Opportunities and challenges for formalizing community-based palliative care volunteer work: An ethnographic study.

Complex needs and mental health difficulties are highly prevalent in forensic populations (–) and many programmes have been developed to address various aspects of these difficulties (–). Within this context, the Offender Personality Disorder (OPD) Pathway was established to provide specialist resources for individuals assessed as high risk of harm who present with complex needs indicative of personality difficulties and to the staff who work with them (, ). These difficulties are usually associated with deprived, abusive, neglectful, or difficult childhoods () and can present as emotional instability or disruptive and risky behaviours that are challenging to manage within services. Since the OPD Pathway’s inception, identifying individuals appropriate for OPD services has relied upon a two-part tool on which an individual must meet set thresholds for (1) (determined by risk) and (2) (determined by clinical needs indicative of a personality disorder). While men and women were identified using different eligibility criteria (due to differences in patterns of risk and offending), the same indicators of suitability for likely personality disorder were used for both groups. Over the past 10+ years, the eligibility criteria for men have remained largely consistent whilst these have evolved for women several times, including changes to offence criteria, measures of risk, and case management status. Most notably, an organisational split within the probation service in 2014 resulted in low- and medium-risk individuals being managed by private sector Community Rehabilitation Companies (CRC) whilst high- and very-high-risk individuals were managed by the public sector National Probation Service (NPS) (). Consequently, in 2017, the eligibility criteria (risk threshold) for women were simply set as “being managed by NPS”. Reunification of probation services in 2021 resulted in eligibility criteria for women changing to a threshold of high or very high risk of serious harm or likely to need Multi-Agency Public Protection Arrangements (MAPPA) management. The initial suitability portion of the tool designed to detect likelihood of “personality disorder” was developed by Craissati and Sindall () and utilised 10 items from the Offender Assessment System (OASys) (). OASys is an electronic risk assessment and management system detailing offence and sentence information, lifestyle factors, family/relationship history, socio-economic information, and attitudes (). These suitability items were mapped to descriptors of male violent and sexual offenders meeting the earlier Dangerous and Severe Personality Disorder (DSPD) programme criteria (), with a threshold score of seven items used to indicate likely “antisocial personality disorder”. The content of these antisocial items related to impulsiveness and aggression, predatory and exploitative behaviour, and violence and recklessness. For the OPD criteria, which sought to identify a broader range of likely personality disorder than antisocial alone, four additional indicators of “personality disturbance” were identified (). These additional indicators (childhood difficulties, mental health difficulties, self-harm or suicide attempts, and challenging behaviour) were intended to account for characteristics of other potential personality disorders such as borderline and narcissistic presentations. In designing this tool, these authors stated the importance of incorporating such developmental variables to help identify adult personality disturbance, which they indicated as relating to sexual, physical, or emotional abuse; childhood behavioural disturbance; self-harm; and previous contact with psychiatric services (). Instructions to probation practitioners carrying out OPD screening noted that the presence of any two of these indicators could be used where the 7/10 threshold was not met (, ). While the 10 core items were directly linked to specific items contained within OASys, evidence for the presence of the additional indicators could be drawn from multiple sources of information, making the latter easier to populate and allowing two items to wield as much influence as seven. Where neither risk nor complexity criteria were met but an OPD clinician deemed it appropriate to admit an individual to the Pathway, an option to clinically override the screening outcome was also available.