Abstract
The offender personality disorder (OPD) Pathway is a network of services across prison, health and community settings in England and Wales providing psychological support for high-risk people who have offended and are thought to have a personality disorder. As part of a national evaluation of the Pathway, semi-structured interviews were carried out with 36 Pathway users to determine their views about their experiences in these services; and whether and how these impacted on their psychological wellbeing. Framework analysis was used to analyze the data. Participants reported positive therapeutic relationships with staff; improved psychological wellbeing; and for some, a shift away from antisocial toward more pro-social identities. They also described a negative impact of staff turnover and uncertainty about the role of prison officers and psychologists within prison services. Pathway services are able to engage individuals who have not previously engaged with services. Constancy of staff is fundamental to the Pathway.
The last two decades in England and Wales have seen policy initiatives focused on improving the management and treatment of high-risk people with Personality Disorders (PD) (His Majesty’s Prison & Probation Service [HMPPS] & National Health Service [NHS], 2023). Additional changes have also been made to both criminal justice and mental health law to make it easier to detain people with PD in secure settings, for longer durations. Alongside which, there has been increasing investment in research, interventions and new clinical guidelines for PD (Pickersgill, 2013). The catalyst for many of these changes was a high-profile case 1996 in which the convicted perpetrator was found to have a prior diagnosis of personality disorder and had been assessed to be dangerous. This raised questions, first about whether actions could have been taken to prevent the crimes committed (such as mandatory psychiatric detention), and second, about the “treatability” of people with PD. The ensuing debate led to the then Secretary of State for the Labor Government, Jack Straw, to state that there are “a group of dangerous, severely personality disordered individuals from whom the public at present are not properly protected” (House of Commons Debate, February 15, 2019). This led to the commissioning of the Dangerous and Severe Personality Disorder (DSPD) Program in 2002 (Home Office & Department of Health, 1999), comprising of four high-security prison and hospital DPSD units for men (Ministry of Justice, 2011; see Trebilcock, 2020, for a review).
DSPD was controversial from the outset, due to its aim of “preventive detention,” that is, identifying and detaining individuals who were thought to be high risk of committing high harm with the aim of preventing the crime (White, 2002); its name (not a clinical diagnosis; Kettle, 2007), and there being no consensus at the time in relation to what a “severe,” let alone “dangerous” personality disorder may look like (see Tyrer et al., 2010). Acceptance to the services required meeting stringent eligibility criteria of high scores on the Psychopathy Checklist—Revised (PCL-R; Hare, 2003) and/or a minimum of two PD diagnoses (Burns et al., 2011) as defined by ICD-10/Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria at the time (these arbitrary criteria did not include a spectrum of severity which has since been added as part of diagnostic criteria in the ICD-11; Bach et al., 2022). While two national evaluations of the DSPD program were commissioned by the U.K. Government, only a summary of the findings were made publicly available in 2011. The program was eventually decommissioned in 2011, following continued criticism around the lack of evidence of risk reduction and the poor cost-effectiveness of the program (Tyrer et al., 2010).
The monies from DSPD were used to commission the Offender Personality Disorder Pathway (OPDP) by the Ministry of Justice (MoJ) and National Health Service England (NHS England). The overarching aims of the Pathway are to (a) reduce serious sexual and/or violent re-offending; (b) improve the psychological wellbeing of people receiving the services; (c) increase competence and confidence of staff; and (d) increase cost-effectiveness and efficiency of Pathway services (National Offender Management Service [NOMS] & National Health Service [NHS] England, 2015a). OPD Pathway services differ from many other traditional criminal justice services because they aim to provide psychologically informed services with an explicit therapeutic focus on “the environment and relationships between staff and service users . . . as a method for change in its own right” (NOMS & NHS England, 2015a, p. 12). To this end, the Pathway provides psychologically informed management in secure services as well as for those who are managed by community probation. Further detail on Pathway services is outlined below under the OPD Pathway Program.
Eligibility for the new OPD Pathway was based on three criteria: (a) assessed as presenting a high likelihood of violent or sexual offense repetition AND as presenting a high or very high risk of serious harm to others; (b) likelihood of having severe PD; and (c) a “clinically justifiable link” between the two (Joseph & Benefield, 2010). With regard to the second criteria, a specific diagnosis of PD is not required, rather the expectation is that the people accessing the pathway will “have complex needs consisting of emotional and interpersonal difficulties” (NOMS & NHS England, 2015a, p. 6).
OPD Pathway services were established across a much wider variety of settings of different security levels and in the community, reaching many more people. Whereas the number of people who had accessed DSPD by 2007 was only 202 patients (Burns et al., 2011), by June 2016, it was estimated that 36,459 people (representing 37% of the National Probation Service caseload [NPS]) had met eligibility for the Pathway, most of whom are in prison settings (Bali et al., 2023).
In England and Wales (as in many other countries), the prevalence of personality disorder in CJS settings is thought to be very high, with 60% to 70% of people in prison and 50% of people under probation supervision in the community, estimated to have a PD (compared with 4% to 11% of the general population) (NOMS & NHS England, 2015b). Not all will be eligible for the OPD Pathway as not all will meet the risk, severity or perceived link criteria. Despite the focus on personality disorder as a diagnostic category being “built in” to the program, criminogenic risk factor models remain relevant within a model of understanding this population (Fritzon et al., 2021).
The national evaluation of the Pathway for men ran between 2014 and 2018. However, the final report (submitted in July 2018) was only approved for publication by the MoJ in November 2022. The quantitative findings of the evaluation were published recently and showed no differences between those receiving Pathway services with those who did not (Vamvakas et al., 2024). These results are likely due to insufficient time to follow-up enough Pathway users to evidence any real difference. The UK government also commissioned other evaluations regarding the OPD Pathway in London, Wales, and in relation to women, but the final reports all remain unpublished. In the meantime, research findings about specific Pathway interventions have started to emerge. This includes research about screening (Mawby et al., 2020); case consultation and formulation, in particular their use in probation services (e.g., Bruce et al., 2020; Wheable & Davies, 2024); Psychologically Informed Planned Environments (PIPEs; for example, Kuester et al., 2022); and implementation of the psychologically informed approach taken in the Pathway (e.g., Bruce et al., 2017). Research has explored the profile of people across the Pathway (e.g., Bali et al., 2023); indeterminate sentence prisoners (King & Crisp, 2021); and women (O’Meara et al., 2021); as well as staffing, training, and supervision (e.g., Radcliffe et al., 2018).
The national evaluation of the Pathway utilized a mixed methods design that combined quantitative criminal justice system (CJS) data with qualitative interview data from staff and service users. The full methodology and abbreviated findings were published in the final report (Moran et al., 2022). The specific aims of this article are (a) to investigate Pathway user views of their experiences in these services, and; (b) assess whether users felt that Pathway services had impacted on their psychological wellbeing. There are few papers that report on the views of this population. They are a population that are difficult to engage in treatment (Sturgess et al., 2016) and so their views on approaches that enable this could potentially inform future policy and practice. While quantitative approaches can tell us who this population are and whether and how their offending patterns can change over time, the experiences of those receiving these services may help inform facilitators and barriers to change and growth. We conclude by considering the implications for desistance.
Method
The OPD Pathway Program
Eligibility for the Pathway is established via a screening process involving NHS psychologists working with Offender Managers (OMs) to review their caseloads. Once identified as eligible for the Pathway, a process of case consultation and formulation should be utilized to develop a sentence/Pathway plan (HMPPS & NHS, 2023). This involves targeted discussions between probation staff, health service providers, psychologists, and (where possible) the service user, to better understand the individual’s psychosocial and criminogenic needs. This should then determine the most appropriate referral pathway and tailored interventions during their sentence (HMPPS & NHS, 2023). Pathway users access their usual Offending Behavioral Programs (OBPs) with Pathway services being an adjunct to these.
The Pathway comprises a network of services based in prisons across the four security levels (from high-security to open prisons), secure hospitals and the community (Campbell & Craissati, 2018). They are located on prison wings, NHS services and community outpatient settings and offer psychological treatment for PD in the form of individual and group therapy by clinicians; prison Democratic Therapeutic Communities (DTCs) providing psychotherapy but the ethos of the unit means that it is a treatment in itself, where staff model behavior and facilitate a sense of community (Rawlings & Haigh, 2018); people on the Pathway may also be referred to nontreatment services, including those known as PIPEs, where psychologists do not necessarily work directly with residents (as they might on a formal treatment unit), but instead provide clinical supervision to unit staff to facilitate therapeutic relationships (Kuester et al., 2022; Turner & Bolger, 2015). Within prisons, different PIPE models can be found. “Preparation PIPEs” are designed to help prepare people for a treatment environment, while “Provision PIPEs” allow people to live in a PIPE environment while they participate in treatment elsewhere in the prison. Progression PIPEs are designed to help people who have successfully completed OPD treatment or an OBP to practice the skills learned in treatment in a supportive environment. Approved Premises PIPEs are residential settings in the community that are designed to support people following their release from prison. Approved Premises in England and Wales have formerly been known as probation/bail hostels.
Sites
The network of Pathway services covers a range of services at various levels of security across England and Wales. We sampled sites purposively to (a) capture all components of the Pathway, (b) be inclusive geographically, and (c) include services in a range of security categories. Participants were therefore recruited from the following Pathway services which encompass the range of services in the Pathway: (a) four prison-based PD Treatment Units (offering individual and group therapy): two in Category A (highest security category) prisons, one each in Category B and Category C prisons (lowest of the three security levels), (b) one DTC, (c) one prison-based Provision PIPE in a Category B prison, (d) three prison-based Progression PIPEs: one each in Category A, B and C prisons, (e) one NHS Medium Secure Unit, (f) one NHS community-based outpatient PD Treatment Unit, (g) two Approved Hostel PIPEs, and (h) four Local Delivery Units where participants had received case consultation and formulations without any other pathway. The selected sites included five of the then seven NPS regions. The five regions included (North East, North West, Midlands, South West, and South East) have since further split into 11 regions in England. 1
Participants and Recruitment
The lead clinician in each service was asked to select a convenience sample of two people who had been managed in the Pathway service for at least 6 months and were able and willing to speak about their experience. The sample size was primarily guided by the aims and scope of the study as outlined above as advised by Vasileiou et al. (2018), as well as pragmatic considerations of limited resources (one researcher, wide geographical area and different types of services). Participants had to be aged 21 years and over and have a good command of English. Information sheets for all participants were sent to the lead psychologist at each site, who was asked to disseminate information about the interviews at meetings approximately 1 month before the interviewer’s planned visit.
Interview Protocol
We used a semi-structured interview schedule to ensure coverage of key themes. The interview schedule was developed in consultation with (a) specially convened Expert Reference Groups comprising senior psychology, prison and probation staff in the pathway, (b) the PD clinical and probation leads in Bristol and Gloucester, and (c) members of the NOMS OPD research team which included Patient and Public Involvement members. Drafts of the interview schedules, participant information sheets, and consent forms were then circulated within the evaluation team for comments and suggestions for revision. All participant-facing written material about the study was discussed with staff and Pathway users during site visits, to ensure that the content was clear and meaningful. The final interview schedule covered domains of participants’ experiences of contact with, and within, the CJS; their main problems; their experiences of the OPD Pathway (knowledge, level of contact, experience of contact, impact of contact); and any changes at follow-up.
Procedure
All participants provided written informed consent. All interviews were conducted face-to-face in a confidential setting by one member of the research team (M.J.). She trained as a Registered Mental Nurse and had worked in prisons for 9 years prior commencing on this study. She had not worked in the prisons and probation services where the interviews took place and had not met any of the participants previously. Interviews lasted between 30 and 60 minutes. All interviews were recorded on a digital audio recorder with PIN and encryption facility in line with NOMS National Research Committee (NRC) requirements, and were transcribed by a university-approved transcribing service.
Data Analysis
Transcripts were approached using a framework analysis as described by Ritchie and Spencer (1994). Framework analysis allows for large quantities of data to be analyzed in a systematic way; it is suitable for evaluation and policy research; and is not tied to any particular epistemology (Goldsmith, 2021; Parkinson et al., 2016; Srivastava & Thompson, 2009). A semantic approach was used to facilitate the analysis of the data which involved a initial familiarization with the data set, and development of a thematic framework. This was informed by the a priori research questions, (e.g., knowledge of pathway, journeys into pathway, difference to other locations, risk, journeys out of pathway, etc.), and emergent themes identified by a semantic approach to data familiarization. Indexing and charting of data was undertaken using a template that summarized the salient features of each participant experience under each thematic heading. The information from these “case summaries” was charted using Microsoft Excel, where each row represented a participant and each column related to each theme. We then subjected these charts to a more formal analysis where we “mapped” range and diversity of experience and perspectives. This approach served to identify themes that enabled us the describe the range of perspectives about Pathway services while retaining a “whole case” perspective enabling us to link key characteristics of each individual participant (e.g., age, Pathway component, type of sentence, etc.) to different themes. The strength of this approach is that it permitted a systematic and transparent review of a large volume of data, enabling us to capture key themes to inform an understanding of the experiences of participants, without compromising the richness of the data.
Reflexivity and Positionality
A reflexive approach was maintained by the research team through the development of the interview schedules, analysis and writing up via discussing and challenging established assumptions. To enhance the interpretive validity of the analysis, other members of the team (J.T., P.M., and T.W.) contributed to the critical review, interpretation and contextualization of the emergent themes. The team approached the evaluation from both an experienced but also questioning stance. J.T. and T.W. had both worked on the DSPD Program evaluation (never published by the MoJ) and took the view that while the criticisms of that program were valid and well grounded, they held the view that there were also some positive aspects of the program, specifically in the psychologically informed approach of working with this population. C.C. works in a Pathway service and also advocated for this approach. However, a key question that emerged early for all of the team was what exactly was meant by the “Pathway.” The term was used frequently by all stakeholders, except people receiving the services, but there did not seem to be a shared understanding of its meaning. Much of our discussions and approach to the evaluation and the data was therefore driven by attempting to understand this concept. Within the broader team, existing assumptions were challenged and clarifications of themes and terminology were enabled during discussions. The basic themes deduced from the analysis remained unchanged as they were framed around the interview questions but further nuance and detail were elicited highlighting what the team believed to be important features expressed.
Ethics
Research governance approvals were granted by the National Research Ethics Committee South Central—Berkshire (Ref: 15/SC/0076) and the National Offender Management Research Committee (Ref: 2015-081 NRC).
Results
Participant Characteristics
In total, 36 Pathway users were interviewed. Table 1 shows the characteristics of the participants and their location at the time of initial interview.
Participant Characteristics
Includes nonviolent offenses against children, false imprisonment, threats to kill, drug offenses and assault.
Includes one offender given a Determinate Public Protection (equivalent to IPP for under 18 years).
10 of the 23 participants serving IPP and Life sentences were over tariff at the time of interview.
At initial interview, approximately half of the participants were located in a prison setting, a third in the community, and the remainder in a medium secure unit within the NHS. Participants had a mean age of 39 years with a range of 23 to 58. Apart from three participants, all indicated that their ethnicity was White British. The majority of participants were serving Life or Indeterminate for Public Protection (IPP 2 ) sentences (63.9%, n = 23). Preventive detention, the notion of detaining perceived dangerous individuals with a view to prevent them committing dangerous acts is neither new nor specific to any one country. The preventive model has been in place for decades, as in the case of IPPs and in fact increased post 2001 in the wake of the 09/11 attacks (Zedner & Ashworth, 2019).
Since both IPP sentences and the OPD Pathway are focused on high-risk individuals, it is not surprising that many individuals serving these sentences would meet screening criteria for the Pathway (King & Crisp, 2021). In this evaluation, those with life sentences had tariffs ranging from 3 to 21 years while those with IPP sentences had tariffs ranging from 2 years 3 months to 10 years. Ten of the 23 participants serving life/IPP sentences were over tariff by between 1 and 12 years. Just over a quarter of the sample were serving a determinate sentence, and these ranged in length from 2 to 14 years. Only one participant had not received a prison sentence and was instead serving a 1-year Community Order.
The participants were a heterogeneous group of individuals, yet they shared some common experiences in their background and in their journey through the criminal justice system. In addition to personality disorder, participants described having a range of other mental health conditions, including episodes of psychosis, anxiety, depression, posttraumatic stress disorder, self-harm, attempted suicide, alcohol and substance use. Almost half disclosed experiences of childhood adversity, including sexual and physical abuse. At least a quarter of the group reported having had regular contact with police prior to the age of 16 years, with a small number having been detained in youth custody at age 15 years. The majority described experiencing a “revolving door” of repeated prison or community sentences for offenses relating to drug use, theft, and violence.
Although a small number of participants described having progressed smoothly through their sentence, most had experienced a difficult and turbulent time in custody. In the early period of their sentence, many described patterns of frequent and often severe conflict with staff and other imprisoned people. Some reported that their main problems in custody resulted from their challenging behavior. They spoke of frequent conflict with staff, being influenced by negative peer groups, being impulsive, not thinking of the consequences of their behavior, fighting against the system and having “problems with authority.” Such incidents often led to regular periods in segregation units, adjudications (prison sanctions) and, for some, additional sentences, so that their total time in prison greatly exceeded the initial determinate sentence length or tariff. A few participants also indicated that they had engaged poorly with treatment programs, often dropping out early. In addition to extra time on their sentences, their challenging behaviors also meant that many had been unable to demonstrate to the Parole Board that their level of risk had changed and, as a result, many had far exceeded their tariff.
Participants’ Experiences of the Pathway
Two broad themes were identified in the data, each with sub-themes. The first related to participants’ experiences of the OPD pathway which gave rise to sub-themes of relationships with staff in secure services, relationships with staff in probation services and the sense of safety within secure settings. The second was related to perceived impact of these relationships in terms of changes in psychological wellbeing and had subthemes of reduced emotional turmoil, increased hope, and shifts in identity. These are explored in turn below.
Relationships With Staff in Secure Services
On the whole, participants held positive views about staff working in secure Pathway services. They were perceived as being approachable, kind and respectful and offering a high level of support: They treat you like a human being and they genuinely want to help you. And I’m not stupid, I can see whether they do or not and obviously over time, it’s a bit of a freak really. I’d say in that, this is not the norm of prison life. (O8, Prison PIPE)
Officers were perceived as fostering both a positive and therapeutic relationship with individuals, while also having to maintain discipline and uphold security. This was perceived by some Pathway users as being confusing. For example, one individual spoke of their resentment at participating in a therapeutic group with a prison officer, shortly after having been disciplined by the same officer. He told us, So you’re not going to listen to what they are going to be saying because you’re thinking ‘well, you stitched me up this morning and now you’re trying to teach me the laws on life . . . how to be a better person or whatever, when you’re not like, I don’t think you’re like that yourself, so why are you preaching to me? (O2, Prison PD Treatment Unit)
Participants’ perceptions of clinical staff were also broadly positive, with many reporting that clinical staff were attuned to the mood of Pathway users and were skilled at knowing when and how to recognize signs of turmoil or distress and how to respond in a timely manner. However, some expressed uncertainty about the role of psychology staff in some prison services. Some viewed them with suspicion, particularly regarding the power to facilitate or hinder progression through the CJS through their recommendations. Illustrating this, one individual commented, You hear a lot of stories of people doing treatment and doing good and then getting bad reports at the end of it [. . .] So it’s like are psychology here to help you or just to get information off you so they can use it against you in reports. (O2, Prison PD Treatment Unit)
While some participants held these concerns, the majority also commented favorably about the transparency of communication in these settings and emphasized the extent to which staff spoke openly with Pathway users. For example, They’ll give you a sheet once a fortnight and say all the good things you’ve done, but they’ll also say the bad things you’ve done. “We need to look at this. We need to look.” It’s an in-depth report on your behaviour over the last fortnight. So you know where you’re going right and where you’re going wrong. (O3, Prison PD Treatment Unit)
The impact on participants of this empathetic, yet transparent and boundaried approach, is captured in our second overarching theme: perceived changes in psychological wellbeing. By focusing on their strengths (rather than just deficits) Pathway users reported that they had experienced improvements to their psychological wellbeing and a belief that they could develop more pro-social identities. Moreover, the increased sense of agency, choice and responsibility felt by Pathway users for their sentence management and progression, served to improve their emotional literacy and hopes for the future.
Relationships With Staff in Probation Services
In the community, the perception of probation staff was overwhelmingly positive, with participants describing feeling listened to, understood, valued and respected. Participants expressed deep appreciation for the extra support they had received. One participant told us about the staff in his Approved Premises: If you’re having a bad day, the staff talk to you more. They sit down with you, they have a talk and it’s more understanding. (O15, Approved Premises PIPE)
A particular theme that emerged from participants in the community was that of being actively involved in decision-making. These participants reported that often they approached their initial contact with probation with an expectation of being told what to do and feeling patronized. When probation staff responded by actively valuing their opinions and offering suggestions, rather than making demands, the participants described a change in their motivation and attitudes toward authority and rules. One individual told us, The power and control they have over me ultimately. I feel valued and listened to and especially over this, the last recall and this time, this release into the community, [. . .] I’m supported. I have had blips, got back to using substances. It hasn’t been automatic, “Go send him back to prison.” (O35, Probation Case Formulation)
One participant described experiencing a change in attitude over a succession of appointments with probation services. Although he initially attended out of a sense of obligation, over time, he recognized the gains he could achieve for himself by attending. Participants who were involved in the discussion about their risk management had a sense of equality and respect, which they contrasted with previous experiences of feeling controlled and wanting to fight back against the system. OMs were praised for taking a less restrictive and controlling role and being more empathetic and understanding. This in turn elicited trust, with participants reporting that they were more likely to disclose information about their own behaviors which could potentially impact on their risk. As a result, they described being open to suggestions from their OMs and being willing to engage in discussions about what would be helpful to them. One participant explained, And one of the big, again, turning points for me on the last recall and working with S and like J is the way that they work with me. They try and, I’m more open and honest. I’m able to be more open and honest and it’s ongoing, it’s like work in progress, when I’m able to share meself and how I actually am rather than lying, cheating and deceiving. (O35, Probation Case Formulation)
Notwithstanding these positive reports, participants also told us that relationships with their OMs had been affected by substantial changes in staffing. Some told us that they had been allocated to several OMs during their sentence and that they had found this lack of continuity unsettling. One participant reported that the longest he had had the same OM for was a year. Another participant in the community reported having had four different OMs in one year alone. Participants reported that changes in staffing were not limited to probation staff. Indeed, one participant spoke of his frustration at having one-to-one psychology sessions with different psychologists due to turnover: I’ve had three different psychologists here, [. . .] you can’t sit there and unburden to someone for so long and then stop them and leave and then get introduced to someone else again and you’ve got to start all over again, so it always gets to the point that you never get finished. (O13, NHS Community Outpatient PD Treatment Team)
The reality of having to disclose personal and often painful information to different people for the same reason was frustrating but also caused a reluctance to invest in those relationships, highlighting the critical importance of a stable workforce in the Pathway.
Safety in Secure Services: Many Pathway users talked about feeling safer while being managed within Pathway services compared with their experiences of normal location where the fear of attack from other residents was widespread: It’s very hard. And [. . .] there’s always fear. You can’t get too complacent. (O23, Prison PIPE) In places like this you do have incidents and stuff, and you think, “Oh, I’ve got to be on my guard,” and then everything goes quiet again and you feel safe again. In normal prison, you’ve always got to be alert. (O27, Prison PD Treatment Unit)
Given the very real threats experienced on normal location, participants described having to put on a tough front to survive: You’ve got to act, like, tough. You keep all that back, keep that for yourself, or whatever, because people see it as a weakness and take advantage of you. It can happen in places, like, but not as much. (O27, Prison PD Treatment Unit) The social skills that you need in prison are the exact wrong things for outside and skills you need outside are the wrong things in prison. They will get you into trouble. (O4, Prison PIPE)
The need to put on a tough front in normal location was often contrasted with their experience of being managed within OPD services. The impact of feeling safe within Pathway services was profound, with participants describing being able to be more open and honest about their feelings rather than focusing purely on survival: It freed me my attention to work on other things, other than to think, where’s the next bit of violence coming from? (O26, Prison PIPE)
Participants’ Perceptions About Changes in their Psychological Wellbeing
Three subthemes emerged in relation to participants’ perception of the impact of the relational environment described above on their psychological wellbeing. Participants talked about experiencing a reduction in emotional turmoil, an increased sense of hope about the future and of having experienced a shift away from antisocial toward more pro-social identities.
Reduced Emotional Turmoil
Many participants described feeling calmer and more tolerant as a result of being managed within Pathway services. They also reported gaining greater emotional literacy, learning to re-interpret events in a less “paranoid” way and being better able to manage their emotions. The increased ability to tolerate distress meant that these participants reported feeling better able to abstain from substances. Furthermore, some participants talked not just of being better able to manage their anger, but of experiencing less anger. For example, one man told us, I don’t really get as angry as much and I don’t feel angry towards the people, if they’ve got opinions and I didn’t like that opinion normally I would have argued with them but now I just let it go over my head. (O29, NHS PD Treatment Unit)
Several participants reported that their self-harming behavior had substantially reduced or even stopped during the period they were within a Pathway service. This included some individuals who had engaged in high levels of severe self-harm that had resulted in close monitoring by staff in prison or in Approved Premises. These participants described continuous observation as being extremely invasive and unhelpful to their state of mind. In contrast, the “Pathway approach” had involved the participant more in seeking help in exchange for less monitoring. Participants, who had been under continuous observation due to their self-harm, spoke of being grateful to psychologists who had negotiated lower levels of monitoring and other ways of working with them. One participant reported, I have a history of self-harm when my mood changes and the staff were constantly always coming to your door, just in case, all the time. So they were the downs but then with agreement with the Manager, that changed and when I felt like that, staff just completely left me alone and allowed me tell them when I was feeling like that because by leaving me alone, it actually allowed me to calm down but the more attention that the staff put into it, the worse it actually made me. (O16, Approved Premises PIPE)
Increased Feelings of Hope
Some participants talked of a growing sense of hope that had developed after they entered a Pathway service. They reported feeling optimistic about their future for the first time in their life and this hope was linked to a feeling of confidence that they could build relationships with others. They described feeling motivated to be better people and reported feeling more confident that they could eventually achieve this. One participant who, prior to entering his pathway service said he had often felt that he would be better off dead stated: My confidence has grown; it’s having hold of the future that’s kept me on the right path. If I didn’t have that hope, then I wouldn’t bother about all this. It’s hope that’s keeping me going. (O27, Prison PD Treatment Unit)
Shifts in Identity
Some participants spoke of experiencing a profound shift in their identity from being “hard” and a “criminal” toward a pro-social identity. Many described how they wanted to socialize, work and live a normal life outside prison. The reasons for the shifts in identity varied. Some said they had simply matured and were now tired of the criminal lifestyle. For a minority, the index offense itself (and the resulting consequences) appeared to represent a key turning point in their life. A few related the shift to re-establishing contact with family and having a sense of role within their family. For others, though, it was the support received in Pathway services, combined with the sense of safety, which allowed them to contemplate possible change. Participants also valued the fact that staff focused on their strengths and positive qualities. For example, one man told us, With (OM name) and the Pathway team and that I found it’s more of a, it’s a look at me situation, it is. Not look at me, it’s like look into me. Why am I like this?. What can I do, you know, or I’ve got the abilities and I’ve got the tools to actually be something else than what I am. And it’s like trying to open me up to those avenues to be someone else. I don’t know, it’s just hard to explain. (O36, Probation Case Formulation)
Discussion
This article aimed to report the experiences people using OPD Pathway services; and whether and how these impacted on their psychological wellbeing. Although our sample were varied in some respects, many described themselves as being difficult individuals with a propensity for violence and a deep mistrust of authority figures. Many also described poor experiences and engagement with treatment interventions. It is notable then, that the majority of participants spoke positively about better engagement in the OPD Pathway (compared with previous services), and attributed positive changes in their behavior and psychological wellbeing to relational practices across the Pathway. The quantitative analysis from our national evaluation did not detect a statistically significant effect between treatment and comparator groups in the OPD Pathway in terms of key criminogenic outcomes (see Moran et al., 2022; Vamvakas et al., 2024). However, qualitative data from the national evaluation suggest that the OPD Pathway (and associated services in secure and community settings) have had a positive effect on Pathway users. While an examination of the quantitative outcomes of the Pathway requires longer follow-up times and higher quality data, it is reassuring to note that Pathway users themselves are identifying that many critical ingredients for reducing risk, progression through the criminal justice system, and ultimately for desistance, represent key features of their experiences of the Pathway.
Among the factors contributing to the relational environment was transparency of communication. The participants’ accounts revealed that this entailed being provided with clear feedback about their behavior. This was often reported as being a novel experience with, in their view, their progression being blocked without their being given a clear explanation. This reflects the importance of explicit communication and the need for open discussion about rules, limits and expectations of all parties, when working with high-risk people who have offended and also have PD (Murphy & McVey, 2010). A systematic review of reasons for noncompletion of offending behavior programs by Sturgess et al. (2016) found that completion of these programs is facilitated by encouragement to engage in the programs, understanding their purpose, recognizing the need for change, readiness to give up an identity of “offender,” and feeling safe. Our qualitative findings show that Pathway services may be able to facilitate these aspects which in turn may increase likelihood of engagement and completion of such programs. When staff can establish positive and empathetic relationships with the people they supervise “while at the same time being willing and able to challenge behavior and recognize feigned compliance,” they are better equipped to support that individual in their desistance journey (His Majesty’s Inspectorate of Probation [HMI Probation], 2023, p. 38). These insights are particularly pertinent for a population with high rates of recidivism, poor individual outcomes, and who have been seen at their worst, as “untreatable,” and at their best, “difficult” to engage in treatment (Sturgess et al., 2016).
Those managed in the community spoke of encountering a less restrictive and more supportive approach from their OMs, and for some participants, for the first time in their experience, the use of case formulation had provided a focus on their strengths rather than just on their shortcomings. An added factor was the perceived involvement in decision-making and participation, with an increased sense of choice leading to greater engagement. When participants talked of working in partnership with their OMs they recognized that they were subject to controls and restrictions. Yet they reported engaging with OMs who actively involved them in discussions about available services in the community and offered choices rather than dictated a particular service or activity.
Agency has been shown to be an important component of desistance (Kemshall et al., 2021) and in particular perception of choice (Ellis & Bowen, 2017). Ugelvik (2022) has noted that “the experience of being trusted by staff can act as a powerful catalyst for desistance” (p. 624). Indeed, it has been observed that an overly restrictive regime can lead to an increase in antisocial behavior as the individual seeks to regain control over their lives (Ramsden et al., 2016; Van den Bosch et al., 2018). Approaches which incorporate individuals’ strengths emphasize their abilities rather than deficits, focusing on developing their current capabilities and resources to promote pro-social change (Bunce, 2023). Strength-based approaches foster the idea of personal growth (Ainslie, 2021) and reject notions of people being inherently bad (Fox, 2022). An emphasis on strengths promotes a sense of self-efficacy (Tyler et al., 2020). Both self-efficacy and agency nurture hope in the individual in their ability to change outcomes (Johnston et al., 2019). Significantly, this increased sense of agency, choice, and responsibility for their management and progression, reminds us how people under probation supervision value sentence management work being a two-way process, where it is “done with” them, rather than something that is “done to” them (HMI Probation, 2023). While criminal justice staff must maintain a difficult balance between rehabilitation and surveillance, where they can facilitate more supportive environments and relationships with service users, these are more effective than authoritative, surveillance-based approaches, for encouraging desistance (Beck & McGinnis, 2022). The finding that the participants reported feeling more hopeful about their future may be particularly important; hope appears to be a critical factor driving desistance from re-offending (Bartels, 2017; Nugent & Schinkel, 2016). Indeed McNeill (2016) has argued that increasing hope should be a specific target for intervention for people who offend.
Those in secure settings valued feeling safer and not having to put on a “tough front” to survive. Increased feelings of safety were highly valued and reported to have been instrumental in helping pathway users to engage with interventions (and staff), and in turn, to help them make important behavioral and psychological changes in their lives. Completion of CJS interventions is higher when staff are perceived as trustworthy, helpful, and skilled in fostering a safe environment (Sturgess et al., 2016). A safe environment removes the need to focus on self-protection and permits the re-direction of energy toward self-reflection and goals (Wanless, 2016). The psychotherapy literature identifies psychological safety as a key component for effective therapy as it promotes change by enabling disclosure, the ability to tolerate distressful feelings and take risks in exploring new behaviors (Podolan & Gelo, 2023).
Notwithstanding the positive findings, some participants indicated that they were disillusioned by the high turnover of staff, which was particularly prevalent among probation and psychology staff. A high turnover of staff results increased numbers of inexperienced staff placing experienced staff under greater pressure impacting on the effective delivery of rehabilitative services (Criminal Justice Joint Inspection, 2024). Stability of staff provides security, stability, facilitates connections and trust building both for users of services as well as for staff (Sheppard et al., 2022).
The role of staff was also a source of contention for a few participants. Notably, psychologists in some prison services were seen as individuals “behind the scenes” wielding the power to hinder and progress Pathway users for reasons that were unclear. Their role in the background to supervise staff but have limited direct dealings with the residents in these services but be able to contribute to progression reports about Pathway users left them feeling suspicious when progress was not as expected. Further, the dual role of prison officers as disciplinarians, as well as therapeutic group facilitators caused conflict. There is limited literature on the topic and what there is focuses on officers’ views around the challenges of such dual roles (Lloyd et al., 2017; Walker et al., 2018).
Another key theme that emerged from the interviews was that of participants experiencing an apparent shift in identity away from an antisocial to a more pro-social identity. This confirms findings by other authors writing about the Pathway (Blagden et al., 2023). This is important because pro-social identity has emerged as a key protective factor in the literature on desistance from crime (Paternoster et al., 2016). Rocque et al. (2016) have argued that services for people who offend can and should play an important role in helping the person achieve personal goals and facilitate activities and relationships that are pro-social with a view to nudging the person toward a pro-social identity. Nugent and Schinkel (2016) talk about the “pains of desistance” referring to the challenges of “going straight,” which can include losing previous criminogenic relationships and the excitement that, for some, may be associated with engaging in criminal acts. A new life desisting from crime can leave the individual feeling bored and isolated, with much time unoccupied and yet with a feeling less control over their lives (Nugent and Schinkel, 2016). Maintaining long-term desistance in the face of such isolation is difficult. McNeill (2012) has argued that it is unrealistic to place the complete burden of responsibility for change on the person who has offended. This is because the person can only be rehabilitated within a societal context where the others lay down the conditions under which they can be re-integrated. Therapeutic relationships may help facilitate a change in the way people in these services perceive themselves and the possibilities that are open to them in the future.
Strengths and Limitations
Our study has several strengths. Our participants were sampled from a wide range of settings. It was representative of the Pathway users in terms of age, but Black and Minority Ethnic people were underrepresented. We may therefore have failed to capture some important views. We consulted widely on the interview schedule with both professionals and service users and revised the guide accordingly, so we are confident that the questions were relevant and important. Members of the team who were supervising the qualitative work stream of the project have specific expertise in undertaking qualitative research with individuals with personality disorder within prisons and forensic settings, and the researcher carrying out the interviews had extensive experience of working in prison settings. Other members of the team had expertise in personality disorders and some were working within Pathway services. The use of case summaries allowed us to record the information in a comprehensive way, so that both commonalities and differences under theme headings were systematically investigated. Emerging themes were discussed in the Project Advisory Meetings with a view to gaining different perspectives of the material. The team was able to take a multi-disciplinary approach comprising of people of backgrounds in psychiatry, nursing, criminology, psychology, health economics and statistics, which allowed for different perspectives to be discussed and integrated in our analysis.
The study also had limitations. The sample was a convenience sample, and participants were selectively identified by psychology staff in each service, and it is therefore possible that we obtained a biased more cooperative sample. Most people in the Pathway do not receive a formal diagnosis of PD as there is no capacity to conduct detailed psychological assessments. Thus, although the criteria for entry to services is likelihood of having PD, this is only assessed on an informal basis and as result, it is possible there are individuals being managed in Pathway services who do not meet formal criteria for PD. People who agreed to participate may have had particular motivations for doing so which influenced their views. Furthermore, the participants may have been motivated to give ‘positive accounts, as they may have learnt that doing this may facilitate progression through prison systems. While this does not diminish the importance of these results, it does mean that they need to be contextualized. One caveat is that we do not know whether the broadly positive views arising from this qualitative work are reflected in reduced re-offending behavior. While it is encouraging to know that people are positive about the interventions that have been offered, and consider them helpful, the medium- and long-term effects are not yet known. Finally, we do not know how the characteristics of the interviewer (MJ)—a White, English female with a mental health nursing background—may have influenced what participants disclosed during the interviews.
Conclusion
Based on the qualitative interview data that we collected, we infer that the relationally focused management provided by Pathway services is having positive effects on the behavior and psychological wellbeing of Pathway users. The increased trust and feelings of safety reported by Pathway users appears to have been associated with more frank disclosure of information, improved engagement with staff and enhanced motivation to change. The increased sense of safety in secure services means that Pathway users are able to put their energy into thinking about their future lives rather than being pre occupied with protecting themselves.
Our findings have implications for services. The relational approach within the Pathway appears to provide a safe base, both physically and psychologically, from which people can reflect and do exploratory work around their lives and offending behavior. This in turn appears to help shift narratives and identities and open up new possibilities for the future. The Pathway does not act as a replacement for the various mandatory programs to address different aspects of offending. However, it can help engage and support Pathway users so that they are able to participate fully and meaningfully and complete such programs.
A further important finding which seems to increase engagement was that of agency. Providing people who have lost their liberty and autonomy with some level of agency could potentially help engage them in rehabilitative approaches.
Open discussions about risk did not seem to be the norm outside of Pathway services. While conversations about risk most likely do occur (at points of progression through a sentence), it seems likely that detailed discussions with high-risk people may be more useful on a relatively regular basis throughout their sentence, to clarify perceptions and expectations of them. There was some lack of understanding over the role of psychologists in PIPE services and this is relatively easily addressed in early conversations with new arrivals in these services.
There is a need for consistency in the Pathway. The high level of staff turnover is potentially detrimental to those receiving the services. Identifying strategies for retainment of staff makes sense in terms of rehabilitation of people in the criminal justice system as well as in terms of cost and morale of staff generally. An implication for research would be to explore further pathway users’ views and impact of working with officers who also have therapeutic roles in the Pathway. Perhaps the most important finding is that of safety in services. Future research should explore how exactly this is achieved given that services house together people who have shown themselves to be among the most challenging to manage within the criminal justice system.
Footnotes
Authors’ Note:
No declarations of interest. The evaluation was commissioned and funded by the National Offender Management Service and NHS England. It underwent ethical review prior to commencement by Health Research Authority. However, the content is solely the authors’ responsibility and does not necessarily represent the official views of the respective agencies.
