Treatment outside the

therapy room: an
experiential learning
approach to PD
awareness

Westgate Dangerous and Severe Personality

Disorder (DSPD) Unit, November 2009
Targets for today

• How can we engage DSPD participants to

promote personal progress?
• How people change: the need for insight within a
long-term process of change?
• Personality Disorder Awareness and an
Experience of Parallel Therapy (PT)
• Service-user experiences and how PT has
evolved.
• How do we assess progress?
• How can progress be maintained using PT
principles?
Conventional
treatment environments
• Conventional Offending Behaviour Programmes (OBPs)
are largely ‘classroom’ based.
• They provide the opportunity to acquire, discuss and
explore information.
• Often a good place to introduce and ‘model’ skills and
understanding.
• But give limited opportunity to generate deeper
understanding and apply this to ‘real-life’ situations.
• Knowledge and skills may be taught in isolation for short
periods and not revisited.
• Rely on participants to be solely responsible for
practicing skills once outside the classroom.
Imagine yourself as a DSPD service
user
• What traits might you have that would get in the way of
engaging in conventional OBP’s?
• Some barriers to engagement:
o Impulsivity
o Uncertain about change (can you change? do you want to?)
o Wanting to be seen in a good light at all times
o Mistrust/resentment of authority
o Difficulty collaborating with therapists
o Uncertain of release date – when will skills be used “for real”
o See things that happen to you as being beyond your control
o Low motivation
• How would this impact on your ability to learn, or
obstruct a ‘teacher’ prepared to help you develop skills?
The Goal…
• …is GENERALISATION.
• This is the process by which you will start to apply a learned behaviour in
more situations than those in which it was first learned.

• How can we make it more likely that DSPD prisoners will use
the skills introduced in the treatment ‘classroom’, in real-world
situations and scenarios…?

• …and minimise prisoners simply saying and doing what they

think the ‘teacher’ wants them to do (sometimes mistaken for
long-term behavioural change)?
Getting to the Goal
• Promoting skill generalisation is an essential part
of achieving long-lasting behavioural change.
• The Westgate Model of Change (WMC)
provides a shared language to aid discussion
about an individual’s progress in skills that target
their problem’s in life.
• It helps to generate meaningful treatment targets
– essential for assessing treatment progress.
The Basis of the WMC
• An adaptation of the Stages of Change Model (Prochaska &
DiClemente, 1982)
• Adequate problem recognition is seen as necessary before authentic
behavioural change can occur.
• Incorporates the importance of change in individual factors that relate
to:
o Personality Disorder traits
o Other traits or factors associated with offending behaviour

• Consistent with Proulx, Tardif, Lamoureux and Lussier (2000) -

before the management of need areas is effective in reducing risk,
participants need insight into how need areas contributed to the
offending process.
o Accepting the impact of treatment needs on their life is the first step
Describing WMC
Precontemplation

• No awareness of the problem and has no intention to change

• Using the Violence Risk Scale (VRS; Wong & Gordon, 2000), 98% of
current Westgate participants meeting DSPD criteria have Lack of
Insight as at Treatment Need
Contemplation

• Recognises problem areas and wants to overcome them

but relevant behavioural change is not yet evident
• Recognition of the need area as relevant to EITHER
offending, or general lifestyle is sufficient for conclusion
of contemplation
Preparation

• The impact of problem areas is recognised in general lifestyle,

offending and (ideally) personality disorder.
• There are observable indications of change, i.e. we can see
behavioural improvements.
• However, changes are recent relative to the duration of the problem
behaviour and tend not to be consistent over time or situation; lapses
are frequent
Action

• Behavioural changes seen in the preparation

stage have been consistent and stable over an
extended period of time, but have not yet been
generalised to key high-risk situations
Maintenance

• The individual is coping with need areas

• They use skills/techniques to consistently consolidate
and strengthen the gains made in the action stage.
• Changes have been generalised to high-risk situations
Lapsing and Relapse in WMC
What is Parallel Therapy?
• An activity-based group intervention developed to
complement formal, classroom-based treatment.
• Designed to reinforce treatment objectives of specific
Formal Therapy (FT) sessions through experiential
learning activities.
• An opportunity to take ‘processes’ from a classroom
environment and practice them in environments that are
closer to ‘real life’.
• Delivered by Parallel Therapists, Formal Therapists and
Complementary Regime Professionals.
• Delivered to a staff-prisoner group, which is directed by
prisoner participants.
Parallel Therapy Aims
• To promote the development of insight and skills
in the pursuit of Good Life Goals (Ward, 2002)

• To facilitate the transition of coping strategies to

everyday life

• To make the prisoner progress during treatment

observable: subject to behavioural monitoring

• To provide activities that promote therapeutic

alliance
PT Session Blueprint
• Before: Staff Preparation (1 hr).
• During: detailed session plan with generic
session structure (1 hr).
o Check In – manage things that might stop the session
being a success
o Recap – reconnect with themes of formal therapy
o Main Exercise – behavioural experience
o Debrief - ‘learning cycle’ (Kolb & Fry, 1975)
o Check Out – disconnect from the experience
• After: Facilitator Debrief and ‘write ups’ (1 hr).
 The Teeter Totter
Challenge

((
Teamwork
((
(( Traits
Today’s Exercise
• This is about developing insight into needs/PD
traits.
• Other PT exercises focus on skills generalisation.
• Task considered most relevant to a PD
conference, as it specifically targets the
identification of traits.
• Intention of helping participants transfer from a
pre-contemplative state to a contemplative state
for their need areas.
Insight as the first step in the change
process
Today’s Exercise
• The PT session is delivered in the Westgate Personality
Disorder Awareness (PDA) module.
• PDA is made up of 10 Formal Therapy classroom-based
sessions and 2 PT sessions.
• The module aims to:
o Increase participants’ understanding of personality
o Explore specific traits and behaviours associated with PDs
(including psychopathy)
o Explores diagnosis, cause, effects and implications
• Having attended PDA formal therapy sessions,
participants would have some relevant PD knowledge
when going into today’s session.
• They would have had limited opportunity to share their
reflections on their own traits.
Today’s Exercise
• 8 volunteers required to actively participate
o What different groups have we got?
o We would like to get a good mix of people
o Some minor ‘roles’ will be assigned – who wants a minor role?

• Roles for observers

o Session plans to follow the exercise
o Behavioural Checklists – pick a group member and record
observations
o Get up, wander around, observe!

• People are going to be working in close proximity - there

may be an element of physical contact
• Health & Safety
PT Session Aims
• The exercise tests the ability of participants to
accept change by asking them to adopt the role
of leader and follower

• During the de-brief participants are asked to give

supportive and respectful feedback to one
another

• By the end ….
o Participant’s should have reflected on at least one of
their PD traits.
 ?

Today’s Session Structure

• Check In
o prepare the group to focus on the current task
and leave behind any issues that might be
concerning them

• Main Exercise
o Introduce the purpose of the session
o Where will we be at the end of the session?
“Storyline”
• MTC Version
o Your team must cross to the other side of the raging river. You
have bridges, but those bridges are not stable. Your team must
manage to stay balanced as you cross the river. If the bridge dips
into the river, the river will grab the tip of the bridge, it will sink into
the river and the team will get tossed back to the river banks.

• Westgate version
o At the Westgate Unit, your group is making a transition from
needs analysis (assessment) phase to the psycho-education
(treatment) phase. You are moving forward together as a group
and as with many journeys you may encounter unknown pitfalls
and setbacks that will be destabilising for you and the group. You
need to work together as best you can to make your personal
transition go as smoothly as possible.
 ?

Session Rules
• Group must stay in direct physical contact
• You have 20 minutes to make it across as a group
• At least 2 people need to have feet on the bridge at any
one time
• If all the team make the safety of the mid-point, the first
part of the task is complete.
• The role of “leader” will be rotated around the group
• The next “leader” will either volunteer or be picked by
the group
• You will be notified when it is time for a new “leader”
 Complete the Teeter
Totter Challenge

((
Teamwork
((
(( Traits
Feedback
 Feedback
• The idea of the session is to help us explore personality
disorder traits. You are now going to give each other
feedback about how you got on. This means providing
feedback on things that people might want to think about
doing differently in the future. When giving feedback, we
do not want you to identify traits. In this exercise, it is
down to the person receiving the feedback to decide
whether it relates to their PD(s). Just make an
observation about their behaviour. Remember, exploring
behaviours associated with a trait, does not
automatically label that individual as having that trait.
• Respectful – help the recipient reflect
 Feedback
• During the session, participants may express the power
imbalance that exists when prisoners make personal
disclosures and staff do not. Remind participants that
the aim of the session is to give them the opportunity to
demonstrate insight into their PD traits. Staff disclosures
are not relevant to this objective and are unlikely to help
participants reach this objective.
• Each participant should have at least one piece of
feedback to reflect on during the debrief.
Participant Debrief
Experiential Learning Cycle
Concrete
Experience

Plan Observe

Conceptualise
Experiential Learning Cycle
(somewhat) simplified.

Experience

This stage involves the

actual ‘doing’ of the skill.
The practicing of whatever it
is that the learner is trying
learn.
Experiential Learning Cycle
(somewhat) simplified.

Experience

After the experience of the

skill, the learner ‘observes’
the consequences of their
actions.
Plan What happened when the Observe
skill was practiced?
Experiential Learning Cycle
(somewhat) simplified.

Experience

Making sense of what

happened:
Relating it to previous
experience and knowledge
Searching for understanding Observe
Generalising, abstracting
principles

Conceptualise
Experiential Learning Cycle
(somewhat) simplified.

Experience

Considering the practical

implications of new
understanding. Planning
Plan how you will put your new
knowledge into practice
Observe
when you next attempt
the skill.

Conceptualise
Reflect
Experiential Learning Cycle
(somewhat) simplified.

Experience

Applying new
understanding or
knowledge to one’s
Plan actions. Observe
Testing your ideas

Conceptualise
Reflect
Debriefs: Applying the ELC

Concrete Experience

PT MAIN EXERCISE

PT DEBRIEF
Plan Conceptualise Observe
Observe
• Ask the group to reflect:
o What was it about the task that made these
behaviours more likely?
o What were your impressions of feedback you
received from the group
o How accurately did your feedback describe
your behaviour during the exercise?
o What did you value about each members
contribution?
Conceptualise
• Ask the group to form more general ideas:
o What piece of feedback was most relevant to
you?
o How would this type of behaviour be unhelpful
for you before you came here?
o What events are likely to trigger the experience
of this trait?
o What PD trait/traits do you think the feedback
you received relates to?
o How can it help to have this insight?
Plan
• Ask the group to think about making
ideas work in practice:
o What can you do to get objective feedback on
PD traits?
o How can you use the knowledge that you have
gained today about yourselves (within therapy
and within interactions on the unit)?
Feedback from
observers
• What observations do observers have?
• How would you feel if you were doing this for real?
• What useful information can be gained from this
process?
• We currently don’t present the ELC model to our service
users before PT.
o Do you think we should?
o Is it more likely to confuse rather than support learning?
• What difficulties/challenges might exist in getting PT off
the ground?
Staff-Prisoner Consultation
Primary Research Question:

“What are the challenges facing Parallel Therapy

development and delivery at the Westgate DSPD
Unit?”
Aims:
• To better understand the perspectives of key
stakeholders.
• To use knowledge about the experience of
service users and deliverers to inform PT
development.
Study Design
• Three Focus Groups:
o Focus Group 1: Prisoners participating in PT
o Focus Group 2: Prisoners expecting to participate within six
months
o Focus Group 3: Staff with experience in delivering PT (including;
Gym, Horticulture, Formal Therapists, Discipline Staff).

• Each group ran in 2006 and repeated in 2007

• Focus group questions centring around: the purpose of
PT, experiences of activities, links to formal therapy,
Multidisciplinary Team dynamics
• Constant comparative analysis
Findings: Prisoner Responsivity
• A range of factors influenced willingness to engage in PT activities.
o ‘I’ve sometimes chosen not to go - got in a sulk’
o strong and varying preferences for Complementary Regime activities

• Many prisoners felt coerced into PT activities as a mandatory aspect

of treatment

• Success of session heavily dependent on the cooperation of the

group
o Prisoners can ‘overpower what is going on in the session’

• Staff reported difficulties promoting engagement

o Knowledge deficits of individual responsivity needs – poor use of
responsivity plans
Findings: Teambuilding
• Breaking down barriers with staff
• Building trust within the group
• Having fun within treatment
Findings: Blurring of PT
objectives
• Prisoners focused on secondary objectives
o (“team building” rather than “skills building”)
• Some prisoners “stick” on the physical tasks
rather than “look at the emphasis, or the learning
points”
• Affirming therapeutic targets in abstract, fairly
contrived group exercises is difficult - the
environment needs to be more real.
• Some activities stereotyped as having “childish”
task content of “low personal relevance”.
Findings: Personal Relevance
• Prisoners want ‘personal relevance’
o difficult with ‘low ropes-style’ teambuilding tasks.
• What can be achieved within a maximum security
setting?
• Broaden scope of PT to individualised and more flexible
methods of reinforcing treatment objectives
• PT on unit landings would be well supported by most
prisoners
o Better application of skills development to the everyday lives of
prisoners
How can we promote skills?
Making Changes to PT
• Development of a coaching service

• A ‘purer’ apprenticeship model

o conscientious skills-building training based around the needs and
interests of the individual
o set in the context of a wider treatment framework

• Retain the principles and structure of experiential

learning…
• …move away from abstract scenarios in groups
• ….to working on an individual basis
• …on realistic, personally meaningful scenarios
Making Changes to PT
• Prisoners have access to a member of
staff identified as a ‘coach’
• The aim of the coaching is to work at
‘ground level', alongside the prisoner on
targets identified during needs analysis
• Assisting the prisoner in use of the
experiential learning cycle to put skills into
practice
Making Skills Practice Real

• A “behavioural experiment” approach involving

meaningful scenarios where skills and ideas can
be tested
• Scenarios need to be ‘authentic’…representative
of their lives/interests (e.g., dealing with conflict
arising from domestic issues on the units)
• Reflecting on the experience of new skills and
the results of applying these promotes the
development of more positive ideas about
managing needs and personality disorder traits
How do we know
progress is real?
• The Westgate Individualised Treatment Needs Analysis and
Progression (WITNAP) sets pre-treatment targets against which
progress is measured
• The WITNAP report, provides a rationale for why the prisoner has
been categorised as DSPD and sets out a plan to for managing risk,
need and SPD
• The report includes:
o feedback from behavioural monitoring (incl. observations from WITNAP-
PT)
o findings of collaboratively disclosed psychological tests
o offence analysis
o the findings of validated structured clinical judgement assessments of
risk and PD (e.g., VRS, HCR-20, PCL-R, IPDE, etc)
o a systematic formulation of the functional links between the individual’s
personality disorder traits and offending behaviour
o a plan for dealing with barriers to treatment (a responsivity plan)
Assessing progress
• The assessment of change made in relation to pre-
treatment WITNAP baselines is conducted at a number
of junctures in treatment through the WITNAP Update
process.
• WITNAP Update involves collaborative discussions
about the attainment of pro-socials skills, and the
relationship between these and pre-treatment needs.
• This provides an opportunity for clinicians and
participants to develop a shared understanding of
ongoing difficulties, and areas of skill development.
• In this process, the WMC is used to enable both parties
to exchange ideas about the progress of the participant
in achieving successful change.
The Next Step
• The Westgate Unit is just one part of the "end-to-end-management” of
Personality Disordered offenders

• In a 5 year period our aim is to:

o identify a participant’s PD(s) and the functional links between these and their
risk.
o encourage contemplation of these factors.
o explore motivation for [and barriers to] change.
o introduce coping-strategies/management techniques.
o begin to explore these skills in practice [encourage a systematic means of
experimenting].
o encourage participant’s to begin linking skills to risk.
o prepare them for a move to a site where they are the active agent in skills
development/testing.

• Accurately communicate to progression sites the progress and needs of the

offender’s they will receive
How do we maintain change?
‘Graduating’ the
Westgate Unit
• An “Exit Report” is completed summarising the progress
made
• Situational factors likely to raise or lower risk are
highlighted, future recommendations are made and
progression pathways are identified
• The prisoner is referred on to site established as a What
Works Informed and Resourced Environment (WWIRE)
• This ‘graduate’ pathway begins with an initial Handover
& Induction Session involving Westgate Treatment &
Progression Staff, a Westgate Coach, and (from the
receiving establishment) the DSPD Liaison and a
Westgate-trained Progression Coach
Coaching in Progression
Sites
• Initially monthly meetings will take place with the
Progression Coach
• Westgate deliver training to Progression Coaches in the
Westgate Skills Directory and the Coaching
methodology
• Coaches can be any staff with the right competencies.
• Coaching at this stage is essentially a scaffolding role,
supporting the prisoner as he tries to maintain or
improve behavioural change
• Monthly meetings encourage reflection on the process
of applying skills…increasing his responsibility and
capability
What have we done today?

• Explored the need for engaging treatment

methods to promote progress
• Explored the need for insight within a long-term
process of change
• Learnt about and experienced PT as a way to
promote insight
• Discussed service-user experiences and how the
PT has evolved.
• Introduced a method of assessing progress
• How progress can be maintained using PT
principles
Contact Us!
• General Enquiries regarding any content in this
presentation
o jason.morrisa1@hmps.gsi.gov.uk

• Enquiries relating to PT Coaching and DSPD

Progression Pathways
o jamie.moffitt@hmps.gsi.gov.uk

• Enquiries relating to the Westgate Model of

Change
o Claire.Power@alderhey.nhs.uk