in Custody. London: Ministryof Justice / NOMS.Moloney, K., van den Bergh, B. et al. (2009)Women in prison: the central issues of gendercharacteristics and trauma history. PublicHealth, 123 (6) 426-430Nehls, N. (1999) Borderline personality disorder:The voice of patients. Research in Nursing &Health, 22 (4) 285-293.NICE (2009) Borderline Personality Disorder:Treatment and management. London: NICE.Niveau, G. (2007) Relevance and limits of theprinciple of ‘equivalence of care’ in prisonmedicine. British Medical Journal, 33 (10) 610.Perseius, K., Ekdahl, S. et al. (2005) To tame avolcano: patients with borderline personalitydisorder and their perceptions of suffering.Archives of Psychiatric Nursing, 19 (4) 160-168.Prison Service (2010) March 2010. Populationin Custody: Monthly Bulletin. London: PrisonService.Rendu, A., Moran, P. et al. (2002) Economicimpact of personality disorders in UK primarycare attenders. The British Journal of Psychiatry,181 (1) 62.Rutherford, M. (2010) Blurring the boundaries:The convergence of mental health and criminaljustice policy, legislation, systems and practice.London: Sainsbury Centre for Mental Health.Sainsbury Centre (2009a) Personality Disorder:A briefing for people working in the criminaljustice system. London: Sainsbury Centre forMental Health.Sainsbury Centre (2009b) The Chance of aLifetime: Preventing early conduct problems andreducing crime. London: Sainsbury Centre forMental Health.Shaw, J., Creed, F. et al. (1999) Prevalence anddetection of serious psychiatric disorder indefendants attending court. Lancet (Britishedition), 353 (9158) 1053-1056.Shaw, J. & Humber, N. (2007) Prison mentalhealth services. Psychiatry, 6 (11) 465-469.Centre for Mental Health POLICY PAPER Under the radar11

Centre for Mental Health POLICY PAPER Under the radarSilk, K., Lee, S., et al. (1995) Borderlinepersonality disorder symptoms and severity ofsexual abuse. American Journal of Psychiatry,152 (7) 1059-1064.Singleton, N., Meltzer, H. & Gatward, R. (1998)Psychiatric Morbidity among Prisoners inEngland and Wales. London: Office for NationalStatistics.Social Exclusion Task Force (2009) Short Studyon Women Offenders. London: Cabinet Office.Social Exclusion Unit (2002) Reducing Reoffendingby Ex-prisoners. London: SocialExclusion Unit.Taylor, R. (2004) Women in Prison and Childrenof Imprisoned Mothers: Preliminary researchpaper. Geneva, Switzerland: Quaker UnitedNations Office.Travers, R. & Reeves, S. (2005) Breaking barriersand building connections. International Journalof Prisoner Health, 1 (2) 199-205.Trull, T., Sher, K. et al. (2000) Borderlinepersonality disorder and substance usedisorders: A review and integration. ClinicalPsychology Review, 20 (2) 235-253.Warren, J. & South, S. (2009) A symptomlevel examination of the relationship betweenCluster B personality disorders and patterns ofcriminality and violence in women. InternationalJournal of Law and Psychiatry, 32 (1) 10-17.Weiss, M., Zelkowitz, P. et al. (1996)Psychopathology in offspring of mothers withborderline personality disorder: a pilot study.Canadian Journal of Psychiatry, 41 (5) 285-290.Whisman, M. & Schonbrun, Y. (2009) Socialconsequences of borderline personality disordersymptoms in a population-based survey:marital distress, marital violence, and maritaldisruption. Journal of Personality Disorders, 23(4) 410-415.Wolff, N. & Shi, J. (2009) Victimisation andfeelings of safety among male and femaleinmates with behavioural health problems.Journal of Forensic Psychiatry & Psychology, 20,56-77.Zlotnick, C. (1997) Post traumatic stress disorder(PTSD), PTSD co-morbidity and childhood abuseamong incarcerated women. Journal of Nervous& Mental Disease, 185 (12) 761-763.12

More from a better waya better way is our campaign to highlight our concerns and provoke political, media andpublic debate about the approach we take to mental health in the criminal justice system.We want to change the way people think about mental health and criminal justice and setout a better way of working.Our campaign includes the following publications:Public Health and Criminal Justice: Promoting and protecting offenders’ mental healthand wellbeing (July 2010)Blurring the Boundaries: The convergence of mental health and criminal justice policy,legislation, systems and practice (March 2010)The Chance of a Lifetime: Preventing early conduct problems and reducing crime(November 2009)Securing Employment for Offenders with Mental Health Problems: Towards a better way(September 2009)The Bradley Report and the Government’s Response: The implications for mental healthservices for offenders (July 2009)Commissioning Mental Health Care in the Criminal Justice System: 10 top tips for PCTBoards (June 2009)A Missed Opportunity: Community Sentences and the Mental Health TreatmentRequirement (March 2009)Diversion: A better way for criminal justice and mental health (February 2009)On the Outside: Continuity of care for people leaving prison (December 2008)The Police and Mental Health: A briefing (September 2008)From the Inside: Experiences of prison mental health care (June 2008)Short-changed: Spending on prison mental health care (May 2008)Visit www.centreformentalhealth.org.uk to find out more about our work and to downloadcopies of these publications.Centre for Mental Health POLICY PAPER Under the radar13

Under the radarWomen with borderline personalitydisorder in prisonMatt Fossey and Georgia Black© Centre for Mental Health,September 2010Recipients (journals excepted) are free tocopy or use the material from this paper,provided that the source is appropriatelyacknowledged.Register for our monthly email bulletinsand copies of new briefing papers atwww.centreformentalhealth.org.ukPOLICYUnder the radarWomen with borderlinepersonality disorder in prisonMatt Fossey and Georgia Blacka better wayCentre forMental HealthRealising a better futureCentre for Mental Health134–138 Borough High Street, London SE1 1LBT 020 7827 8300F 020 7827 8369www.centreformentalhealth.org.ukCharity registration no. 1091156. A Company limited by guaranteeregistered in England and Wales no. 4373019.