Under the radar: Women with borderline personality disorder in prison
Matt Fossey and Georgia Black
© Centre for Mental Health, September 2010
You can download this article free of charge as a PDF from the Centre for Mental Health.
- What is Borderline Personality Disorder?
- Borderline Personality Disorder and Women in Prison
- What is the impact of prison on women with BPD?
- The impact on children
- Strategies for Intervention
- More from ‘a better way’
Women in prison are particularly vulnerable to mental health problems and self-harm (Corston, 2007). It is estimated that around a fifth of women in custody fulfil criteria for borderline personality disorder (BPD) (Singleton et al., 1998), making it a significant issue for the prison health service and an expensive drain on limited prison management resources.
Despite the principle of ‘equivalence of care’ in prison health care, guidelines for the management of BPD (NICE, 2009) are rarely observed in prisons. In addition to health care deficits, the prison environment can be traumatic for women with BPD due to the hostile, punitive environment and the experience of incarceration (Wolff & Shi, 2009).
Family environments are significantly disrupted for all women on custodial sentences, with children frequently relocated and one in ten sent into social care (Caddle & Crisp, 1997). Women with BPD often have unstable family environments prior to being taken into custody, compounding the effect of this disruption (Whisman & Schonbrun, 2009).
Looking ahead to future generations, this upset to family life may contribute to the effects of ‘transgenerational transmission’ of criminal behaviour and mental health problems (Feldman et al., 1995; Warren & South, 2009).
- Increased screening and appropriate diversion should be implemented to avoid custodial sentences where possible for women with BPD.
- Prison staff could benefit from increased training to raise awareness and improve the
quality of care in prison.
- Where custodial sentences are necessary, evidence-based therapeutic interventions
should be available to support women with BPD in prison.
- Where appropriate, evidence-based family interventions should be made available.
This policy paper is based on a review of relevant academic literature and policy relating
to borderline personality disorder within the women’s prison estate. The main findings
were complemented by interviews with two women who have been in prison and who have
a diagnosis of borderline personality disorder.
The interviews were semi-structured, giving the women the opportunity to talk about the full range of their experiences and opinions. These interviews were digitally-recorded, and then transcribed and anonymised before inclusion in this report.
Since the NHS took over health care in prisons between 2003 and 2006, there has been an
important guiding principle: that health care in prisons should be equivalent to that in communities. This has been achieved for some health conditions, but mental health problems are difficult to treat in prison due to the differences in environment, referral pathways, lower resources, greater complexity of needs and the lack of continuity of care (Birmingham et al., 2006; Niveau, 2007), and good treatment is not universally available.
Women coming into prison are almost twice as likely to have recently received help for mental health problems than men, are more likely to need help in prison for mental illness, are more likely to use prison health services and to take medication, and are much more likely to selfharm (Singleton et al., 1998; Corston, 2007).
Younger women have particularly complex, multi-faceted needs: Douglas and Plugge
(2006) report that 40% of under 17-year-olds in women’s young offender institutions (YOIs) have previously been looked after by local authorities, and 90% have left school before the age of 17. This means that in order to achieve equivalence of care, women’s prisons should take account of the differences in women’s health problems compared to men and tailor their services accordingly.
A fifth of women in custody fulfil criteria for a borderline personality disorder (BPD) (Singleton et al., 1998). Borderline personality disorder is a debilitating and distressing condition (Perseius et al., 2005), and research suggests that prison itself may make it worse (Wolff & Shi, 2009).
There are clear guidelines about the best practice in treating women with a BPD diagnosis
(NICE, 2009), which are equally applicable in prison. Specialist dangerous and severe personality disorder (DSPD) services for women in HMP and YOI Low Newton have rigorously followed these guidelines in the development of the Primrose Programme (Travers & Reeves, 2005) (See Box 1).
However, this service only accommodates twelve women at a time who are deemed to be a significant danger to society. Women in other prisons receive treatment that falls short of this standard, and receive far less than the financial resources given to those in DSPD services (Barrett et al., 2009). This paper gathers evidence from health, prison and psychiatric research about women with BPD in prisons.
When considering the provision of services for prisoners with personality disorders, political
debate and policy decision making seem to be disproportionately skewed towards those offenders who pose the greatest risk to society.A recent report by the Centre estimates that up to £60 million is spent annually on containing and treating prisoners in services for Dangerous and Severe Personality Disorder (DSPD) in only a small number of prisons and high security hospitals (Rutherford, 2010), yet DSPD is a non diagnostic term without a clinical meaning (Buchanan & Leese, 2001).
An economic evaluation argues that these services are more costly than prisons and result in a deterioration in outcomes (Barrett et al., 2009). Under 0.5% of prisoners have access to the specialist interventions offered by DSPD units due to the nature and degree of their condition, yet research suggests that 78% of male remand, 64% of male sentenced and 50% of female prisoners have a diagnosis of personality disorder (Singleton et al., 1998).
Although significant resources are directed towards interventions for male prisoners in dangerous and severe personality disorder services very little resource is used to help
women prisoners with debilitating conditions such as borderline personality disorder.
What is Borderline Personality Disorder?
The term personality disorder has been used to describe people who have “an enduring
pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture” (DSM-IV, 1994). There are twelve different types of personality
disorder (Sainsbury Centre, 2009a). Borderline personality disorder (BPD) is a diagnosis used to describe people who show “a pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsivity, beginning by early adulthood and present in a variety of contexts” (DSM-IV, 1994).
“It was like as if someone had injected me with … I don’t know speed or something, and I
was just getting out of control. I was told ‘if you don’t come off the ladder you’re going to fall off the top, you’re going to run out of rungs’.”
Many people with BPD experience a life full of emotional pain and distress (Perseius et al.,
2005). The reality of the symptoms described in the diagnostic manual is that these difficulties often lead to self-harm and self-mutilation, associated with the complexity of expressing difficult emotions (Nehls, 1999). A systematic review found that over half of people with BPD also fulfilled criteria for drug or alcohol dependence (Trull et al., 2000).
Many people with borderline personality disorder have experienced some form of childhood trauma, especially physical abuse (71%), sexual abuse (68%), and witnessing serious domestic violence (62%) (Herman et al., 1989). This leads to some of the underlying cognitions behind borderline personality disorder, for instance feeling that the world is
hostile (Silk et al., 1995).
Treatment for BPD in the community has changed in recent years following publication
of government policy implementation guidance (Department of Health, 2003). This has been further reinforced by new evidence-based guidelines, recommending longer treatment courses, a reduction in medication prescription and continuity of care (NICE, 2009).
Borderline personality disorder and women in prison
BPD is very common in prison, with a recent estimate at 30% for men and women in the US (Black et al., 2007). A decade before, Jordan et al., (1996) estimated that 28% of female prisoners met criteria for BPD in the US, suggesting this figure is stable. BPD has a high co-morbidity with other mental health diagnoses and risk factors such as substance use and selfinjury.
Women represent one-twentieth of the prison population, with the current figure at 4,420
(5.4%), of whom one-fifth are on remand (Prison Service, 2010). There was a rapid increase in numbers of women in prison from 1,180 in 1992 to 3,340 in 2002 (Councell, 2003) since which time the figure has been relatively stable. There are still concerns that there are too many women in custody (Corston, 2007; MoJ, 2007).
“… to tell the truth, the first time, I don’t even remember going into prison, I was so ill. It was only … talking to xxx, that she said ‘yeah you’ve been in prison twice’. I said, Oh!”
The female population in custody has different demographic characteristics to the male
population, with 19% being foreign nationals, and 29% being of an ethnic minority compared to 13% and 27% respectively for men (Prison Service, 2010). Half the women in prison have experienced domestic violence, and women are twice as likely as men to have experienced some form of mental illness in the year preceding their admission to custody (Singleton et al., 1998).
Sixty-five per cent of imprisoned women have substance use problems, compared to 70%
of men (Social Exclusion Task Force, 2009). Worryingly, 83% of women in prison have a
longstanding illness, compared with 32% of the general female population, and many are on prescription medication (HM Chief Inspector of Prisons, 2009).
The Corston Report suggested an agenda of radical change to provision for custodial
sentences for women. The Government has responded by addressing sentencing recommendations, alternative custodial arrangements, life skills/learning, hygiene and
self-harm programmes (Corston, 2007).
The report also highlighted that while services in the community are targeting women who are at risk of offending, for instance by providing ‘one stop shops’ (www.justice.gov.uk) and by monitoring those with mental ill health, that ethos has not translated to prisons.
The Corston Report did not mention BPD itself, but it included many vignettes about self-harm without recognising it as a key indicator of BPD (See Box 2). Despite only representing 5% of the custodial population, women represent half of all self-harming incidents in prison (Home Office, 2009).
In 2009, the Bradley Report raised concerns about the provision of mental health care
in the criminal justice system, particularly highlighting that there is no formal provision of services for people with personality disorder in prison (Bradley, 2009). This is not equivalent to the community, where specialist services for personality disorder have been in development since 2003 (Department of Health, 2003).
The report recommended that the Department of Health, the National Offender Management Service (NOMS) and the NHS develop a strategy for managing personality disorder at all levels of service, from custody to probation and in the community (Bradley, 2009). As the new strategy takes hold (Department of Health, 2009), it is a good time to address borderline personality disorder within the general context of female offender mental health.
What is the impact of prison on women with BPD?
It has been recognised that people with BPD have frequently experienced some form of
trauma during childhood, such as sexual abuse (Herman, et al., 1989). The prison environment is hostile and punitive, having been designed primarily for the male prisoner (Corston, 2007).
Prisons are predominantly staffed by men, with only 35% of prison service staff being female (Fawcett Society, 2008). Women who have experienced abuse are more
likely to feel traumatised by routine prison procedures such as body searches (Moloney
et al., 2009). This was found in a study of 800 male and female prisoners in a US study, where the greatest feelings of unsafety in prison were expressed by women with depression, anxiety, post traumatic stress disorder (PTSD) or recent victimisation (Wolff & Shi, 2009).
“Well it’s a bloody awful place. It smells like horse piss as soon as you walk in that health
care department … They’ve got so many psychiatric patients in there … They just leave
you in a cell with a hatch open and keep you in there most of the day … When you go on the blocks most of them are mentally ill and they’re all on drugs. They’re all trying to nick your drugs. They’re a nightmare. It’s a horrible place.”
The reaction of emotionally vulnerable women in prison may be to re-experience many of the features of childhood sexual abuse, namely traumatic sexualisation, betrayal, powerlessness and stigmatisation (Heney & Kristiansen, 1998; Dirks, 2004). This poses a threat to their mental and physical wellbeing, and may cause them to adopt maladaptive strategies to address the trauma of being in prison such as substance use, violence, self-injury and suicide (Heney & Kristiansen, 1998; Zlotnick, 1997).
Avoiding trauma in people with a personality disorder is important, as it directly affects their general and mental health. One study found that any type of recent victimisation was significantly associated with serious mental disorder for 48.1% of male prisoners and 47.2% of female prisoners (Wolff & Shi, 2009). Poorer health increases the disruption and ill-effects of prison for women with BPD and also raises the cost to the prison estate. People with BPD cost health services three times as much when they develop other health problems as those without BPD (Rendu et al., 2002).
“I was self-harming quite, quite a lot. And anybody who self-harms goes straight to the
hospital wing, which is horrible … just sitting there until somebody opens the cell door …
I think that that was where the self-harm got worse … basically if you didn’t go to work you’d get locked in your cell all day. It goes round in circles. Because you’d self-harmed as a punishment you’d get locked up, so you selfharm even more to get out of the cell, but they won’t have you at work because you’ve selfharmed.”
Women’s pathways to custody differ greatly from those of men, as the majority of offences
are non-violent or property related and as such rarely pose a threat to public safety Moloney et al., 2009). Women’s offending patterns are more likely to be directly affected by their families, with property crimes such as petty theft being associated with family poverty (Taylor, 2004).
“Didn’t see my son and daughter for six months which broke my heart and killed me.”
When mothers are imprisoned the impact is highly disruptive on their families, as female
prisoners are often the only carers of their children, frequently resulting in custody being
taken by grandparents or other female relatives (Caddle & Crisp, 1997; Home Office, 2004).
This is not the case for men, whose children are usually cared for by their female partners during their incarceration (Taylor, 2004). Fathers take custody of female prisoners’ children in just 9% of cases in the UK, only marginally higher than the number taken into care, at 8% (Caddle & Crisp, 1997). Around two-thirds of women in prison have dependent children under 18, and 40% of those are children under 10 years.
Women with BPD have potentially difficult family situations. This may be dependent on
the severity of BPD symptoms, as men and women with increasingly severe symptoms
experience more marital distress, commit more domestic violence and have more disruption in their marriages (Whisman & Schonbrun, 2009). Imprisoned women with more antisocial and borderline traits also show greater parenting deficits based on the Parenting
Stress Questionnaire (Warren & South, 2009).
Women with anti-social personality disorder also report difficulties with child attachment,
feeling competent as a parent and their degree of child contact. This may be a part of the
‘transgenerational transmission’ of BPD (Warren & South, 2009).
“All the effort I was making for people, you know. I send them cards and I write letters to
them and they couldn’t even be bothered. It’s like, ‘oh she’s a loon and she’s in prison. No, we don’t want to flipping know’. I just thought … what do I do now?”
The Impact on Children
There are no studies specifically examining the relationship between incarceration of women with BPD and the effect on their children. By drawing conclusions from what is known about the effects of having a mother with BPD, we can see that these children are more vulnerable to separation and family disruption. It is known that 80% of these children show a disorganised attachment pattern (Hobson et al., 2005).
Disorganised attachment is characterised by a confused relationship with the parent, usually caused by finding them frightening. Children may be dazed and avoidant at a young age, but at a later age begin to take on ‘parenting’ roles and ‘look after’ the parent. In terms of the repercussions on the child, some studies show that this may lead to aggressive behaviour (Lyons-Ruth, 1996).
There are a few studies on the children of women with borderline personality disorder, and
their findings show the effects of this diagnosis on parenting style. Children aged 4-18 years whose mothers have this diagnosis are more likely to experience traumatic events such as maternal suicide attempts, parental substance abuse, changes in custodial arrangements, moving schools and changes to household membership (Feldman et al., 1995).
The children of mothers with BPD have a higher prevalence of psychiatric diagnoses, specifically attention deficit hyperactivity disorder (ADHD) and disruptive behaviour disorders, than children of women with other psychiatric problems (Weiss et al., 1996). They also show greater anxiety, depression and low self-esteem than children of mothers without any psychiatric diagnosis (Barnow et al., 2006).
Behaviourally, these children also show more attention deficits, delinquent behaviour and aggression between ages 11 and 18 years (Barnow et al., 2006). These same risk factors are also increased for the children of incarcerated mothers in general. All of these children are similarly exposed to households characterised by dysfunction, with the incarceration of the mother providing an added trauma in addition to existing risk factors such as substance and domestic abuse in the home (Greene et al., 2000).
Drawing these results together, it seems that separation from an incarcerated mother may exacerbate negative outcomes for children whose mothers have a BPD diagnosis. Drawing more generally on what is known about the link between criminality and parental incarceration, there are five main factors to consider (Cunningham & Baker, 2004):
- Unhealthy coping strategies: Children with an incarcerated mother have great anxiety, shame and experience more violence and poverty. While coping strategies can help them to deal with these situations, those strategies are often unhealthy, such as denial, anger, self-blame, emotional numbness and alcohol or substance use. These in turn lead to greater problems in the future, and perhaps to criminality.
- Rationalisation: Children refuse to accept negative criticisms of their mother and instead blame the people expressing those criticisms. They may go further and think
that those people are malicious, that crime is sometimes noble or justified, or that their mother is a victim of a ‘system’. In some cases this may lead to a belief that going to prison is part of their family identity, and confers a ‘badge of honour’.
- Poverty: Children in poverty can have greater stress and strain, live in neighbourhoods with higher crime, have poor nutrition, and have a stronger sense of injustice.
- Lack of supervision: Children with a mother in prison often lack parental guidance which may lead to educational under-achievement, early pregnancy, job difficulties and difficult or abusive relationships. Seeking a guidance figure, children may turn to dominant community figures on the street, leading to substance use and involvement in the sex trade. These factors contribute to the likelihood of criminal behaviour.
- Associated stigma: Children of incarcerated parents suffer the stigma of criminality, with staff in the criminal justice system being prone to bias in decision making about the child. Some may believe that “the apple does not fall far from the tree” and impose higher sanctions for criminal behaviour, rather than giving them community or social service provision.
The potential economic burden of these intergenerational effects could be mitigated by effective early intervention and parenting programmes. A recent report (Sainsbury Centre, 2009b) estimates that the total cost of crime attributable to people who had conduct problems in childhood is approximately £60 million a year in England and Wales.
Strategies for intervention
In order to tackle a complex mental health problem, it first needs to be identified in a timely fashion, and then treated appropriately, for an effective period of time. In the criminal justice system, mental health diagnoses are identified either at the arrest, court or prison reception stage, but many mental health problems are missed due to inadequate screening procedures (Shaw & Humber, 2007). Black et al. (2007) conclude that correctional facilities need to systematically screen for BPD specifically, such is the impact of the diagnosis on other mental health needs in prison.
The Corston Report recommended increased attention to health care, mental health and
self-harm, but the report does not specifically address BPD. Programmes such as Carousel,
which combines group therapy with individual counselling and other activities, were
mentioned. The Government has subsequently implemented the CARE (choices, actions,
relationships and emotions) programme for self-harm at HMP Downview with the intention
of widespread use. However, these programmes are inconsistent with NICE guidelines for BPD.
Simple additions to prison procedure, such as care in transition periods, could greatly reduce the risk for women prisoners with BPD. The current lack of specific provision for BPD means that evidence-based practice for women with this diagnosis is ignored, despite the high prevalence in the prison population. The following interventions would help to tackle this problem.
The aim of prison mental health services is to screen for mental health problems at all
levels of the system: from reception screening and induction or ‘first night’ centres onwards (Department of Health, 2005). The early detection stage is extremely important as this determines the level of care provided in prison. Screening tools used at reception have been criticised, with many instances of psychiatric morbidity being missed (Birmingham, 1997). This suggests that comprehensive screening at the court stage would make a dramatic difference (Shaw et al., 1999; Bradley, 2009).
A screening programme for BPD at the stage of court trial would be able to target the 57,875 women who were charged with indictable offences in 2008 (Home Office, 2010). Of these, 14.8% are found guilty, leading to 16,440 women starting a period in custody (Home Office, 2010). Of these, 12,676 are first receptions into prison, suggesting that a high number of those screened at reception will not have been screened before.
This may benefit women who have not been diagnosed outside the criminal justice system
and therefore have not previously received any support for their diagnosis and mental health needs. In this way, the prison service can play a major role in increasing the number of women receiving help for BPD.
In order to screen and treat women with BPD appropriately, prison health care staff should
not be exempt from NICE guidelines, which state that “mental health professionals working in secondary care services, including communitybased services and teams, CAMHS and inpatient services, should be trained to diagnose borderline personality disorder, assess risk and need, and provide treatment and management in accordance with this guideline” (NICE, 2009).
Staff training and recruitment
It has been widely recognised that looking after people with a personality disorder can be
difficult, and some people are better suited to it than others (Bowers et al., 2003). By providing specialist training and setting up a supportive system for staff, most will find it easier to cope with and will be able to provide a better service. This will also save money in staffing costs, as positive attitudes towards people with personality disorder lead to improved general health and job performance, decreased burnout, and favourable perception of managers in prison staff (Bowers et al., 2006).
There are already programmes designed to train staff who are working with people with personality disorders. For example, the University of East London provides a part-time
postgraduate certificate entitled Working with People with Personality Disorders which is
aimed at staff working in statutory or voluntary sector mental health services.
The provision of support for staff working with individuals with a personality disorder is
recommended to include the following (Duff, 2003):
- Specialised induction
- Personal development plans and teaching programmes linked to organisational
- Support and supervision systems
In addition, Duff (2003) recommended that staff increase their self-awareness of their
vulnerabilities and blind-spots. They should also be more aware of people with a personality disorder diagnosis, of their perspectives and positive attributes, and be able to build on their existing skills. It is important for staff to have awareness of potential complications within the team due to the difficulties of working with people who have a diagnosis of personality disorder.
Transition periods in prison custody are high risk, with increased likelihood of suicide for
all prisoners (Shaw & Humber, 2007). Prisons protect new prisoners from harm by the
use of a ‘first night’ centre and an induction wing which are designed to ease transitional periods. Care is still lacking in transitions back to the community, however, especially for
prisoners with mental health difficulties. Rapid engagement with community mental health
services significantly reduces risk during this period (Shaw & Humber, 2007).
Equally, a specific NICE target for treatment of BPD is to take added care in transition periods. NICE guidelines say that extra care should be taken when a person with BPD has to make a transition between different sources of care due to the incurred emotional difficulty with this process. The guidelines recommend that:
- Such changes are discussed carefully beforehand with the person (and their family
or carers if appropriate) and are structured and phased.
- The care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis.
- When referring a person for assessment in other services (including for psychological
treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them (NICE, 2009).
We suggest that these detailed arrangements are made for women with BPD, in addition to the measures already taken as part of prison policy. Therapeutic interventions in prison
Treatment programmes for BPD should be based on psychotherapeutic principles. There
is a list of suggested therapeutic approaches in the NICE guidelines which includes dialectical and cognitive behavioural therapy-based programmes, mentalisation-based therapy and part hospitalisation, cognitive analytical therapy and psychodynamic therapies (NICE, 2009).
Dialectical behavioural therapy, which focuses on acceptance and behaviour change, is the only treatment that has shown consistent benefits for people with a borderline personality disorder diagnosis, according to a Cochrane systematic review (Binks et al., 2006).
In the Carousel programme, group therapy is combined with individual counselling, physical
exercise, relaxation, educational activity and art therapy. Some of this programme conforms to the guideline and therefore may be beneficial, but it is currently lacking an evidence base. NICE guidelines also suggest that psychotherapeutic interventions are embedded within a programme of strategies for associated co-morbidities such as substance use and eating disorders (NICE, 2009). It is also stipulated in the guidelines
that therapy should last for not less than three months. In remand prisons and with short
sentences this may be difficult (the average sentence is just 9.6 months), requiring
in-reach/bridge services to continue treatment in the community.
Women with BPD frequently have co-morbid mental health problems, including eating
disorders or substance use issues, and according to NICE guidelines these should be
treated under the same umbrella as BPD. A practical strategy is to have a care co-ordinator
facilitating access to BPD treatment in a way that complements substance use programmes. This strategy needs to be introduced into prisons to enable women to address multiple needs affecting their mental health.
Alternatives to prison
By diverting women with BPD from custody, the problem of inadequate mental health care
provision in prison may be avoided. There are several different schemes that enable women, specifically, to be diverted at any point in the criminal justice process. This can include diverting women with a severe mental illness to hospital under the Mental Health Act (1983) rather than keeping them in the criminal justice system.
There are also broader schemes supporting prisoners with a variety of mental health
problems and linking them to community services. A review of existing diversion schemes
found that only 2-3% of female offenders coming through the criminal justice system
were being diverted (Hunter et al., 2005), which grossly excludes the 50% of female prisoners with a personality disorder diagnosis.
The Primrose Service is the only service designed specifically for the diversion from
prison of women with a personality disorder diagnosis. But it has just 12 beds, and it is
housed within the prison system rather than a secure hospital.
The Bradley Report recommended that the Government should evaluate the existing
treatment options for personality disorder in prison including therapeutic communities, and
also that the DSPD units should be assessed to see if they are adequately addressing
prisoners’ needs. It also recommended that the Department of Health, NOMS and the NHS
should develop a personality disorder strategy that would cover management from custodial to community services for women who are serving short sentences (Bradley, 2009).
Given the considerable costs of crime attributable to conduct disorders (Sainsbury
Centre, 2009b), and the links made between mothers with BPD, incarceration and
intergenerational risk factors for crime, evidence-based parenting programmes
may be a cost-effective intervention that could have longitudinal benefits. The Centre
(Sainsbury Centre, 2009b) estimates that these programmes cost as little as £600-£900 per person for group-based therapies and up to £4,000 per person for individual interventions. The brevity of parenting programmes also means that they could potentially be delivered for women who are serving short sentences.
Recommendation 1: Where appropriate, alternatives to custody should be sought at all
stages of the criminal justice system for women with a diagnosis of borderline personality
Prison can be especially traumatic for women with a diagnosis of borderline personality disorder, due to their personal histories of abuse and victimisation. Staff should be vigilant to symptoms of BPD at all stages of the criminal justice pathway, leading to professional assessment and diversion to appropriate services.
Recommendation 2: Prison staff should be aware of self-harm as a key symptom of borderline personality disorder. This is consistent with the NICE guidelines for this
condition (NICE, 2009).
Prison staff should be given training to recognise the symptoms of borderline personality disorder, and equipped with the basic understanding and skills to manage sensitively those who self-harm.
Recommendation 3: Where possible, interventions consistent with NICE guidelines
should be offered to women with BPD in the criminal justice system.
The NICE guidelines recommend that evidencebased psychological therapies are used in
the treatment of people with a diagnosis of borderline personality disorder. The minimum
period of treatment suggested in the guidelines is three months.
Women with a diagnosis of borderline personality disorder who are serving long sentences should be given access to psychological therapies to help them to manage their condition.
Where women are on shorter sentences, therapies should still be offered and continued
after release. Adequately provisioned mental health in-reach services may provide an effective solution.
Recommendation 4: ‘Meet and greet’ care should be provided on discharge to improve
links between prison and community services.
People with a borderline personality disorder diagnosis benefit greatly from well-managed
transitions between different health care providers. A ‘meet and greet’ procedure would
avoid disruption in the provision of services. This is often ignored due to the absence of
adequate hand-over procedures between community mental health teams and prison health care. Prison health care staff should liaise with prisoners’ local community mental health teams to prepare for release.
Recommendation 5: An adequate number of trained therapists with dialectical behavioural
therapy (DBT) skills should be commissioned.
The Government is committed to delivering an increase in access to evidence-based
psychological therapies (Department of Health, 2010). Currently, Improving Access to
Psychological Therapy (IAPT) services are being introduced across England. This roll-out includes the provision of training for psychological therapists. This training should be expanded to include dialectical behavioural therapy
Recommendation 6: More research needs to be undertaken to understand the impact of
custody and family separation on women with a diagnosis of borderline personality disorder.
The lack of contact with their children and the uncertainty surrounding their custody
arrangements is a source of great distress to all parents in prison, but particularly for women. There is little specific research available in the context of women with this diagnosis.
Recommendation 7: Family-based and parenting interventions should be provided to incarcerated women with a borderline personality disorder.
Children of incarcerated women with a borderline personality disorder diagnosis are particularly at risk of conduct problems and future offending behaviour. Women with a borderline personality disorder diagnosis tend to have more disrupted families, and so require greater support to maintain a stable family unit.
By seeking suitable diversion at an earlier stage within the criminal justice pathway, family units can be maintained and the risk of disruption to children’s lives can be minimised.
Where incarceration is the only option, social services should be sensitive to the beneficial
effects of family interventions. All options should be sought to maintain the integrity of the family unit. This may include the provision of parenting and lifestyle interventions both in prison and on release into the community.
This paper was written by Matt Fossey, Centre for Mental Health and Georgia Black, Institute of Psychiatry. The authors would like to thank:
- The women who agreed to share their experie nces and stories of living with a diagnosis of borderline personality disorder in prison.
- All of the professionals who participated in the drafting of this report and contributed
their views and experiences. In particular, Michael Parsonage, Dr Chiara Samele, Claire Warrington, Lorraine Khan, Dr Graham Durcan and Max Rutherford.
Barnow, S., Spitzer, C. et al. (2006) Individual characteristics, familial experience, and
psychopathology in children of mothers with borderline personality disorder. Journal of
American Academy of Child & Adolescent Psychiatry, 45 (8) 965.
Barrett, B., Byford, S. et al. (2009) The assessment of dangerous and severe personality disorder: service use, cost, and consequences. Journal of Forensic Psychiatry & Psychology, 20 (1) 120-131.
Binks, C. A., Fenton, M., McCarthy, L., Lee, T., Adams, C.E. & Duggan, C. (2006) Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews (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) Prison medicine: ethics and equivalence. The British Journal of Psychiatry 188 (1) 4-6.
Black, D., Gunter, T. et al. (2007) Borderline personality disorder in male and female offenders 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 staff that will adjust positively and productively to working in the new personality disorder (PD) services. Report to the Home Office.
Bowers, L., Carr-Walker, P. et al. (2006) Attitude to personality disorder among prison officers working in a dangerous and severe personality disorder unit. International Journal of Law and Psychiatry, 29 (5) 333-342.
Bradley, K. (2009) The Bradley Report: Lord Bradley’s review of people with mental health
problems or learning disabilities in the criminal justice system. London: Ministry of Justice.
Buchanan, A. & Leese, M. (2001) Detention of people with dangerous severe personality
disorders: a systematic review. The Lancet, 358 (9297) 1955-1959.
Caddle, D. & Crisp, D. (1997) Imprisoned Women and Mothers. Home Office Research Study No. 162. London: Home Office.
Corston, J. (2007) The Corston report: A review of women with particular vulnerabilities in the criminal justice system. London: Home Office.
Councell, R. (2003) The Prison Population in 2002: A statistical review. Home Office Findings 228. London: Home Office.
Cunningham, A. & Baker, L. (2004) Invisible Victims: The children of women in prison. Ontario, Canada: Centre for Children & Families in the Justice System.
Department of Health (2010) Press Release 23 June 2010 Psychological therapies offered
across the NHS. (http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_116919)
Department of Health (2009) Improving Health, Supporting Justice: The national delivery plan of the Health and Criminal Justice Programme Board. London: Department of Health.
Department of Health (2006) Planning and Delivery Guide for Women’s DSPD Services
(Primrose Programme). Home Office DSPD programme. London: Department of Health and HM Prison Service.
Department of Health (2005) Offender Mental Health Care Pathway. London: Department of
Health. Department of Health (2003) Personality Disorder: No longer a diagnosis of exclusion – policy implementation guidance for the development of services for people with personality disorder. London: Department of Health.
Dirks, D. (2004) Sexual revictimization and retraumatization of women in prison. Women’s
Studies Quarterly, 32 (3) 102-115.
Douglas, N. & Plugge, E. (2006) A Health Needs Assessment for Young Women in Young
Offender Institutions. London: Youth Justice Board/University of Oxford.
DSM-IV (1994) DSM-IV: Diagnostic and statistical manual of mental disorders. Arlington
VA: American Psychiatric Association.
Duff, A. (2003) Managing personality disorders: making positive connections. Nursing
Management (Harrow), 10 (3) 27-30.
Fawcett Society (2008) Women and the Criminal Justice System: The facts. London: Fawcett Society.
Feldman, R., Zelkowitz, P. et al. (1995) A comparison of the families of mothers with
borderline and non-borderline personality disorders. Comprehensive Psychiatry, 36 (2)
Greene, S., Haney, C. et al. (2000) Cycles of pain: risk factors in the lives of incarcerated mothers and their children. The Prison Journal, 80 (1) 3.
Heney, J. & Kristiansen, C. (1998) An analysis of the impact of prison on women survivors of childhood sexual abuse. Women and therapy, 20 (4) 29-44.
Herman, J., Perry, J. et al. (1989) Childhood trauma in borderline personality disorder.
American Journal of Psychiatry, 146 (4) 490.
HM Chief Inspector of Prisons (2009) Race Relations in Prison: Responding to adult women
from black and minority ethnic backgrounds. London: HM Inspectorate of Prisons.
Hobson, R. P., Patrick, M. et al. (2005) Personal relatedness and attachment in infants of
mothers with borderline personality disorder. Development and Psychopathology, 17 (02)
Home Office (2010) Statistics on Women and the Criminal Justice System: A Ministry of Justice publication under Section 95 of the Criminal Justice Act 1991. London: Ministry of Justice.
Home Office (2009) Statistics on Women and the Criminal Justice System. London: Home Office.
Home Office (2004) Women’s Offending Reduction Programme (WORP) Action Plan. London: Home Office.
Hunter, G., Boyce, I. & Smith, L. (2005) Criminal Justice Liaison and Diversion Schemes: A focus on women offenders. Mental Health Briefing. NACRO. London: NACRO.
Jordan, B.K., Schlenger, W.E., Fairbank, J.A. & Caddell, J.M. (1996) Prevalence of psychiatric disorders among incarcerated women part II. Convicted felons entering prison. Arch Gen Psychiatry, 53 (6) 513-519.
Lyons-Ruth, K. (1996) Attachment relationships among children with aggressive behavior
problems: The role of disorganized early attachment patterns. Journal of Consulting and
Clinical Psychology, 64 (1) 64-72.
Ministry of Justice (2007) Monthly Bulletin: April 2007. Population in Custody. London: Ministry of Justice / NOMS.
Moloney, K., van den Bergh, B. et al. (2009) Women in prison: the central issues of gender
characteristics and trauma history. Public Health, 123 (6) 426-430
Nehls, 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 the principle of ‘equivalence of care’ in prison
medicine. British Medical Journal, 33 (10) 610.
Perseius, K., Ekdahl, S. et al. (2005) To tame a volcano: patients with borderline personality disorder and their perceptions of suffering. Archives of Psychiatric Nursing, 19 (4) 160-168.
Prison Service (2010) March 2010. Population in Custody: Monthly Bulletin. London: Prison
Rendu, A., Moran, P. et al. (2002) Economic impact of personality disorders in UK primary
care attenders. The British Journal of Psychiatry, 181 (1) 62.
Rutherford, M. (2010) Blurring the boundaries: The convergence of mental health and criminal justice policy, legislation, systems and practice. London: Sainsbury Centre for Mental Health.
Sainsbury Centre (2009a) Personality Disorder: A briefing for people working in the criminal justice system. London: Sainsbury Centre for Mental Health.
Sainsbury Centre (2009b) The Chance of a Lifetime: Preventing early conduct problems and reducing crime. London: Sainsbury Centre for Mental Health.
Shaw, J., Creed, F. et al. (1999) Prevalence and detection of serious psychiatric disorder in
defendants attending court. Lancet (British edition), 353 (9158) 1053-1056.
Shaw, J. & Humber, N. (2007) Prison mental health services. Psychiatry, 6 (11) 465-469.
Silk, K., Lee, S., et al. (1995) Borderline personality disorder symptoms and severity of
sexual abuse. American Journal of Psychiatry, 152 (7) 1059-1064.
Singleton, N., Meltzer, H. & Gatward, R. (1998) Psychiatric Morbidity among Prisoners in
England and Wales. London: Office for National Statistics.
Social Exclusion Task Force (2009) Short Study on Women Offenders. London: Cabinet Office.
Social Exclusion Unit (2002) Reducing Reoffending by Ex-prisoners. London: Social
Taylor, R. (2004) Women in Prison and Children of Imprisoned Mothers: Preliminary research paper. Geneva, Switzerland: Quaker United Nations Office.
Travers, R. & Reeves, S. (2005) Breaking barriers and building connections. International Journal of Prisoner Health, 1 (2) 199-205.
Trull, T., Sher, K. et al. (2000) Borderline personality disorder and substance use
disorders: A review and integration. Clinical Psychology Review, 20 (2) 235-253.
Warren, J. & South, S. (2009) A symptom level examination of the relationship between
Cluster B personality disorders and patterns of criminality and violence in women. International Journal of Law and Psychiatry, 32 (1) 10-17.
Weiss, M., Zelkowitz, P. et al. (1996) Psychopathology in offspring of mothers with
borderline personality disorder: a pilot study. Canadian Journal of Psychiatry, 41 (5) 285-290.
Whisman, M. & Schonbrun, Y. (2009) Social consequences of borderline personality disorder symptoms in a population-based survey: marital distress, marital violence, and marital disruption. Journal of Personality Disorders, 23 (4) 410-415.
Wolff, N. & Shi, J. (2009) Victimisation and feelings of safety among male and female
inmates 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 abuse among incarcerated women. Journal of Nervous & Mental Disease, 185 (12) 761-763.
More from a better way
a better way is our campaign to highlight our concerns and provoke political, media and
public 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 set
out a better way of working.
Our campaign includes the following publications:
- Public Health and Criminal Justice: Promoting and protecting offenders’ mental health
and 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
- 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 health services for offenders (July 2009)
- Commissioning Mental Health Care in the Criminal Justice System: 10 top tips for PCT
Boards (June 2009)
- A Missed Opportunity: Community Sentences and the Mental Health Treatment
Requirement (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 download
copies of these publications.
Under the radar: Women with borderline personality disorder in prison
Matt Fossey and Georgia Black
© Centre for Mental Health, September 2010
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You can download this article free of charge as a PDF from the Centre for Mental Health.