Working with Women with Personality Disorder

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Working with Women with Personality Disorder

Anna Motz, Consultant Clinical and Forensic Psychologist, Psychoanalytic Psychotherapist

Women’s pathways into forensic settings differ from men’s. In particular, women in forensic settings, whether in prison, hospital, or the community frequently share histories of multiple trauma and attachment disturbances, often leading to profound difficulties in relating to others, despite a wish to do so. They present with high rates of relational difficulties and a significant proportion could be considered to have personality disorder.  Consequently, effective engagement with such women requires gender-sensitive techniques, both in assessment and treatment.

How can frontline workers including prison officers, nurses and offender managers work effectively with women who have severe difficulties in forming relationships, managing violent feelings, and trusting others? Women who have experienced multiple trauma and adversity in early life can often develop deep distrust, not wanting to make contact with those tasked with helping them; workers in turn, can feel helpless, confused and frustrated, while, the women can be left with unmet needs for containment and understanding.

For example, self-harm is a major problem for women with personality difficulties in the Criminal Justice System; in 2017, the rate among women was 2,093 self-harm incidents per 1,000 prisoners, nearly five times higher than the rate of 445 per 1,000 prisoners in the men’s estate (MOJ, 2018) Self-harm, verbal and physical aggression, and other expressions of distress profoundly impact on staff, as well as on the women themselves. Female prisoners are more than twice as likely as male prisoners to report needing help for mental health problems, 49% and 18% respectively (MoJ, 2013).

Laura d’ Cruz, Lead for the Women’s Offender Personality Disorder Programme clearly identified that ‘staff working on the women offender personality disorder pathway will require specialist gender specific training that gives them the skills, knowledge and confidence they need in order to work most effectively, and in a psychologically informed way, with female service users. Staff will also require supervision, reflective space and support to help keep themselves healthy and motivated .’ (d’Cruz, 2015:49)

To address this need for gender sensitive, trauma-informed training for staff innovative, evidence based programmes were co-designed and co-delivered by a psychoanalytic psychotherapist/clinical psychologist and an educational consultant with a lived experience of personality disorder.

The Women’s Enhanced Knowledge and Understanding Framework is a four-day course that enables workers to understand the development of personality difficulties in women within a trauma model, and the intersectional roles of race, gender, class and poverty in terms of creating relational difficulties for women.

The training has now been delivered to over 600 practitioners in the criminal justice system, mental health and voluntary sector settings working on the Women’s Offender Personality Disorder Pathway. This training and the eight-day standalone BSc modules demonstrate that staff within CRCs and NPS settings are key attachment figures for the women, and have a significant role to play in helping them engage with services, gain understanding of themselves and ultimately reduce the risk of harm to others. The trainings draw on attachment theory, using psychoanalytic concepts, sociological perspectives on gender identity and criminological data on the experiences of women within the criminal justice and secure mental health systems.

Understanding that there is hope for women with personality difficulties, that lives can be transformed with the right help and support, is a key message in the training which is embodied in the service user trainer. (Blazdell & Morgan, 2015: 58)

Those working with women with personality disorders will need to remain mindful of the possibility of re-enactments, and that staff working with the women will be unconsciously recruited to replay traumatic scenes from their early lives. When these pressures can be resisted and thinking stays focused, the intensity of the work with women presenting in challenging ways can be managed, and strong relationships forged in which women with histories of trauma and distrust can learn to work effectively with criminal justice staff.

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