Working with offenders with ASPD: an evaluation of potential difficulties and treatment strategies in probation settings
1PSY633: Forensic Psychology (Stefanie Oliveira Antunes, w149785401)
CONTENTS
I. Introduction 3-4
1. What is Anti-Social Personality Disorder?
i. Definition
ii. Symptoms and diagnosis
iii. Causes: Who is at risk?
2. Antisocial Personality Disorder and crime
II. Potential difficulties in working with offenders with ASPD 5-6
1. Co-morbidity
2. Typical offender’s personality profile
3. Family history and attachment issues
4. Issues in the criminal justice system
III. Treatment programs: an evaluation 7-8
1. Psychological treatment approaches
i. Benefits
ii. Disadvantages
2. Pharmacological treatment approaches
i. Benefits
ii. Disadvantages
IV. Recommendations for work with ASPD offenders in probation 9-10
1. Choosing an appropriate treatment approach
2. Training of staff
i. Spotting deception
ii. Resisting and withstanding abuse
iii. Considering individuals’ needs and preferences
iv. Developing a safe relationship
v. Develop social support network
V. Conclusions 11
VI. References 12-14
I. Introduction
This report aims to provide an insightful guide for working with offenders with antisocial personality disorder, especially in probation settings. It will attempt to explain the disorder in-depth, identify the main difficulties in working with sufferers, evaluate current treatment programs and conclusively provide expert recommendations to best care for these patients.
I.1 What is Anti-Social Personality Disorder?
I.1.i) Definition
Antisocial Personality Disorder (ASPD) is a mental illness characterized by sociopathic behaviour towards others, lack of guilt and disregard for rules, social norms and morality (National Health Service, 2015). Affected people will often behave recklessly, impulsively and irresponsibly, which is why it is highly prevalent in criminal offenders (Loeber & Hay, 1997). However, ASPD, like any personality disorder, exists on a spectrum and not every individual will commit serious crimes (Aggarwal, 2013).
I.1.ii) Symptoms and diagnosis
According to the DSM-5, individuals with ASPD will show a blatant disrespect for others without guilt or remorse, either through manipulative deception for self-amusement, irresponsible, aggressive and impulsive behaviour or difficulties in obeying rules. Age is an important criterion for diagnosis: disordered behaviour needs to be present before the age of 15 and persist into adulthood. Furthermore, antisocial behaviour should not be due to other mental issues, such as bipolar or schizophrenic disorders (American Psychiatric Association, 2013). Individuals with ASPD tend to have low tolerance for frustration, resorting to violence easily, and are described as charming and self-confident, traits used to manipulate others (Aggarwal, 2013). Maintaining long-term relationships and controlling emotions (especially anger) are equally difficult. An individual with ASPD is also likely to lead an irresponsible lifestyle, leading to negative consequences (NICE, 2013).
I.1.iii) Causes: Who is at risk?
Statistically, men (3%) are more likely to develop ASPD than women (1%) (Hines, 2004). There is no unified cause for this disorder, but it has been associated with low levels of serotonin and underdevelopment of the limbic system, responsible for impulse control (Nolen-Hoeksema, 2008). Environmental causes include traumatic childhood experiences, parental alcohol misuse or separation, and abuse resulting in difficulties in forming relationships (Mendez, 2009). ASPD tends to be diagnosed more frequently in children from low SES background and with lower levels of education. There is vast evidence for a genetic predisposition for ASPD (Goldstein et al., 2012).
I.2 Antisocial Personality Disorder and crime
Antisocial personality disorder has been linked to crime: Fridell et al. (2008) found that patients diagnosed with ASPD were two times more likely to commit thefts and other crimes and could be predisposed for substance abuse and subsequent criminal behaviour. Similarly, Kranzler et al. (1997) found that offenders with ASPD tended to spend more days in jail due to trouble complying with the strict lifestyle imposed. Recent reports by the Ministry of Justice (2011) suggest that ASPD might affect up to 70% of incarcerated offenders, making the development of a treatment program urgent to guarantee effective probation services.
II. Potential difficulties in working with offenders with ASPD
Antisocial personality disorder was long considered untreatable, mainly due to the difficult behavioural profile of typical individuals with ASPD. This section will elaborate the difficulties in working with offenders with ASPD.
II.1 Co-morbidity
ASPD is likely to coexist with narcissism, sadism or borderline personality disorder, but is also highly comorbid with anxiety (almost 50% of individuals with ASPD) and depression (Derefinko & Wideger, 2008). Furthermore, according to Jones (2010), 84% of individuals with ASPD display signs of substance abuse and reversely, 14% of alcohol and 18% of drug abusers have shown signs of ASPD. Tackling personality disorders without consideration for comorbid issues is unlikely to be successful.
II.2 Typical offender’s personality profile
The characteristic behavioural patterns of individuals with ASPD, namely aggression, deceitfulness and manipulation, can be problematic in probation. Offenders with ASPD are likely to be hostile towards the system and new settings and unable to form healthy attachment to the staff (Aggarwal, 2013). Furthermore, characteristic lack of behavioural control and impulsivity might interfere with the treatment approach: the need for instant gratification is unlikely to be satisfied in treatments in probation settings that require longitudinal accompaniment. Individuals with ASPD have marked difficulties in obeying social norms, rules and laws, leading to criminal issues in the first place. Therefore, treatment plans for offenders with ASPD need to acknowledge that individuals might compulsively work against the treatment.
II.3 Family history and attachment issues
Although not applicable to every case of ASPD, most sufferers tend to have traumatic childhood experience or negative relationships to caregivers, resulting in insecure attachments mirrored in other relationships. However, forming strong interpersonal relationships is the key predictor of treatment effectiveness (Dryden & Reeves, 2013). Due to the characteristic manipulative aspect of ASPD, it is possible for offenders to lose their support system, which can be problematic for the post-probation effectiveness. Taking a social and family history of offenders is key to understanding their thinking (MOJ, 2011).
II.4 Issues with the criminal justice system
A large part of individuals with ASPD only receive treatment once they are already involved with the criminal justice system, either in prisons or probation services (NICE, 2013). However, places available for these services are highly limited and it is likely that only the most severe cases will benefit from interventions, that are likely to be insufficient due to the lack of qualified staff. Furthermore, these services will focus on reducing offending behaviours rather than the underlying issues, such as childhood trauma (Landenberger & Lipsey, 2005).
III. Treatment programs: an evaluation
III.1 Psychological treatment approaches
III.1.i) Benefits
In most cases, support for offenders with ASPD is delivered through cognitive-behavioural therapy to address the most evident issues, impulsivity and affect. In these sessions, individuals are taught essential skills to prevent harm to self and others through anger management (Davidson et al., 2008). Several analyses suggest that CBT, administered either individually (Dugan & Everett, 1998) or in a group (Austin et al., 1997), can be effective in dealing with substance misuse issues and reducing the number of offences in combination with probation. Group-based interventions yield a high success rate by re-socialising offenders in an intimate community (Alemi et al., 2006).
III.1.i) Disadvantages
First of all, psychological approaches are expensive: estimates of costs per adult benefitting from CBT over a year average £38,000 (NICE, 2013). Furthermore, studies have also shown that while this treatment is effective, there is still a 40% re-offending rate (Ministry of Justice, 2011). Similarly, non-compulsory treatment programs for adults with ASPD have high attrition rates, due to the highly impulsive nature of the disorder. Nonetheless, while psychological approaches are costly in relation to their efficiency, they may be cost-effective by reducing costs associated with offending behaviours in the long-term (Davidson et al., 2008).
III.2 Pharmacological treatment approaches
III.2.i) Benefits
Psychological approaches tend to be more or equally as effective as pharmacological treatments (NCCMH, 2004). However, due to potential biological and neurochemical causes of ASPD, treatment plans are increasingly integrating pharmaceutics to help sufferers. Keller et al. (2005) found that it is especially offenders with ASPD and no history of abuse benefit from pharmacological interventions, mainly using nefazodone, a serotonin-targeting anti-depressant. Other anti-depressants, (SSRIs, MAOIs, tricyclic) have been shown to have similar advantages. Similarly, low doses of antipsychotic medicine have been shown to relieve cognitive distortion in ASPD (Goldberg et al., 1986). Anti-convulsive medication can be used to target ASPD-related aggression (Barratt et al., 1997). Medication does not eliminate the disorder, but could provide a stable basis for psychological interventions to be effective.
III.2.ii) Disadvantages
Pharmacological treatments can potentially lead to substance misuse, as a core symptom of ASPD is the vulnerability to substance abuse. Strict monitoring of ASPD offenders who have been prescribed medication would use a substantial part of limited resources and incur a high cost. Furthermore, if the individuals with ASPD are already taking other drugs, there is a high risk for efficiency-reducing interaction. Finally, the NICE (2013) suggests that most studies have only found a small effect in reducing symptoms through medication. Depending on the case, pharmacological interventions may bear more risks than benefits and their use needs to be carefully evaluated on a case-to-case-basis.
IV. Recommendations for working with offenders with ASPD
IV.1 Choosing an appropriate approach
Antisocial personality disorder exists on a spectrum and therefore, there is variation in symptom severity and range across cases. When deciding between individually or group-administered psychological or pharmacological treatments, it is essential to gather an extensive familial, social and offending history and get a clear overview of comorbid diagnoses. Psychological treatment approaches are most beneficial for offenders with ASPD who have comorbid issues, and for those who could benefit from resocialisation in small communities (Landenberger et al., 2005). Pharmacological therapy should be used with care to tackle especially severe comorbid disorders, but also bears certain risks. A combination of both can be considered.
IV.2 Training of staff
IV.2.i) Spotting deception
Individuals with ASPD, especially at the high end of the spectrum, are likely to use manipulation or deception throughout their engagement with their therapist at some point (Alemi et al., 2006). Staff dealing with these individuals need to be trained to spot deceitfulness early to avoid providing a platform. Through extensive screening and professional emotional distance, staff can improve attention and awareness of potential manipulation attempts (NICE, 2013).
IV.2.ii) Resisting and withstanding abuse
ASPD patients are also likely to attempt to harm others for pleasure (Derefinko et al., 2008). Staff dealing with these individuals need extensive training in dealing with emotional or physical abuse and external supervision and support from mental health professionals. It is important to recall that the offenders have a mental disorder and are not in control of their behaviour as others would be. Distancing oneself from expectations and close emotional attachment can help develop resilience to potential abuse.
IV.2.iii) Considering individuals’ needs and preferences
ASPD makes obeying rules hard. To guarantee the best results when working with offenders with ASPD, simply sticking to a strict treatment plan is likely to be unsuccessful. Instead, setting up some rules that can actually be broken and others that are more rigid can provide some gratification for sufferers of ASPD while simultaneously establishing boundaries. Use of sanctions within reason is inevitable to maintain discipline and can support the development of moral understanding without further antagonising the offender (Fridell et al., 2008).
IV.2.iv) Developing a safe relationship
Individuals with ASPD tend to have issues in maintaining long-term relationships due to self-sabotage. Therefore, the relationship to the therapist needs to be trusting and mutually respectful, as it forms the basis and a learning platform for further relationships. Caution is advised: manipulation is always a risk when engaging with individuals with ASPD. As far as possible, any disruption to this relationship, for example through transfers to different institutions, should be avoided, as it will considerably strain the individuals’ ability to trust and care for others (Austin et al., 1997).
IV.2.v) Develop social support network
While work with offenders during probation should mainly focus on the individual, involving close friends and family in the process can guarantee support for the offender after probation ends. Involvement of the close support circle can range from simply discussing the implications of the diagnosis to teaching valuable skills in dealing with the patients (Davidson, 2008).
V. Conclusions
Working with offenders with antisocial personality disorder can be challenging due to its inherent nature. Individuals tend to display characteristic symptoms: disregard for rules and irresponsible behaviour towards others and self, hence being commonly found amongst criminals. To improve work with these offenders and reduce re-offending risk, it is essential to identify the main difficulties of this work: ASPD’s high co-morbidity with various other issues, potentially adherence-hindering behavioural patterns displayed by the individual with ASPD, potential childhood and attachment issues, difficulties in complying with rules and general issues with the criminal justice system.
The two most common treatment routes for ASPD, psychological and pharmacological approaches, attempt to address these issues. Both have advantages and disadvantages, but treatment approaches for ASPD do not attempt to “cure” the disorder, but rather manage the symptoms to increase life quality of the sufferer.
Based on these conclusions, recommendations for working with offenders with ASPD, especially in probation settings seeking rehabilitation and offending reduction, include guidelines for choosing appropriate treatment routes and staff training. Staff dealing with offenders with ASPD need to be aware of deception, develop resilience to withstand abuse, work with the individual’s preferences, aim to develop a trusting relationship with the offender and consider the solidification of a social support circle by involving close friends and family.
However, it is important to highlight once again that ASPD exists on a spectrum and therefore, these recommendations need to be implemented with respect to severity of the disorder and willingness to contribute. Antisocial personality disorder is still one of the most challenging issues in probation settings and only continuous research will yield more generalizable recommendations for work with these individuals in the foreseeable future.