Personality disordered offenders in the community

1. Personality disordered offenders in the community What is the role of mental health services? Dr Rajan Darjee State Hospital rajan.darjee@tsh.scot.nhs.uk

2. Overview • Who are personality disordered offenders in the community? • What is the current policy context? • What should forensic mental health services do and how?

4. Attitudes to personality disorder in forensic mental health services • Diagnosis of exclusion • ‘Untreatable’ • ‘Behaviour’ v ‘Illness’ • Control • Responsibility • Not something we can do anything about • Not something we should make an effort to deal with

5. ‘Her Majesty’s Institution for Personality Disorders’ Senior Forensic Nurse’s description of H.M.P. Cornton Vale • ‘Could you tell me if they’re ill or if they’re a personality disorder wasting everyone’s time?’ Defence Solicitor requesting a report

6. Media – High profile cases

7. Personality disordered offenders in the community PRISON HOSPITAL Personality disordered offenders in the community COURT NOT YET OFFENDED

8. Personality disorder and offending • Prison • Violent offenders • Sexual offenders • Mentally disordered offenders in hospital

9. Antisocial personality disorder

10. PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

11. VIOLENT & SEXUAL OFFENDERS PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

12. glibness / superficial charm grandiose sense of self-worth need for stimulation / proneness to boredom pathological lying conning / manipulative lack of remorse or guilt shallow affect callous / lack of empathy parasitic lifestyle poor behavioural controls promiscuous sexual behaviour early behaviourproblems lack of realistic long-term goals impulsivity irresponsibility failure to accept responsibility for own actions many short-term marital relations juvenile delinquency revocation of conditional release criminal versatility Hare Psychopathy Checklist- Revised (PCL-R)

13. Heterogeneity - studies • Violent offenders • Sex offenders • Mentally disordered offenders • Non-offenders

14. Heterogeneity

15. Diagnosis versus formulation • Making diagnosis using ICD-10, DSM-IV or PCL-R is of little practical use if you’re interested in helping/managing/treating • Diagnosis should be part of formulation • Formulation: • Use theoretical framework • Communicate with patient • Help others understand patient • Re-formulate as learn more

16. Services for personality disordered offenders in England and Wales • DSPD • High secure hospitals • Broadmoor, Rampton • High secure prisons • HMP Frankland, HMP Whitemoore • Medium secure units • Newcastle, South London, North London • Community • Newcastle, South London, South East London • Non-DSPD • High secure hospitals • Broadmoor, Rampton, Ashworth • Prisons • Grendon, Close Supervision Units, Offending Behaviour Programmes • Medium secure units • Arnold Lodge, Independent Sector, Standard NHS Units • Community • MAPPA, Probation services, PD services, Sex Offender services

17. What happens at the moment in Scotland? • NHS Forensic inpatient units • State Hospital • Orchard Clinic • Low secure forensic units • SPS • Offending behaviour programmes • Risk • Segregation units • Vulnerable prisoner units • Community • Criminal Justice Social Work • Mental Health Services

18. What happens at the moment in Scotland?

19. Should mental health be the lead agency? • Resources • Risk management • Responsibility • Lack of expertise and experience

20. Should there be hospital treatment for personality disordered offenders? • Primarily psychopathic high risk offenders – assessment and treatment in specialist units in prison • Small number of non-psychopathic personality disordered serious offenders - hospital • Most primarily anti-social personality disordered offenders - usual criminal justice process • Comorbid mental illness / learning disability and personality disorder – health care

21. Legislation and Policy • Scottish Office MEL(1999)5 Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland. • Millan, MacLean & Cosgrove Reports (2000 – 2001) • Forensic Mental Health Services Managed Care Network • Mental Health (Care and Treatment) (Scotland) Act 2003 • Criminal Justice (Scotland) Act 2003 • Sexual Offences Act 2003 • Risk Management Authority (RMA) • Management of Offenders etc. (Scotland) Act 2005 • Protection of Children and Prevention of Sexual Offences (Scotland) Act 2005 • Scottish Executive HDL(2006)48 Forensic mental health services

23. Forensic Network Working Groups • Levels of Security • Services for Women • Services for Learning Disabled • Personality Disorder • Community Services • Children & Adolescents • Care Standards • Conflict Resolution • Critical Incident Review • CPA Guidance for Restricted Patients • Psychological Therapies

24. Forensic Network Working Group on Personality Disorder • Not a diagnosis of exclusion • Proper assessment • Better training • Pilot community services • Pilot prison services • No change to hospital practice

25. Issues to address • Risk assessment and management • Attention to interpersonal relationships and psychopathology • Treatment targeting dynamic risk domains which takes account of personality dysfunction • Treatment which addresses personality dysfunction • Positive focus and approach goals

26. Criminal justice agencies

27. Forensic mental health services working with criminal justice: SEARCH AND RESCUE

28. Forensic mental health services working with criminal justice: WORKING TOGETHER

29. Multi Agency Public Protection Arrangements (MAPPA) • Management of Offenders etc. (Scotland) Act 2005 sections 10 & 11 • Sexual offenders and violent offenders being managed in the community • Statutory basis for inter-agency cooperation and information sharing • Responsible authorities: Police, Criminal Justice Social Work, Prisons, (Health) • Duty to cooperate agencies include Health • Three MAPPA levels depending on risk

30. Offending behaviour programmes Accreditation criteria: • have a clear model of change (i.e. a theoretical underpinning to the programme, based on a model of personality development and disorder) • have clear criteria for selection • target relevant dynamic risk factors • use effective methods • teach skills that will assist individuals to avoid offending and pursue legitimate pursuits • have a clear description of the sequencing, intensity and duration of the different components of the programme • maximise engagement and motivation • ensure continuity with other programmes/services • monitor its performance • undertake a long term-evaluation

31. Problems of personality disordered offenders in standard offending behaviour programmes • Readiness • Motivation • Engagement • Drop-out • Lack of flexibility • Integration • Interpersonal dynamics • Core schema

32. Forensic mental health role • Personality Assessment • Case Formulation • Context for relationships • Treatment • Engagement, motivation, education • ‘Basic’ skills • Offending behaviour programmes • Specific psychological interventions for personality dysfunction • Medication • Risk assessment and management

33. Future developments • Pilot Forensic Mental Health Personality Disorder Services • Multi Agency Public Protection Arrangements

34. Multi-Agency Public Protection Arrangements

35. PERSONALITY DISORDERED OFFENDERS HEALTH CRIMINAL JUSTICE

36. HEALTH CRIMINAL JUSTICE

37. HEALTH CRIMINAL JUSTICE

38. HEALTH CRIMINAL JUSTICE

39. The way forward • Partnership working between forensic mental health and criminal justice agencies • Forensic mental health staff with experience, expertise and enthusiasm • Impetus for development of community and local forensic mental health services • Resources for development of services for personality disordered offenders ? ??

40. Summary • Personality disordered offenders in the community are not untreatable psychopaths • Criminal justice agencies are left holding the baby • Mental health services have a circumscribed but useful role to play • MAPPA provides a framework for joint working • Mental health would need to use a ‘working together’ model instead of a ‘search and rescue’ model of working with criminal justice • Health can primarily assess and treat, while criminal justice agencies primarily monitor and supervise • A relatively small amount of resources would go a long way

41. Can you work in forensic mental health without being able to deal appropriately with offenders with personality disorders?