Dangerousness and Therapy: Containment by relationship and

understanding

Personality:People and Pathology

David Jones Psychoanalytic PsychotherapistGrendon Prison22nd February 2006

Introduction Who are our clients? What do we mean by Personality

Disorder? How do we treat Personality

Disorders? What do you think?

Who Are Our Clients? Men. Aged between 21 and 50+ Who have all asked to come to Grendon. Who have committed serious offences,

usually many of them. 30% have committed serious sex offences. About 50% have life sentences. They almost all have personality disorders. Come to Grendon with 2+ years of sentence

remaining.

What are Personality Disorders? It is difficult to define a personality

disorder. There is no general agreement. Some labels, e.g. Psychopathy,

have serious and long lasting consequences.

A Definition A personality disorder is a severe disturbance

in the characterological constitution and behavioural tendencies of the individual nearly always associated with considerable personal and social disruption.

Or ‘enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment’

Causes Many potential causes, including

psychosocial, biological and genetic factors.

However symptoms do not usually develop unless a number of developmental factors have been present.

For example, a history of neglect, parental over involvement and physical and sexual abuse.

Personality Disorder @ HMP Grendon

PDQ4 scale % past threshold score Antisocial pd(aspre + asopt)

63.2 Paranoid PD 57.5 Borderline PD 52.2 Avoidant PD 50.4 Obsessive compulsive PD 43 Schizotypal PD 27.7 Narcissistic PD 18.7 Schizoid PD 16.7 Dependent PD 11.3 Histrionic PD 9.5

Personality Disorder @ HMP Grendon

Number of PDs % over threshold 0 16.4 At least 1 83.6 At least 2 71.8 At least 3 59.8 At least 4 47.7 At least 5 35.7 At least 6 23.4 At least 7 13.8 At least 8 7 At least 9 2.8 10 0.4

 

Psychopathy, Social and Emotional Development. PCL-R Scores

Grendon Population. Psychopathy Check List Revised (PCL-R) Scores.

49% Psychopaths (UK score +25) 26% 30+ (US score) Mean for the prison 24.15

(Shine and Hobson 1996)

Personality Disorder Social and Emotional Development. Marital Status

MARITAL STATUS

172 66.4 66.9 66.9

25 9.7 9.7 76.7

11 4.2 4.3 80.9

8 3.1 3.1 84.0

38 14.7 14.8 98.8

3 1.2 1.2 100.0

257 99.2 100.0

2 .8

259 100.0

single

married

co-habiting

separated

divorced

widowed

Total

Valid

SystemMissing

Total

Frequency Percent Valid PercentCumulative

Percent

Personality Disorder Social and Emotional Development. Employment

WERE YOU EMPLOYED AT TIME OF OFFENCE?

156 60.2 64.5 64.5

86 33.2 35.5 100.0

242 93.4 100.0

17 6.6

259 100.0

No

Yes

Total

Valid

SystemMissing

Total

Frequency Percent Valid PercentCumulative

Percent

Personality Disorder Social and Emotional Development. Attachment Issues

DID PRISONER EXPERIENCE LOSS OF OR SEPARATION FROM PARENTS (ORSURROGATE) FOR A PERIOD OF AT LEAST ONE YEAR?

104 40.2 43.0 43.0

138 53.3 57.0 100.0

242 93.4 100.0

17 6.6

259 100.0

No

Yes

Total

Valid

SystemMissing

Total

Frequency Percent Valid PercentCumulative

Percent

Personality Disorder Social and Emotional Development. Physical abuse.

HAS PRISONER BEEN THE VICTIM OF PHYSICAL ABUSE

73 28.2 30.0 30.0

170 65.6 70.0 100.0

243 93.8 100.0

16 6.2

259 100.0

0

1

Total

Valid

SystemMissing

Total

Frequency Percent Valid PercentCumulative

Percent

Personality Disorder Social and Emotional Development. Sexual Abuse

HAS THE PRISONER BEEN THE VICTIM OF SEXUAL ABUSE

140 54.1 57.6 57.6

103 39.8 42.4 100.0

243 93.8 100.0

16 6.2

259 100.0

No

Yes

Total

Valid

SystemMissing

Total

Frequency Percent Valid PercentCumulative

Percent

Psychopathy, Social and Emotional Development

‘The parents of psychopaths can do little but stand by helplessly and watch their children tread a crooked path of self absorbed gratification accompanied by a sense of omnipotence and entitlement.’

(Robert Hare, Without Conscience)

, ‘…psychopathic attitudes and behaviours very likely are the result of a combination of biological factors and environmental forces.’

of biological factors and environmental forces.’

(Robert Hare, Without Conscience)

Personality Disorder Social and Emotional Development. Aetiology continuum

Personality Disorder Social and Emotional Development. Where Do I Stand?

Psychopathy, Images

Psychopathy, Images.

Psychopathy, Images

Psychopathy, Images

The Psychopath. We generally think of these men as

being the most difficult to work with and treat.

They may leave treatment early. They can be disruptive in treatment

activities. Has been a dustbin label for many years. It still is!

Description or Understanding? What is the degree of identity

integration? What are the type of defensive

operations habitually employed? What is the capacity for reality

testing?

Does Treatment Work? Yes (and research is now demonstrating

that PD is not as enduring as some had thought)

The answer to the question depends on what you are aiming to change.

Re-offending is not the only criterion for successful treatment.

But it may be a primary focus in the Prison Service.

What treatments work? Treatment should be long term. The effectiveness of Psychodynamic

and Cognitive Behavioural methods is supported by research evidence.

Treatments need to be well structured, have a clear focus, be theoretically coherent and be well integrated. (Bateman and Fonargy. 2000)

A Case Example Name – Peter Age 35 Sentence; 7 1/2 years for GBH. Chronic alcohol problem.

The Offence He went to a party where he began drinking

and became intoxicated. He knows that when he drinks the devil in

him comes out. He had an argument with a man which led

to him throwing a punch and then smashing him over the head with a loudspeaker.

The man remained in a coma for over a year.

His Background Born in Ireland, eldest of six

children. Parents were 16 and 15 years old. Mother quickly became pregnant

again. Brought up mainly by

Grandmother.

His Background Mother was violent to all of the

children but particularly with Peter. He remembers being punched in the

face when he was three years old. He was at school with the Christian

Brothers who exercised strict physical punishment.

He left school age 14.

His Background He had been introduced to alcohol

at an early age and by 16 he was a heavy drinker.

He came to England at age 16 and worked on building sites.

His Background He was soon an alcoholic and getting

into regular violent fights. The number of these far exceeds the tally of convictions.

He married but continued drinking and the marriage ended because of this and his aggression.

He has a son and is engaged in a custody dispute.

His Complaints Firstly, that we did not want him. That we put him in a damp cell. When we moved him that we

would not allow him to go to a cell of his choice.

That we would not agree to him getting married.

How did he present? With extreme anger. With threatening behaviour. With promises that he had

renounced drink and violent behaviour.

How Did We Feel? Like kicking him out?

Why Didn’t We? This is his behaviour and why he

came. His behaviour can be understood

and treated in several ways.

How is this done? By identifying and challenging his

delinquent social behaviours. By understanding the unconscious

processes which drive his behaviour.

The nature of his internal world and how this is imposed upon the external world.

How is this done? By providing a secure and containing

environment and therapy structure which he can take in as a corrective emotional experience.

By facilitating the groups in a way that enables unconscious processes to emerge, be noticed, understood and fed back in a way that the inmate can understand.

Finally The healthier the staff group. The more it can tolerate acting out

behaviour The better it can tolerate and

understand powerful projections and powerful disturbed transferences.

The more effective will be the treatment.