“That Was a Challenging Interview!” A Guide for Interviewing Individuals Given a Diagnosis of a Personality Disorder in Forensic Settings

Phil Willmot, School of Psychology, University of Lincoln, Lincoln, UK
Sue Evershed, School of Psychology, University of Lincoln, Lincoln, UK

Extensive histories of complex developmental trauma and insecure attachment are widespread among people given a diagnosis of personality disorder in forensic settings, and are likely to be important predisposing factors that contribute to their offending behavior. In working with this population, it is important to bear this in mind, and helpful to formulate clients’ challenging behaviors as a set of learned responses to perceived threat, or as survival strategies. Such an approach not only makes the interviewing process more effective, it also helps to avoid perpetuating destructive patterns of behavior and relationship between forensic clients and people in authority. We present seven principles for effective interviewing with this population: (a) careful preparation; (b) a constant focus on the therapeutic relationship; (c) providing structure and containment; (d) adopting a flexible approach; (e) managing therapy-interfering behaviors; (f) obtaining supervision; and (g) adopting a whole-team approach.

Personality disorder, interviewing, power threat meaning framework

“…The consensus statement for people with complex mental health difficulties who are diagnosed with a personality disorder uses the term ‘people given a diagnosis of personality disorder.’ We use the term throughout this article as it is neutral as to the value or legitimacy of the label, while reflecting the fact that a diagnosis has been made, and that it is ‘given’ by others, but not necessarily accepted by the person…While interpersonal dysfunction may be common among people given a diagnosis of personality disorder, the anti-authority attitudes of forensic clients often make relationships with people in authority particularly problematic…” (p.338-339)

“As an alternative to traditional medical diagnostic categories, the Power Threat Meaning Framework (PTMF)…has been developed to enable ‘the construction of non-diagnostic, non-blaming, de-mystifying stories about strength and survival, which re-integrate many behaviors and reactions currently diagnosed as symptoms of mental disorder…’ The PTMF suggests several provisional general patterns of meaning-based threat responses to power…they represent patterns in the meaning of threat and the function of the threat response…Using the PTMF, we propose that, for clinicians working with such individual in forensic settings, personality disorder is best understood as a set of learned responses to perceived threat, or as survival strategies for keeping physically and psychologically safe in interpersonal environments that are seen by the individual as dangerous, hostile, abusive, or neglectful. Common survival strategies in forensic settings include, emotional detachment, hypervigilance to threat, hostility, and aggression…” (p.339-340).

“Perhaps the most obvious difficulty in interviewing this client group is the wide range of challenging or therapy-interfering behaviors with which they can present, both within and outside the session…Schema mode theory…describes these survival behaviors as coping modes and divides them into three categories: avoidant, over-compensatory, and surrender…People given a diagnosis of personality disorder rarely have a single mode of presentation. More often they will switch between several of these, sometimes in quick succession…Once identified, many of these can be offset or minimized by flexible planning, careful presentation of the process, and contracting that is sensitive to the client’s needs” (p.341-342).

“Arguably, all therapeutic approaches developed specifically for people given a diagnosis of personality disorder stress the importance of the therapeutic relationship. With forensic clients given a diagnosis of personality disorder this can often be the key issue in the success of the intervention…On the basis of their past experiences, clients may approach interviews with the expectation of being rejected, abused, or misled, and may respond in a hostile or defensive manner in anticipation of such treatment. By anticipating such negative responses, the interviewer can guard against responding punitively to the client’s hostility or avoidance. We have found it helpful to preempt such responses by starting the interview process with a discussion of the client’s previous experiences of interviewing, and asking what they found helpful and unhelpful in previous interviews” (p.342).

“As with any therapeutic relationship, the key facilitative conditions of empathy, congruence, and positive regard identified by Rogers (1957) are essential in working with forensic clients given a diagnosis of a personality disorder…Clients are unlikely to relate to an interviewer who feigns views they do not hold or who offers only the professional aspect of themselves. This does not imply the need for boundary breeching, but it does require the interviewer to be ‘real’ or ‘radically genuine’…having a relatively active therapist, a clear structure, and setting limits on unacceptable client behavior are uniquely important in working with people given a diagnosis of personality disorder” (p.342-343).

“Establishing and maintaining motivation and hope are essential if clients are to engage and stay engaged. However, low motivation and feelings of helplessness are common in this client group, with their histories of frequent conflict with authority and disengagement from services. Clinicians need to make extensive use of motivational interviewing techniques…to maintain a commitment to change…At times when motivation is poor, clinicians should maintain a supportive stance and attempt to reinforce motivation by exploring the consequences of maladaptive behavior, rather than adopting a more confrontational and challenging approach which is likely to further damage the therapeutic relationship and increase reactivity” (p.344).

“…Clinical supervision can also offer a restorative function for interviewers, particularly when faced with some of the more distressing an anxiety provoking behaviors…while the observation of personal limits is recommended to prevent frustration and burn out, it is also acknowledged that interviewers’ personal limits may change over time and in the face of competing demands…The process of understanding and accepting personal limits, and observing them but allowing considered extensions is best done within a supervisory context…” (p.346).

“It is inevitable in teams that different team members with different roles and different personalities will trigger different responses in individuals given a diagnosis of personality disorder. Often forensic clients, with insecure attachment patterns and long histories of conflict with authority figures, will tend to dichotomize clinicians into ‘good’…and ‘bad’…and to treat them accordingly. It is important that clinicians recognize that such thinking and behavior is, first and foremost, a transference response…Teams should ensure that their behavior toward the client does not inadvertently reinforce the client’s dichotomous thinking…by ensuring that it is not always the ‘good’ staff who give the client positive feedback and not always the ‘bad staff’ who carry out ‘custodial’ roles…Above all, team members should avoid criticizing their colleagues in front of clients, or appearing to agree with criticism of colleagues by not challenging it. It should be made clear to clients that team decisions are made by the whole team, not by individuals…(p.347).

“…Most of the therapeutic models used to make sense of the client’s presenting problems focus on an underpinning structure of maladaptive thoughts, feelings, and behavioral patterns. Without structure, there is a danger that the therapist will simply end up reacting to the client’s shifting and dysfunctional coping behaviors. If this prevents the clinician from discussing difficult or distressing issues, then this risks negatively reinforcing those behaviors. For clients with a history of abuse, structure and predictability can reduce feelings of uncertainty and predictability. It can also enable the clinician to model a relationship in which the client is able to feel contained without feeling controlled or manipulated” (p.343).

“The goals of forensic clients and what they perceive to be the interviewer’s goals may at times be very different. Particularly if the client has previous negative experiences of services, professionals, and authority, his/her own primary goals may be about survival…while their perceptions of the interviewer’s primary goals may be colored by their previous negative experiences…Clients may also be reluctant to give up behaviors that others see as dangerous and dysfunctional, such as self-harm or aggressive behavior, if those behaviors have survival value for them. It is particularly important with this client group to begin a discussion about treatment goals by asking the client what he/she wants to change. Acknowledging that dysfunctional behaviors can have value to the client may enable the client to explore the costs of these behaviors and to consider how they could be modified” (p.344).

As always, please join the discussion below if you have thoughts or comments to add!