Strategies for Improved Collaborative management of Personality Disorders in Correctional Facilities

Decades ago, before apps and social media, most people going on a date were set up by friends, coworkers, classmates, or relatives. It was not uncommon that one didn’t know what their date looked like or the type of person they were. Terms like “they have a really good personality” were used as descriptives. The specific definition of personality can be somewhat elusive.

The Big 5 Model (or 5 factor model of personality), which is based on research dating back to the 1970s, continues the age-old nature vs nurture debate. While some of one’s personality appears to be passed on from generation to generation, it seems that the other half is shaped by childhood and other life experiences. One’s personality is a combination of characteristics that form a general nature and disposition. These traits are enduring characteristics that describe how people think, feel, and behave. A personality is not static and is influenced by various factors throughout a person’s life.

The Big 5 Model uses the mnemonic OCEAN to describe the major characteristics of personality:

Openness — how you respond to new situations and ideas

Conscientiousness — how thoughtful or thorough you are

Extraversion— where you get your energy and what fulfills you

Agreeableness — how you care for others vs caring for yourself

Neuroticism — how you respond or react to feelings, stress and anxiety¹

Examples of personality traits that are generally considered positive or valued are intelligence, resilience, integrity, kindness, and loyalty, whereas we devalue traits like stubbornness, laziness, spitefulness, or insensitivity. Traits like being strong willed or curious can be construed as either valued or devalued depending on the context or situation. These traits may also vary depending on the cultural lens by which they are being viewed. There are endless combinations of positive, negative, and neutral personality traits which is what makes us unique individuals!

Personality Disorders in Corrections

Rates of personality disorders in correctional settings are significantly higher than in the general population. Of the 3 personality disorder clusters outlined in the DSM 5-TR, Cluster B (dramatic, emotional, or erratic) is predominantly represented in correctional settings and includes antisocial, borderline, narcissistic and histrionic personality disorders.² While personality disorder prevalence in the general population typically ranges below 5%, research indicates that incarcerated individuals meet criteria for antisocial personality disorder at rates ranging as low as 21% or as high as 77% depending on the study population.^3,4 Borderline personality disorder rates are also significantly higher (as high as 30% for meeting the full criteria) with over 90% of individuals having at least one trait.⁵ Narcissistic and histrionic personality disorders are not as well studied, and while these rates may be elevated compared to the general population, it is unclear by how much. Despite the higher prevalence of personality disorders in correctional populations, they are still typically underdiagnosed.

There are many factors that contribute to the underdiagnosing of personality disorders in correctional settings. These include:

1. Misattributing symptoms: Individuals with personality disorders are often seen as “difficult” or “manipulative,” rather than as having a mental illness.
2. Diagnosis of other mental health conditions: Clinicians tend to concentrate on primary mental health disorders like anxiety or depression, focusing less on personality disorder symptoms.
3. Limited insight: Individuals with personality disorders may not recognize or acknowledge their condition, making it harder to seek help.
4. Vague diagnostic criteria: The criteria for personality disorders can be broad and open to interpretation, leading to inconsistent diagnoses.
5. Stigma: The stigma associated with personality disorders can prevent people from seeking help. It also hinders clinicians from discussing these disorders openly with their patients.^6,7

There is a high cost to both patients and facilities when personality disorders are ignored. The underdiagnosis of personality disorders can lead to delayed or inappropriate treatment, potentially worsening symptoms, and hindering recovery. These undiagnosed and untreated personality disorders in turn strain mental health and correctional systems as individuals who are already distressed themselves provoke discord in their daily living situations, often requiring a multidisciplinary response. Without appropriate intervention, this can often lead to conflict, at times resulting in verbal and physical altercations.

Treatment of Personality Disorders

To understand best practices in treatment of personality disorders, we must start at the beginning by looking at theories of how personality disorders develop. A number of factors, including genetic predisposition, environmental factors, and a person’s interpretation of their own experiences each play a unique role in the development of personality.When an individual experiences adversity during childhood (eg, living in poverty, having a parent living outside of the household, or significant illness) and does not receive appropriate support or guidance, this is more likely to lead to continued adversity in adulthood. Clinicians now commonly measure this using the adverse childhood experiences (ACE) questionnaire. While any adverse experiences have the potential to put individuals at risk, it is believed that an ACE score of 4 or more places an individual at high risk for negative outcomes in adulthood, including the development of personality disorders.

A longitudinal study conducted in Norway linked ACEs with later diagnosis of Personality Disorder. In this study from 2024, 90% of adolescents who developed a personality disorder had experienced ACEs. Emotional abuse was the biggest predictor, followed by other forms of abuse and household dysfunction.⁷ A systemic review published in 2021 of juvenile offenders and ACE scores concluded that there is a statistically significant correlation between elevated ACE scores and juvenile justice system contact in the United States.⁸ These studies suggest, as many other studies with correctional populations have, that assessing ACEs gives clinicians an important foundational diagnostic frame to begin with.

Unique Challenges of the Corrections Environment

Nonsuicidal self-injury:

In a corrections setting, individuals facing incarceration often grapple with a multitude of stressors, ranging from the loss of personal freedoms to the challenge of adapting to a confined and regimented lifestyle. Nonsuicidal self-injury (NSSI) can emerge as a coping mechanism for inmates attempting to manage overwhelming emotions, express internal pain, or regain a sense of control within the constraints of their new environment

Interventions for NSSI in corrections settings demand a multidisciplinary approach, where medical and mental health professionals come together to develop a behavioral plan and mutual understanding of the treatment approach. Interventions using techniques from cognitive behavioral therapy and dialectical behavioral therapy have demonstrated efficacy in addressing the underlying cognitive, emotional, and impulsive aspects of NSSI. Education programs that raise awareness about mental health, adaptive coping strategies, and available support systems can contribute to creating a more supportive and understanding environment in the jail. Correctional health services, both medical and mental health, can promote a culture of empathy, support, and understanding, recognizing that each patient is an individual with unique experiences and challenges.⁹

Aggression:

Aggression is an unfortunate yet prevalent characteristic of personality disorders in corrections, often due to underlying negative traits such as hostility, impulsivity, and emotional dysregulation. A 2018 study on aggression, victimization, and institutional misconduct among incarcerated individuals diagnosed with borderline personality disorder found that these individuals were twice as likely to report having disciplinary infractions.¹⁰ A 2019 study connected the aggression and impulsivity typically found in antisocial personality disorder with recidivism, suggesting how essential addressing antisocial traits is to reducing re-arrest in this population.¹¹ Joseph Baskin, MD, noted in his 2018 article discussing treatment challenges for antisocial personality disorder in corrections, that addressing comorbid conditions of ADHD and substance use can reduce the impulsivity which leads to aggressive behaviors. These symptoms are focused on the frontal lobe of the brain, the area responsible for suppressing impulses and engaging in reasoning— interventions should be geared toward this.¹²

Isolated confinement:

Those with mental illness are overrepresented in solitary confinement, despite the vulnerability and threats to the mental health of those being isolated. Research shows that the effects of solitary confinement on mental health are often fatal, both during and after incarceration. Half of all suicides in prisons and jails occur in solitary confinement. A recent study shows the long-lasting effects: any amount of time spent in solitary increases the risk of death in the first year after release. Individuals were overall 24% more likely to die in the first year after release, including from suicide (78% more likely) and homicide (54% more likely). They were also 127% more likely to die of an opioid overdose in the first 2 weeks after release.¹³

Whenever possible, advocate to have individuals housed in isolation brought to a separate location for private mental health conversations. If an interdisciplinary team does not exist in your facility to review individuals housed in isolation, consider advocating for mental health to have an active role in these discussions.

Evidence Based Treatment for Personality Disorders

We have long been told as clinicians that personality disorders cannot been treated, and they can only be managed. However, as emerging research supports the broader use of modalities like CBT and DBT for a range of behavioral health diagnoses including personality disorders, treatment programs are under development to provide much needed treatment to this long under-served population.

Cognitive behavioral therapy (CBT) is well-suited to address the varied and often longstanding problems of individuals with personality disorders for several reasons. From a cognitive behavioral perspective, personality disorders are maintained by a combination of maladaptive beliefs about self and others, contextual and environmental factors that reinforce problematic behavior and/or undermine effective behavior, and skill deficits that preclude adaptive responding. CBT incorporates a wide range of techniques to modify these factors, including cognitive restructuring, behavior modification, exposure, psychoeducation, and skills training. In addition, CBT for personality disorders emphasizes the importance of a supportive, collaborative and well-defined therapeutic relationship, which enhances the patient's willingness to make changes.¹⁴

While originally designed to be used with individuals diagnosed with borderline personality disorder, dialectical behavior therapy (DBT) has shown promise in its use to address self-destructive behavior and anger associated with antisocial personality disorder. DBT principles use cognitive and behavioral techniques to focus on four key skill modules of mindfulness, interpersonal effectiveness, emotional regulation and distress tolerance.¹⁵

Most available evidence supports the use of medication for reducing impulsivity and aggression associated with borderline and antisocial psychopathology. While there are no US Food and Drug Administration approved medications specifically for personality disorders, medication can help manage related symptoms and conditions. Pharmacotherapy interventions are used to stabilize an individual's acute symptoms in order to facilitate psychotherapy interventions

Psychotropic medication may relieve co-morbid conditions:

Antidepressants - for depression and anxiety symptoms

Antipsychotics - for distorted thinking and agitation

Mood Stabilizers - for mood swings and impulsivity^16,17

Back to Basics

• Employing mindfulness, cognitive restructuring, and distress tolerance can reshape emotional and behavioral responses.
• Learning communication and conflict resolution skills can help navigate and improve social interactions.
• While medications cannot “cure” personality disorders, they can help control symptoms like mood swings or impulsive behavior.
• Helping an individual improve their understanding of their diagnosis helps them manage symptoms better and make proactive changes.
• Increasing awareness of the disorder’s effects can pinpoint where changes are needed and influence treatment choices.
• Learning to forge and maintain healthier interpersonal connections can offer significant life improvement.
• Incorporating family and friends in care can boost morale, improve treatment adherence, and assist with everyday challenges.
• Encourage a commitment to treatment. Continuously attending and being open to therapy, even when it is difficult, is crucial for progress.
• Therapy takes time to work and setting realistic, achievable goals can make the process more satisfying and less disappointing.¹⁸

Final Takeaways

Each of us can work within our facilities to improve the availability of behavioral health services for individuals impacted by the symptoms of personality disorders. It begins with improved diagnostics related to personality disorders; once individuals are formerly diagnosed, individual counseling should be made available. Referrals to psychiatry can be considered to address symptoms of impulsivity and behavior management plans should be created to address challenging behaviors. Ensure that clinical rounds are being completed in all areas of segregation and advocate for a mental health representative to sit on your facility’s disciplinary review board.¹⁹ Provide cross training of medical and custody teams on personality disorders and their impact on operations. Most importantly, check in with your staff. Provide clinical supervision for countertransference and ensure resources are available to encourage self-care and guidance when working with this unique population.

Dr Federbush is a forensic psychiatrist with over 37 years’ experience in the field. He is currently the Chief of Psychiatry for CFG Health and has worked in multiple correctional facilities.

Ms Genberg is a Licensed Clinical Social Worker with over 25 years’ experience the field. She is currently the Health Services Administrator for the Passaic County Sheriff’s Office and a member of the CFG Health Travel Team.

Dr Federbush and Ms Genberg have a successful forensic psychiatry practice where their focus includes guardianship evaluations, will contests, testamentary capacity, fit for duty evaluations, risk assessments, emotional distress, not guilty by reason of insanity and competency to stand trial. They have given national lectures on topics including prediction of violence and crisis de-escalation, suicide risk reduction, feigned mental illness, anxiety, PTSD, schizophrenia, personality disorders and stages of cognitive impairment.

AI Usage Disclosure: the authors acknowledge the use of Google Gemini for topic prompts in the writing of this article.

References

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9. Graf GH, Chihuri S, Blow M, Li G. Adverse childhood experiences and justice system contact: a systematic review. Pediatrics. 2021;147(1):e2020021030.

10. Sanchez J. “The first cut is the deepest.” – non-suicidal self-injury in a corrections environment. Corr Health. February 22, 2024. Accessed January 8, 2026. https://mycorrhealth.com/non-suicidal-self-injury-in-a-corrections-environment/

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12. Baskin J. Corrections psychiatry: antisocial personality disorder a difficult personality disorder and other challenges to treatment. Psychology Today. October 4, 2018. Accessed January 8, 2026. https://www.psychologytoday.com/us/blog/cell-block/201810/corrections-psychiatry-antisocial-personality-disorder

13. Sandoval J. How Solitary Confinement Contributes to the Mental Health Crisis. National Alliance on Mental Illness. March 17, 2023. Accessed January 8, 2026. https://www.nami.org/advocate/how-solitary-confinement-contributes-to-the-mental-health-crisis/

14. Matusiewicz AK, Hopwood CJ, Banducci AN, et al. The effectiveness of cognitive behavioral therapy for personality disorders. Psychiatr Clin North Am. 2010;33(3):657-685.

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19. Position statement: solitary confinement (isolation). National Commission on Correctional Health Care. April 2016. Accessed January 9, 2026. https://www.ncchc.org/wp-content/uploads/Solitary-Confinement-Isolation.pdf