Pathway Progression case study

The London Offender Personality Disorder (OPD) Partnership is consortium of London NHS trusts that work with the Probation Service and other third sector organisations to deliver psychological treatment to complex high-risk offenders in the community and prisons.

This case study describes the benefits of psychologically informed partnership working to provide safe, understanding and effective interventions to support this man with complex needs.

Richard was referred to the Integrated Community Pathway Service (ICPS) Case Prioritisation Meeting (CPM) November 2021. He is a white-British Male, convicted in 1992 for murder within the context of an armed robbery. Richard was allocated to an ICPS psychologist for an assessment upon release in February 2022, into the Housing and Accommodation Support Service (HASS) project. It was noted in the referral that previous substance use concerns had been raised during release on temporary licence (RoTLs), and that a supported living arrangement in the first instance might provide a more stabilising environment in which an assessment of Richard’s support needs could be completed.

Shared understanding/formulation:

Richard and his psychologist thought together about how he developed a sense of self-worth and identity - from his lifestyle of acquisitive offending and developing a reputation for violence, which was endorsed and encouraged by his family and friends. Given the early sense of shame at his personal circumstances (growing up in poverty and facing rejection by his peers), the self-worth gained from this lifestyle likely served to protect from feelings of judgement, rejection or powerlessness. Being placed in care at a young age, due to his parents own mental health difficulties and addiction to alcohol, was considered with Richard to perhaps further his need to feel a sense of belonging, avoiding judgement and rejection, and develop an identity which enabled both safety and respect from others. Throughout adolescence and early adulthood, at which time the index offence occurred, the influence of others seems to have been important, whether this was using substances as part of a social environment and lifestyle, offending to obtain the money/possessions to fund and maintain this desired identity, or boosting self-worth and shielding against physical threats of others and the threat of shame through behaviour that garnered the respect of others (e.g. threats of violence, reputation). It is within the context of armed robbery, carried out whilst under the influence of drugs and alcohol, to fund his lifestyle and identity, that the index offence occurred.

Upon release, Richard was motivated to address and abstain from drug use, recognising that peer influence, significant boredom, and a lack of alternative coping strategies for emotions, were factors which could place him in a vulnerable position to relapse. At the time of assessment key presenting difficulties were: low mood and anxiety, relating to a sense of overwhelm at the journey ahead in the community and struggling to establish a new identity outside of previous lifestyle, feelings of low self-worth and worry about judgement and rejection from others who were perceived to have ‘matured’ whilst he felt he had work to do to prove himself to others. This related to financial instability, awaiting benefits approval, which was at odds with previous identity and lack of reliance on others and ability to present desired image of self to others. We considered the role that self-criticism plays, with Richard ruminating that he should ‘know better’ or should be doing better. As a means of coping, he would withdraw and avoid others, which in the short term might help by avoiding the situations which trigger feelings of anxiety. In the long term, we thought about how this keeps Richard away from his goals, and from developing a new sense of identity and self-worth.

Summary of support offered, and work completed to date:

Key worker support from HASS:

• Contained and supported living environment to accommodate needs relating to adjusting to life in the community following a long time in custody and previous difficulties in open conditions with drug use.

Weekly support from ICPS clinical practitioner:

• With practical matters; filing in forms and paperwork to ensure access to benefits, universal credit, to support financial stability (supporting letters provided by ICPS psychologist)
• Exploring and developing an understanding of any volunteering, training or employment opportunities Richard would like to pursue (Inclusion & Involvement (I&I) Hub referral completed – see below)
• Support with budgeting and managing finances, where financial instability and resulting impact on mood and sense of identity and self-worth relating to both wellbeing and risk of return to aspects of previous lifestyle
• As time progressed, the work with his clinical practitioner focused on exploring his values and meaningful activity [building sense of identity], working closely with the I&I hub to access opportunities which Richard has been proactive in engaging with. These sessions are also focused on noticing, naming and managing difficult emotions.

Drug and alcohol support:

• Change Grow Live (CGL): Richard has been engaging with the local drug and alcohol service, engaging with groups and reporting these spaces to have been helpful, though at times difficult due to exposure to others who are using drugs more (in terms of frequency, and breadth of substances including significant opioid use). He has struggled to remain abstinent from drugs, however has not returned to use of heroin and regularly collects his script to manage symptoms of withdrawal and support abstinence from heroin. Richard has however struggled to abstain from use of cocaine and cannabis.
• Testing from probation: The initiation of drug testing from probation, as recommended in his ICPS report, revealed positive tests for cocaine, and less frequently cannabis.
• Richard has been open to discussing this with his ICPS clinical practitioner and psychologist, developing an ongoing formulation, understanding of motivations and functions. An escalation in use was responded to by multiple professional network meetings, working across agencies (probation, NHS, HASS and the various ICPS staff members involved) to collaboratively agree a plan forward, including review meetings with Richard to jointly agree this plan.
• Sessions with ICPS psychologist: As per the above described meetings, increased contact with his ICPS psychologist was initiated, to revisit the formulation and the role of drugs in providing an escape and avoidance of difficult emotions. His sense of overwhelm and fear of failure and worthlessness, were explored.

Inclusion & Involvement hub engagement:

• Richard has been engaging well with the Maintain the Difference employment project, which is due to come to an end in March/April.
• Redemption Roasters barista training has begun, as an opportunity to further his employment skills, and offer the opportunity for employment and financial stability following the end of the MtD project.

Therapeutic intervention:

• Richard began to engage early on with Mentalisation Based Therapy (MBT) as per the recommendations of his ICPS assessment – this was to support Richard to develop an understanding of his patterns of thinking and feeling about himself and others. He described feeling overwhelmed by the volume of appointments and areas he was working on following completion of MBTi, and so the professional network were responsive and MBT was paused to prioritise i.e. employment, financial stability, relationship to drugs.
• Richard has been engaging with a series of 1:1 sessions with his ICPS psychologist following escalating lack of stability, drug use and stress and overwhelm. This has focused on an evolving formulation following disclosure of certain previously undisclosed childhood trauma as trust and rapport with his psychologist developed.
• Current therapeutic planning includes work to address the origins and impact of self-criticism, compassion focused psychoeducation relating to trauma and its impact, with plans to consider with Richard EMDR (eye movement desensitisation and reprocessing) sessions to support reprocessing of key memories underpinning sense of shame and worthlessness, formulated to underpin both the function of his drug use and past offending lifestyle.

It has been important throughout the work with Richard to ongoingly consider and revisit sequencing, meeting Richard where he is at and considering the impact of feeling overwhelmed in order to take a paced approach within his window of tolerance, being mindful of tendencies towards self-criticism, sensitively to feelings of failure, and resulting withdrawal, avoidance or drug use. Building trust, rapport and relational safety has been essential; providing reassurance, containment, and clarity around who is doing what, why, and when, rooted in a shared formulation and responsively moving towards his needs and goals. Richard has notable strengths and has worked hard and been receptive to support, and developed good working relationships with his professional network. Despite ongoing road bumps relating to a longstanding history of addiction to drugs, he is engaging well with the ICPS and his pathway plan.