In December 2023, HM Prison and Probation Service and the NHS published a welcome and ambitious document The Offender Personality Disorder (OPD) Pathway1. This sets out the joint vision for psychologically informed services for offenders with a diagnosis of personality disorder, linking the systems. Crime in Mind followers will particularly welcome the authors’ advocacy for ‘evidence-based relational and environmental approaches’. In clear support for this position, they then wisely list ‘building the evidence base’ as one of the three main service level ambitions for the five full years 2024-2028.
One small gripe – accepting that the document is principally about establishing an optimal environment and framework for treatment and change, it seems unnecessary and bizarre that there is nonetheless a single reference to medication – to ‘governance requirements for medication to manage sexual arousal’. Here it seems likely that the reference is to antilibidinal drugs, but singling out one small group of people who may benefit from a psychologically informed pathway in this fashion is unfortunate for implying that concern is primarily about personality disorder and sex offending – most people with personality disorder are not sex offenders. There is, however, substantial evidence about how medication of various kinds may support progress for the much wider group of people diagnosed with personality disorder, but here too it may be useful to consider protocols and governance requirements?
This apart, the document is excellent in giving aims that can form the basis for building that evidence base for the pathway and, indeed, effective treatments. Assuming that the framework is operating as envisaged – and in line with feasibility findings noted – then the following research questions clearly emerge from the aims of the work programme, not necessarily in order of priority:
For the offenders –
Is passage through the OPD pathway associated with a reduction in offending, especially high harm offending?
Is passage through the OPD pathway associated with Improved psychological health, wellbeing, pro-social behaviour and relational outcomes?
For the staff –
Is the OPD programme associated with Improved competence, confidence and wellbeing of staff working with people in the criminal justice system who have been diagnosed with a personality disorder?
For us all –
The reoffending question is central, but also
Is there evidence of increased efficiency, cost effectiveness and quality of services for offenders diagnosed with personality disorder as they pass through the OPD pathway?
This last question will be particularly difficult to answer as any effective new service generally uncovers substantial unmet need so, in the short term, costs of adequate service delivery may apparently rise. Thus, efficiency measures will have to be very carefully designed.
Further praise is due to the authors of this document as they note the need for funding and make at least some commitment to providing it in the commitment to ‘Continue to fund academic work to ensure OPD Pathway practice is based on developing knowledge in this field and that the Pathway develops informed leadership that recognises relational principles and practice.’ While we hope that such funding is forthcoming, we also need to think of new funding sources, particularly as growing success is likely to raise ever more specific questions about sound healthcare input.