Correctional psychologists treating women offenders diagnosed with Borderline Personality Disorder (BPD) in institutional settings are faced with the challenge of doing so in a way that is sensitive and responsive to offender characteristics and needs yet is effective and comprehensive in addressing the range of BPD features and co-morbid diagnoses. The gendered and multifaceted nature of BPD warrants consideration of a brief therapeutic approach that is integrated and woman-centered. This article presents a case example to illustrate how the use of such an approach in the context of brief individual therapy may effectively and holistically address BPD features, co-morbid diagnoses, and cultural issues in women offenders. Conclusions and future directions concerning the use of this treatment approach are highlighted.

Introduction

The Diagnostic and Statistical Manual of Mental Disorders² defines BPD as a pervasive pattern of instability in one's relationships, self-image, emotions, and impulses that disrupts daily functioning. The gendered nature of this disorder is obvious; it is predominantly women (approximately 75%) whom are diagnosed with BPD. Some defining features of BPD are as follows: (a) real or imagined abandonment by others; (b) intense relationships marked by idealization and devaluation; (c) impulsivity expressed as substance abuse; (d) suicidal thoughts or behaviours; and (e) outbursts of anger. BPD is often co-morbid with psychological diagnoses of post-traumatic stress disorder, major depressive disorder, and substance dependence disorder.

Treatment issues

Variability in treatment outcome may occur due to specific factors such as matching style and mode of therapy to reflect offender personality and learning style (e.g., responsivity) and the intensity of intervention to the risk level of the offender. Correctional psychologists treating women offenders with BPD especially need to consider how to provide psychological service in a way that balances institutional resources and matches offenders' personal, psychological, and correctional needs. Guiding principles and characteristics of what constitutes "good correctional intervention" with women offenders include the following: cognitivebehavioural focus; self-empowerment and connectionist emphasis; multifaceted interventions with theoretical underpinnings; criteria for selection of specific therapeutic strategies; genderresponsiveness and cultural awareness³

An Integrated and Woman-Centered Approach to Intervention

Although Correctional literature on women offenders has featured articles on innovative treatment programs that tap BPD features, there is little available literature featuring interventions that target BPD features and co-morbid diagnoses. This suggests a gap in the literature. Accordingly, this article presents an integrated and woman-centered approach to intervention as a way of achieving goodness-of-fit in terms of tailoring specific treatments to women offenders' personal characteristics, special needs, and cultural issues in order to enhance treatment effectiveness. This article by no means offers a comprehensive review of BPD treatment. Rather, it focuses only on an integrated and womancentered intervention comprised of Dialectical-Behaviour Therapy (DBT) as a primary approach and therapeutic letter-writing (TLR) (i.e., client letterwriting between sessions) as an adjunct strategy in the context of brief individual therapy.

DBT is a broad-based cognitive-behavioural therapy developed specifically for BPD, a core component of which is psychosocial skills training⁴. Psychosocial skills training enhances client interpersonal and emotional functioning. Some skills include: 1) Core mindfulness - balancing clients' logical and emotional thoughts by objectively observing situations, focusing on the moment, and being effective, 2) Interpersonal effectiveness - challenging clients' negative expectancies regarding their relationships and themselves by asking for what one needs, saying no, and coping with interpersonal conflict, 3) Emotional regulation - encouraging clients how to identify and appropriately express emotions, decrease emotional stressors, and increase positive emotions, and 4) Distress tolerance - teaching clients to tolerate and survive crises by distracting and self-soothing, pro/con thinking, and altering situations.

Letter-Writing strategy

Therapeutic Letter-Writing (TLR) is a strategy grounded in both narrative and feminist therapy approaches. Narrative therapy proposes that clients "write their own story" based upon their own perceptions and suggests that TLR facilitates client change in the process of exploring experiences, expressing emotions, and increasing self-awareness⁵. Feminist therapy suggests that TLR can be a powerful therapeutic tool in helping women who are sexual abuse survivors explore their experiences and express their emotions safely, develop self-esteem and self-empathy, and empower a sense of selfsufficiency⁶. TLR may empower a client by helping her break the silence she experiences as a consequence of harboring secrets of abuse or neglect. TLR may help a client discover her "voice" and provide for her an opportunity to engage in reflection before communicating with other family members who neglected or abused her or with whom she is experiencing interpersonal conflict. Although group and process based writing has typically been used in women's correctional institutions and shown to be effective in enhancing personal growth and healing, there is evidence suggesting that TLR can be equally effective when used in individual therapy⁷

The following case example is typical of what correctional psychologists may encounter in a women's correctional institutional setting. The case example is based on an actual therapeutic encounter with a woman offender diagnosed with BPD. The intervention used is an integrated and womancentered approach in the context of brief individual therapy. DBT was the front-line treatment and TLR was introduced from a feminist perspective as an adjunct.

A Case Example Illustration

"Niaomie" (a pseudonym) was an 18-year-old Aboriginal woman offender charged once again with drug trafficking. She was incarcerated in a correctional institution in Western Canada. Shortly after being incarcerated she was referred to counseling for depression and suicidal ideation concerns. At intake she reported a history of child sexual abuse by her stepfather. She attributed her personal problems to mother-daughter conflicts, drug and alcohol addictions, and prior offences. Niaomie reported that her mother had "abandoned" and neglected her in childhood and adolescence. She stated that she felt alienated from her mother because her mother did not stop the sexual abuse and blamed her for the abuse. Niaomie stated that she abused drugs and alcohol to cope with the sexual abuse and the non-support from her mother. Niaomie was diagnosed with BPD and displayed notable features such as abandonment beliefs, idealization and devaluation of others (mother), impulsive substance abuse, and explosive anger.

Aprimary treatment goal for Niaomie was to improve communications with her mother specifically and to increase her sense of social support generally. Within the framework of DBT, Niaomie worked on: social skills building specific to her relationship with her mother, enhancing her ability to develop a support system, and attempting to be self-supporting. Core schemas linked to depression and suicidal ideation were identified, explored, and challenged in reference to her past abusive experience, present relationship with her mother, and future goals to stop the "vicious cycle" of her addictions and offending behaviours. Niaomie came to see connections between mother-daughter conflicts, depressive symptoms, and impulsive/self-destructive behaviours. Core beliefs of personal worthlessness and social ineffectiveness were addressed.

TLR was introduced from a feminist perspective to help Niaomie seek self-connection and connection with her mother. Letter-writing to herself after therapy sessions acted as a "snapshot" and captured Niaomie's own thoughts and ideas that were clear to her during the session. She was encouraged to refer back to this information to help her counter her "black-and-white" thinking and negative emoting. Writing letters (but not sent) to her mother helped Niaomie explore feelings of anger and betrayal related to her experiences of abuse and abandonment. For Niaomie, TLR became a starting point for further discussion and conflict resolution with her mother. Through the letter-writing process, Niaomie discovered her "voice" and in doing so developed empathy for herself and for her mother. She gained a new perspective (i.e., reframing) of her abuse and abandonment experiences and came to see that she could receive caring and support from the person (mother) by whom she had felt most betrayed. Given Niaomie's Aboriginal heritage of story-telling, she was encouraged to consider the benefits of "telling her story" in another way that was emotionally safe for her such as circle sharing.

A secondary treatment goal was to help Niaomie stop the cycle of her addictions and offending behaviours. Within the DBT framework, Niaomie learned more about the potential effects of her drug and alcohol abuse on her body, mind, and spirit. The latter was of particular interest to her given her Aboriginal heritage. She learned stress, anger, and crisis management strategies to help her to consider heal their ways of coping with stress and anger and to develop distress tolerance. Consequential thinking exercises helped her to realize that her addictions drove her criminal behaviours. She could see more clearly how her feelings of pain and anger acted as precursors to drug and alcohol abuse and subsequent criminality.

Niaomie reported improved communications with her mother attributed psychosocial skills building and letter-writing. Niaomie credited the DBT approach generally and the feminist-focused TLR strategy specifically in helping her develop the skills needed to resolve conflicts with her mother and to develop skills to make her life better. She reported improved mood, confidence in managing her emotions, and awareness of risk factors for future substance abuse and re-offence. It was her intent to continue applying what she learned in therapy in working towards better life quality.

Conclusion

As illustrated in this article, correctional psychologists treating women offenders with BPD may consider the resourcefulness and effectiveness of using an integrated and woman-centered approach to intervention as a means of balancing institutional resources and matching offenders' personal, psychological, and correctional needs. An advantage of this approach is its comprehensiveness in addressing the multifaceted and gendered nature of BPD. Arelated advantage is its flexibility in terms of treating co-morbid diagnoses and touching on cultural awareness. Afuture direction for practice and research is to establish the effectiveness of integrated and/or woman-centered treatment approaches while taking into account special needs and social/cultural issues of women offenders with BPD or other personality disorders⁸.

¹ 11151-178th Street, Edmonton, AB T5S 2H9; Department of Psychology, University of Regina, Regina, SK S4S 0A2.

² American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: Author.

³ Serin, R. C. (1995). "Psychological intervention in corrections" in T. A. Leis & L. L. Motiuk (Eds.), Forensic psychology: Policy and practice in corrections, 36-40. Ottawa, ON: Correctional Service of Canada. Also see Bloom, B. (1999). Gender-responsive programming for women offenders: Guiding principles and practices. Forum on Corrections Research, 11(3), 22-26.

⁴ Linehan, M. M. (1993). Cognitive behavioral therapy for borderline personality disorder. New York, NY: Guilford Press.

⁵ Payne, M. (2000). Narrative therapy: An introduction for counsellors. Thousand Oaks, CA: Sage.

⁶ Lepine, D. (1990). Ending the cycle of violence: Overcoming guild in incest survivors. In T. Laidlaw & C. Malmo (Eds.), Healing voices: Feminist approaches to therapy with women, 272-287. San Francisco, CA: Jossey-Bass.

⁷ Stino, Z. H., & Palmer, B. C. (1998). Improving self-esteem of women offenders through process-based writing in a learning circle: An exploratory study. Journal of Correction Education, 49, 142-151.

⁸ Strauss, S. M., & Falkin, G. P. (2001). Social support systems of women offenders who use drugs: Afocus on the mother-daughter relationship. American Journal of Alcohol Abuse, 27, 65-89.

Submissions for publication in FORUM

Recently, we have received articles for publication in FORUM that do not follow the Guide for Prospective Authors. In future, articles that do not meet these guidelines will be returned to the originator for the necessary adjustments. When forwarding your article please:

• include the data points for any figures in your article;
• include a mailing address for the authors; and
• ensure the diskette is enclosed along with two paper copies of the article.