Re-entering the community following a prison sentence is a critical period for rehabilitation, especially for people in prison with a likely diagnosis of personality disorder. A joint health and criminal justice initiative across England and Wales, called the Offender Personality Disorder (OPD) Pathway, aims to support individuals with a likely diagnosis of personality disorder with services across different prison and community settings. Pathways Enhanced Resettlement Services (PERS) are OPD services operating in five open prisons in England, which aim to support people at high risk of being returned to closed conditions or reoffending in the community after release. We aimed to understand how service users and staff experience PERS. We purposively selected staff and service users within male prisons to encompass a range of staff roles and current and ex-service users. We conducted semi-structured interviews with ten staff and nine service users (seven current and two ex-service users). We conducted a reflexive thematic analysis, generating three themes: (1) "A shock to the system": this theme describes the challenges of adapting to open prison culture as a liminal space between closed conditions and the community; and understanding and accepting PERS as a service to provide support within and beyond that space. (2) "We've got some understanding of their journey": This theme describes how service users felt valued by PERS support that was centred around their needs, a personalised approach that enabled the development of trusting, therapeutic relationships. (3) "Internal states can be real barriers to progression": this theme describes how PERS staff were able to use the therapeutic relationships they developed with service users to support them to progress through their sentence. Staff and service users felt that PERS provided support to progress through open prison, largely by developing positive trusting relationships and individualised support plans.

Objectives To test whether individuals identified as having a likely personality disorder and high reoffending risk, who opted in to psychologically informed support in minimum security prisons (Pathways Enhanced Resettlement Service (PERS)), were (a) less likely to return to more restrictive closed prison conditions, and (b) released to the community sooner, compared with matched non-PERS users.Design Quasi-experimental retrospective cohort design using routine PERS and UK Ministry of Justice administrative data, for all clients enrolled on PERS between 1 April 2019 and 30 April 2022.Setting Five minimum security male prisons in England.Participants 258 PERS users matched for ethnicity, age at first offence and sentencing, education, sentence type, personality disorder screening, risk of reoffending scores and historical drug and alcohol use to 358 controls.Intervention PERS.Results PERS users waited longer for community release (HR=0.16, 95% CI 0.03 to 0.71) and had a lower likelihood of return to closed conditions prisons (HR=0.73, 95% CI 0.53 to 0.99) than matched controls.Conclusions PERS supports individuals to remain in open conditions for longer; however, further evaluation is needed to understand why PERS users waited longer for release, and if this was associated with a more successful release, without return to prison or reoffence.

Background: Personality disorders (PDs) are typically associated with higher mental health service use; however, individual patterns of engagement among patients with complex needs are poorly understood. Objective: The study aimed to identify subgroups of individuals based on patterns of service receipt in secondary mental health services and examine how routinely collected information is associated with these subgroups. Methods: A sample of 3941 patients diagnosed with a personality disorder and receiving care from secondary services in South London was identified using health care records covering an 11-year period from 2007 to 2018. Basic demographic information, service use, and treatment data were included in the analysis. Service use measures included the number of contacts with clinical teams and instances of did-not-attend. Results: Using a large sample of 3941 patients with a diagnosis of PD, latent profile analysis identified 2 subgroups characterized by low and high service receipt, denoted as profile 1 (n=2879, 73.05%) and profile 2 (n=1062, 26.95%), respectively. A 2-profile solution (P<.01) was preferred over a 3-profile solution, which was nonsignificant. In unconditional (t(3941,3939)=19.53; P<.001; B=7.27; 95% CI 6.54-8) and conditional (t(3941,3937)=-3.31; P<.001; B=-74.94; 95% CI -119.34 to -30.56) models, cluster membership was significantly related to receipt of nursing contacts, over and above other team contacts. Conclusions: These results suggest that routinely collected data may be used to classify likely engagement subtypes among patients with complex needs. The algorithm identified factors associated with service use and has the potential to inform clinical decision-making to improve treatment for individuals with complex needs.

Purpose Previous reviews suggest minoritised ethnic patients face inequalities in aspects of inpatient care including involuntary admission and forced medication. This rapid review aimed to identify ethnic disparities in acute adult mental health care and explore to what extent these provide evidence of institutional racism, as defined by the Macpherson report. Methods Ovid MEDLINE, Cochrane Library, Ovid PsycINFO, Web of Science and Ovid EMBASE were searched for studies published from January 2018 to August 2024. Quality of evidence was assessed using the Joanna Briggs Critical Appraisal Tools. A synthesis of the studies was performed. Results Quantitative studies (n = 34) revealed ethnic disparities in involuntary admission, psychiatric diagnoses, forced medication, physical restraint, seclusion, length of stay and access to appropriate services/facilities. Qualitative data (n = 2) revealed experiences of disempowerment, confusion and loss of autonomy. Collectively these findings mapped onto components identified as underlying institutional racism as defined by the Macpherson report. Conclusion Our current evidence can be used to understand the genesis and perpetuation of insitutional racism in health care settings. This will enable us to better target intervention or change management to address issues where they arise. Further research and analyses are needed however, in order to verify whether ethnic disparities in inpatient services and treatment reflect or are themselves exacerbated or contributed to by institutional racism.

IntroductionWe evaluated a modified procedure for making more detailed ratings of the presence of risk factors for violence using the HCR-20 V3 in a field study.MethodParticipants were 225 offenders recruited from correctional and forensic mental health institutions who were assessed by trained clinicians. We examined the measurement precision and predictive validity of ratings made using the modified procedure compared to ratings made by the same clinician using the standard procedure.ResultsRatings made using the modified procedure had equivalent or superior internal consistency to the original rating procedure and had equivalent predictive accuracy (validity) with respect to future violence according to logistic regression analyses.Discussion and conclusionThese findings suggest that the modified procedure may increase the sensitivity of Presence ratings of the HCR-20 V3 risk factors.

Complex posttraumatic stress disorder (CPTSD) is characterized in the International Classification of Diseases-11 by affect dysregulation, negative self-concept, and relationship impairments, symptoms also presented in borderline personality disorder (BPD). Some research shows CPTSD as a distinct disorder, others as a subgroup or a replacement for BPD. No review currently amalgamates the findings on whether CPTSD presents too similarly to BPD to be a standalone disorder. This article systematically reviewed similarities and differences in symptom presentations of the two disorders. Six databases were searched (PsycINFO, EMBASE, PubMed, Web of Science, PsycEXTRA, and Open Access Theses and Dissertations) and identified papers were summarized narratively. The majority of studies found distinct profiles for CPTSD and BPD. One study found no differences between the constructs; however, this used a population without severe trauma. CPTSD and BPD can present comorbidly, these individuals will have likely experienced earlier and more frequent interpersonal trauma and display greater functional impairment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background The Offender Personality Disorder (OPD) Pathway, a joint health and criminal justice initiative across England and Wales, aims to support rehabilitation of individuals with a likely diagnosis of personality disorder. Pathways Enhanced Resettlement Services (PERS) is an OPD service currently operating in five open prisons in England, which aims to support people at high risk of being returned to closed conditions or reoffending in the community after release. We aimed to understand service user and staff experiences of PERS. Methods We conducted semi-structured interviews with ten staff and nine service users. We then conducted a reflexive thematic analysis generating three themes. Results The three themes identified were: (1) A shock to the system, describing the challenges for service users posed by the liminal space of open prison (between higher security conditions and the community); and how in this context PERS might be viewed with suspicion but was for interviewees ultimately a space where they felt valued. (2) We've got some understanding of their journey; staff and service users described PERS staff developing more trusting relationships with service users than non-PERS staff, where service users felt understood and supported, practically and emotionally; and (3) internal states can be real barriers to progression; PERS staff supported service users to understand and overcome barriers, through enabling self-reflection, and tailoring support to times of greater stress, including key milestones such as parole boards or periods of trial leave. Conclusions Staff and service users feel PERS provides support to progress through open prison, through development of positive trusting relationships and individualised support in a challenging context where such support was not otherwise available. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by LISS-DTP, an ESRC funded doctoral programme. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of Queen Mary University of London (Joint Research Management Office) gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Due to the sensitive nature of the work and for confidentiality purposes, the ethics committee did not permit making data produced in the study available.

Personality disorders (PDs) are associated with higher service utilisation, however individual patterns of engagement within complex needs are poorly understood. The study aims to identify subgroups of individuals based on patterns of service receipt in secondary mental health services, and examine how routinely collected information is associated with these subgroups. Describe and predict patterns of engagement in personality disorder treatments using routine data. A sample of 3,941 patients with a diagnosis of personality disorder in contact with secondary services in South London was assembled from healthcare records, with an exposure period of 11 years (2007 – 2018). Basic demographic information, service use and treatment data were included in the analysis. Service use measures included number of contacts from clinical teams and Did Not Attends (DNAs). Latent profile analysis (LPA) identified two statistically distinct groups of patients as a function of service contact measures. Cross-validation modelling tested out-of-sample predictive performance. LPA identified two subgroups, characterised by high and low service receipt. Variables associated with profiles included diagnostic information and number of contacts from clinical teams. Model evaluation considered classification accuracy and predictive relevance of routine measures in determining likely subgroup. Nursing contacts were shown to differentially impact profiles by fitted rate of DNAs. Results suggest that routinely collected data may be used to classify likely engagement archetypes in complex needs. Employed algorithm identified factors associated with service utilisation, and may shape clinical decision making in complex needs treatments.

Background The current study is a secondary analysis of qualitative data collected as part of EURIPIDES, a study which assessed how patient experience data were used to improve the quality of care in National Health Service (NHS) mental health services.Objective We undertook a detailed realist secondary qualitative analysis of 10 interviews in which expressions of racialisation were unexpectedly reported. This theme and these data did not form part of the primary realist evaluation.Methods Interviews were originally conducted with the patients (18–65 years: 40% female, 60% male) from four different geographically located NHS England mental health trusts between July and October 2017. Secondary qualitative data analysis was conducted in two phases: (1) reflexive thematic analysis and retroduction; (2) refinement of context–mechanism–outcome configurations to explore the generative mechanisms underpinning processes of racialisation and revision of the initial programme theory.Findings There were two main themes: (1) absence of safe spaces to discuss racialisation which silenced and isolated patients; (2) strained communication and power imbalances shaped a process of mutual racialisation by patients and staff. Non-reporting of racialisation and discrimination elicited emotions such as feeling othered, misunderstood, disempowered and fearful.Conclusions The culture of silence, non-reporting and power imbalances in inpatient wards perpetuated relational racialisation and prevented authentic feedback and staff–patient rapport.Clinical implications Racialisation in mental health trusts reflects lack of psychological safety which weakens staff–patient rapport and has implications for authentic patient engagement in feedback and quality improvement processes. Larger-scale studies are needed to investigate racialisation in the staff–patient relationships.

Background Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of “research-friendly” clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. Objective SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. Methods Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. Results The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β=.034, P<.001) and increased A&E use (β=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β=–.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (β=–.072, P<.001), having depression (β=.018, P=.007), and receiving mental health treatment (β=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. Conclusions Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set.

Objectives This systematic review explored factors associated with successful reintegration into the community for male offenders and investigated which factors may be causally related to reintegration. Methods Database searches were conducted in November 2021; a narrative synthesis and associated causal model with directed acyclic graph (DAG) was used to analyse the factors of reintegration. Results Thirty-four studies met the inclusion criteria. Risk-Need-Responsivity–based interventions had the strongest evidence for reducing post-release offending. Fourteen good-quality studies met the inclusion criteria. The DAG shows six exposure variables (prison visits, witnessing victimisation, recovery perception, risk assessment, in-prison treatment, and pre-prison health) which link to several post-release outcomes (criminal justice outcomes, drug use, mental health, housing, and reintegration barriers) and confounding variables (demographics, offending history, prior reintegration barriers, substance misuse and attitudes). Conclusions The review identified factors that may be causally related to reintegration for male offenders and warrant further empirical investigation.

Summary Psychiatry understands narcissism as a pathological condition associated with poor social outcomes and difficulty relating to others. Millennials have been depicted by psychological research as ‘narcissistic’, and the term has lost accurate meaning. We underline the intellectual laxity of conflating social changes with narcissism and suggest ways forward.

Previous research has indicated that autism is over-represented among inpatients in forensic high secure hospitals in England. The aim of this study was to assess the feasibility of estimating the prevalence of autism without an intellectual disability in medium secure units (MSU). Male inpatients on three MSU wards were approached to participate in the study following ethical approval. Patients who met the inclusion criteria and consented were screened for autism using the AQ (Autism Quotient), and the EQ (Empathy Quotient). Out of a total of 46 patients on these wards, sixteen individuals were ineligible to participate. Of the remaining 30, 12 (40%) subsequently consented to participate. After ruling out an intellectual disability using the Schonell Graded Work Reading Test, these individuals were screened for autism using the AQ, and completed the EQ. None of those who participated scored above screening threshold for further diagnostic testing using the AQ. However, three inpatients (of the original 46 patients on these wards) were previously diagnosed with Asperger's Syndrome suggesting a prevalence of 6.5% (95% CI 1.7-.18.9%). The results indicate that this group is over-represented within medium secure forensic psychiatric units and highlight the difficulties in undertaking research in this population.

BACKGROUND:Offenders with personality disorder can be challenging to engage and retain in treatment. The UK Offender Personality Disorder (OPD) pathway aims to proactively and responsively identify and engage offenders with personality disorder. However, a subpopulation of offenders on the pathway have been found to not be accepted into any OPD service and therefore fail to progress.OBJECTIVE:This study aims to identify and describe offenders on the OPD pathway who fail to progress and to understand the causal drivers by which individuals fail to progress in the pathway.METHODS:A sample of 50 offenders on the OPD pathway who had been refused from at least two OPD services (nonprogression group) were compared to 100 offenders accepted into OPD services (control group). Partial least squares structural equation modeling was used to model the causal factors involved in not being accepted into OPD services.RESULTS:The path coefficients in the structural model showed that the most influential factor in nonprogression was attitude toward treatment (β=.41; P<.001; f2=0.25) alongside those with psychopathology (β=.41; P<.001; f2=0.25), specifically, psychopathy, psychosis, and co-occurring personality disorder.CONCLUSIONS:The findings of the study provide a basis of how to work with this population in the future to increase the likelihood of acceptance into OPD services.

BACKGROUND Offenders with personality disorder can be challenging to engage and retain in treatment. The UK offender personality disorder (OPD) pathway aims to proactively and responsively identify and engage offenders with personality disorder. However, a sub-population of offenders on the pathway have been found to not be accepted into any OPD service and therefore fail to progress. OBJECTIVE This study aimed to identify and describe offenders on the OPD pathway who fail to progress as well as understand the causal drivers by which individuals fail to progress in the pathway. METHODS A sample of 50 offenders on the OPD pathway who had been refused from at least two OPD services (non-progression group) were compared to 100 offenders accepted into OPD services (control group). Partial least squares structural equation modelling (PLS-SEM) was used to model the causal factors involved in not being accepted into OPD services. RESULTS The path coefficients in the structural model showed that the most influential factor in non-progression was attitude towards treatment (β = 0.41, P <.001, f2 = 0.25) alongside those with psychopathology (β = 0.41, P <.001, f2 = 0.25); specifically, psychopathy, psychosis and co-occurring personality disorder. CONCLUSIONS The findings of the study provide a basis of how to work with this population in the future to increase the likelihood of acceptance into OPD services.

BACKGROUND Large datasets comprising routine clinical data are becoming increasingly available for use in health research. These datasets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of ‘research friendly’ clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. OBJECTIVE SEM was applied to a large dataset of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilisation, and increased healthcare costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical datasets. METHODS Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and A&E use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. RESULTS The results provided partial support for the application of SEM to routine clinical data. 19% of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β = 0.034, p <.0001) and increased A&E use (β = 0.071, p <.0001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β = -0.055, p <.0001), and receipt of mental health treatment did not impact upon diabetic control (p = 0.392). Receipt of diabetes care was associated with better diabetic control (β = -0.072, p <.0001), having depression (β = 0.018, p = .007), and receiving mental health treatment (β = 0.046, p <.0001), which might suggest that comprehensive integrated care packages are being delivered in East London. CONCLUSIONS Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this dataset. CLINICALTRIAL n/a

BACKGROUND:Case formulation plays a key role in effective management of offenders' needs, particularly on the Offender Personality Disorder Pathway (OPDP).AIMS:To validate a method of investigating formulations with offenders still in prison but in the OPD Pathway and investigate agreement over the content of formulations between each of the main dyadic pairs: offender-clinician, offender-key worker and clinician-key worker.METHODS:We developed a checklist of the main features of a formulation from a review of initial formulations in the files of prisoners in two prisons which operate within the OPD Pathway system. We then recruited 30 violent offenders in each OPD wing of two prisons, and asked each of them, their clinically qualified worker (usually a psychologist) and the criminal justice system key worker to complete a formulation summary according to a card-sort process based on this checklist. We calculated the level of agreement between pairs of raters (e.g. offender and key worker) about the importance of aspects of each domain to the case using intraclass correlation coefficients.RESULTS:The rating tool showed good internal validity. Analysis of inter-rater ratings showed agreement among teams on aspects relating to prisoners' observable actions, experiences and external support domains, but little agreement on cognitions, feelings, risky situations or staff/self-support, mainly affecting the prisoner-key worker dyad. There were, however, significant differences in agreement rates between the two sites.CONCLUSIONS:Agreement within teams about formulations is strong where content relates to overt behaviours and points of fact, but weaker on risk, cognitions and support. The appropriateness of this approach to formulation across cultural groups may need further evaluation as the main measured difference between the prisons was in distribution of ethnic and cultural groups.

Background Mental illnesses may explain vulnerability to develop extremist beliefs that can lead to violent protest and terrorism. Yet there is little evidence. Aims To investigate the relationship between mental illnesses and extremist beliefs. Method Population survey of 618 White British and Pakistani people in England. Extremism was assessed by an established measure of sympathies for violent protest and terrorism (SVPT). Respondents with any positive scores (showing sympathies) were compared with those with all negative scores. We calculated associations between extremist sympathies and ICD-10 diagnoses of depression and dysthymia, and symptoms of anxiety, personality difficulties, autism and post-traumatic stress. Also considered were demographics, life events, social assets, political engagement and criminal convictions. Results SVPT were more common in those with major depression with dysthymia (risk ratio 4.07, 95% CI 1.37–12.05, P = 0.01), symptoms of anxiety (risk ratio 1.09, 95% CI 1.03–1.15, P = 0.002) or post-traumatic stress (risk ratio 1.03, 95% CI 1.01–1.05, P = 0.003). At greater risk of SVPT were: young adults (<21 versus ≥21: risk ratio 3.05, 95% CI 1.31–7.06, P = 0.01), White British people (versus Pakistani people: risk ratio 2.24, 95% CI 1.25–4.02, P = 0.007) and those with criminal convictions (risk ratio 2.23, 95% CI 1.01–4.95, P = 0.048). No associations were found with life events, social assets and political engagement. Conclusion Depression, dysthymia and symptoms of anxiety and post-traumatic stress are associated with extremist sympathies.

Objective: Clinicians are tasked with assessing the relationship between violence and mental illness. Yet, there is now a legal expectation in some countries that public services, including health professionals, assess risk of violent extremism – with few available measures. We previously developed a new measure of Sympathies for Radicalisation, using items that measure Sympathies for Violent Protest and Terrorism. In this paper, we present the detailed psychometric properties of a reduced item measure of Sympathies for Violent Protest and Terrorism. We use data from two studies to test replication and then validity against outcomes of self-reported violence and convictions in the entire sample and in those with depressive symptoms. Methods: Data from two cross-sectional neighbourhood surveys, consisting of Pakistani and Bangladeshi adults (survey 1, n = 608) and White British and Pakistani adults (survey 2, n = 618), were used to undertake confirmatory factor analysis of Sympathies for Radicalisation and produce a short measure of Sympathies for Violent Protest and Terrorism. Survey 2 data were used to test the Sympathies for Violent Protest and Terrorism’s convergent validity to classify presence/absence of violence and convictions in the whole sample and for subgroups by depressive disorder. Results: The seven-item measure’s structure was a consistent measure of extremist attitudes across the two surveys. A threshold score of zero to classify violence was optimal (specificity = 89.7%; area under the curve = 0.75), but sensitivity to a risk of violence was poor (34.5%). The short version Sympathies for Radicalisation was a better classifier of violence in respondents with depression, dysthymia or both (area under the curve = 0.78) than respondents with neither (area under the curve = 0.69; β = 0.62, 95% confidence interval = [−0.67, 1.92]; standard error = 0.66). Conclusion: The seven-item measure of Sympathies for Violent Protest and Terrorism is an accessible and valid measure for clinical assessments and helpfully identifies low risk of violence. It enables clinicians to conduct detailed assessments of people endorsing one or more of the items, although further research is needed.

Background Indeterminate sentences for Public Protection (IPPs) were introduced in England and Wales under the Criminal Justice Act 2003 for offenders not eligible for a life sentence but considered to pose a serious risk to the public. In 2012, new IPPs became illegal, in part after the European Court of Human Rights ruled in three cases that failure to make appropriate provision for rehabilitation services while the men were in prison breached their rights under Article 5 of the Convention and thus from arbitrary detention. People already sentenced under this provision, however, remained in the system. Humberside Indeterminate Public Protection Project (HIPPP) supports intensive case management of male IPP offenders still serving this sentence. Aims To examine variables associated with pathway outcome among men under IPPs in one English region-Humberside. Our primary hypothesis was that programme engagement in prison would be significantly associated with release. Methods The HM Prison and Probation Services National Delius (nDelius) and Offender Assessment System (OASys) were used to identify all men from the region subject to IPPs and beyond tariff (the fixed, punishment part of their sentence) and to retrieve data on the sentence, pathway status and specific risk factors. We used content analysis to identify variables of interest, and logistic regression models to explore associations of variables with different types of pathway outcome. Results A total of 82 men were identified, 34 of whom had ever been recorded as having been given a diagnosis of anti-social personality disorder (ASPD). Men experiencing relationship difficulties with professionals were significantly more likely to be denied release [Odds Ratio (OR) = 7.75, Confidence Interval (CI) 2.08-28.57], have a deferred parole (OR = 7.81, CI 1.59-38.46) or be awaiting parole (OR = 4.46, CI 1.09-18.18) compared with men released to the community or serving in an open prison. Completion of programmes was not associated with pathway outcome. A modest association between diagnosis of anti-social personality disorder and pathway outcome association was confounded by other variables. Conclusions and Implications for Practice While programme completion did not have the expected association with release, relational difficulties with professionals proved significant barriers to release. This suggests that ambitions for the Offender Personality Disorder (OPD) pathway in supporting professionals to develop collaborative relationships with offenders are well founded. Part of this approach lies in sophisticated, psychologically informed case formulations which may help to discriminate between risk factors and personality disorder traits which have social rather than risk implications.