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Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
A Forensic Perspective
The Risks of Excluding Offenders with Personality Disorder
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Conference Aims
• To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk.
• To consider the aetiology of PD as a route to both engagement and management, in particular the issue of disadvantage.
• To discuss current progress and future plans for services for people with PD who offend
• To present a model of assessment and management based on shared risk and to examine this in community, hospital and prison settings.
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Conference Aims: Outline
• To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk.
- Prevalence - Current service & practice
- Recidivism - Current issues
• To discuss current progress and future plans for services for people with PD who offend
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Background: Prevalence of ASPD
• General population 2-3%
• Prison population 80%
• State Hospital - primary diagnosis 5.4%
- secondary diagnosis 27-42%
- psychopathy : PCL-R 30+ 0%
: PCL-R 25+ 15%
• ISD 5.1% of discharges in 2000 primary or secondary dx
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Background: SPS
• Identify problem behaviours and needs• 3 principal structures:
Sentence Management
Risk Management groups
Mental Health teams. • CBT interventions - focus on violent behaviour and
sexual offending behaviour
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Recidivism Rates
Prison
State Hospital
Recidivism Rate Violent Recidivism Duration
60% - 2 years
31% (20%) 19% (12%) 11 (2)
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Survey of Services for People with Forensic Personality Disorder in Scotland
• 7 implicitly exclude people with a primary PD Dx from admission
• 7 assess people with a primary diagnosis of PD• 8 use multidisciplinary and 10 comprehensive methods of
assessment• 4 use structured clinical tools for the assessment of PD• 6 services did not accept people with a primary diagnosis
of PD for specific intervention, treatment or management, 4 services did not accept people with a secondary dx
• No reliable figures
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Background: Current Practice
• Do not admit individuals with a primary diagnosis of personality disorder to forensic psychiatric units.
• Community forensic mental health services - rudimentary.
• Most forensic psychiatrists - a small cohort of outpatients with a primary diagnosis of personality disorder.
• Offender + Primary Personality Disorder Prison / Y.O.I.
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Background: Serious, Violent & Sexual Offenders
Maclean Committee 2001 Risk Management Authority Risk Assessment Order Order for Lifelong Restriction Emphasis on offence and risk, rather than on a diagnosis
such as psychopathy or severe personality disorder.
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Background: England and Wales
• Rejection of personality disorder as a diagnosis of exclusion
• Multiagency Public Protection Arrangements
• Significant investment by the Department of Health and the Home Office: pilot services for people with personality disorder in general psychiatric and forensic services including pilot community forensic personality disorder services and five inpatient forensic personality disorder units.
• Dangerous and Severe Personality Disorder - 4 DSPD units:
• HMP Grendon - therapeutic community
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Forensic Network Report on Services for People with Personality Disorder
Dr Fiona Biggam Forensic Clinical PsychologistDr Derek Chiswick Consultant Forensic PsychiatristDr Raj Darjee Lecturer in Forensic PsychiatryProf. Kate Davidson Consultant Clinical PsychologistCaroline Doyle Lead Nurse, DSPD Unit, HMP FranklandDr Edward Duncan Clinical Specialist Occupational Therapist Prof. Don Grubin Professor of Forensic PsychiatryProf. Roisin Hall Chief Executive, Risk Management Authority
Formerly Director of Psychological Services, SPS Annie McGeeney Social WorkerDiane Perera Registered Mental Nurse, HMP PerthDr Maureen Sturrock Psychiatric Adviser, The Scottish Executive
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Summary 2005
• No longer a diagnosis of
exclusion
• Training
• Sharing of Risk
•Prison based pilots
• Inpatient initiatives
•Community pilots
• Patient engagement
• Staff engagement
• Improved patient care
• Improved public safety
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Mental Welfare Commission: Mr G
Impact of diagnosis of personality disorder:
• “Untreatable”, “get out clause for services”
- Speciality services not offered or withdrawn
- No use of structured psychological treatments, despite good evidence supporting their use
- Little help given to alter behaviour – capable of choosing
- Historical information distorted to support diagnosis
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Mental Welfare Commission: Mr G
• SGMHD & SPS to review specialist mental health input to prisons
• SPDN to produce guidance on appropriate interventions for people with a diagnosis of personality disorder
• Education on fronto-temporal dementia
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Summary 2005
• No longer a diagnosis of
exclusion
• Training
• Sharing of Risk
•Prison based pilots
• Inpatient initiatives
•Community pilots
• Patient engagement
• Staff engagement
• Improved patient care
• Improved public safety
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Fatal Accident Inquiry
• Death in Custody• Evidence• Expertise
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Legislation MH(C&T)(S)A 2003
Definition of Mental Disorder Mental disorder means any mental illness, personality disorder or learning disability however caused or manifested
Exclusions - relevant when the exclusion category listed is the only factor.
Sexual orientationSexual deviancyTranssexualismTransvestismAlcohol or drug dependence or useBehaviour that causes, or is likely to cause, harassment, alarm or distress to any other personActing as no prudent person would act.
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Criteria for Detention
Mental disorderSignificantly impaired ability to make decisions about
treatment [Not for MDOs]Significant risk to health, safety or welfare; or safety of
othersAvailable treatments likely to prevent mental disorder
from worsening or alleviate symptoms or effectsNecessity
Underlying principles
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Summary 2005
• No longer a diagnosis of
exclusion
• Training
• Sharing of Risk
•Prison based pilots
• Inpatient initiatives
•Community pilots
• Patient engagement
• Staff engagement
• Improved patient care
• Improved public safety
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Multi-Agency Public Protection ArrangementsMAPPA
Management of Offenders etc. (Scotland) Act 2005
Health service:
Duty to co-operate for all offenders
Responsible authority for restricted patients
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
MAPPA – Types of Offenders
Registered Sex Offenders – April 2007
Restricted patients – 30 April 2008
Violent Offenders – 2009 or 2010?
‘Category 3’ – others with a conviction
posing a risk of serious harm
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
MAPPA Levels
Level 1 – no specific review meetingLevel 2 – regular review meetings considering a number of
casesLevel 3 – dedicated Multi-Agency Public Protection Panel
(MAPPP) considers an individual case
Level based on complexity of multi-agency risk management,not risk assessment.
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Summary 2005
• No longer a diagnosis of
exclusion
• Training
• Sharing of Risk
•Prison based pilots
• Inpatient initiatives
•Community pilots
• Patient engagement
• Staff engagement
• Improved patient care
• Improved public safety
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Problem Behaviour Clinic
• Stalking • Threatening • Fire Setting • Violent Offending• Persistent Complaining • Morbid Jealousy • Problem Gambling
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Perpertrator
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
PREVALENCE OF STALKING IN SCOTLAND
• “Persistent and unwanted attention”
: 17% women ]: 7% men] lifetime: 5% women]: 2% men] in last year• “Stalked”
: 10% women]: 4% men] lifetime
2002•Non harassment orders 37PROTECTION FROM HARASSMENT ACT 1997
•Interdicts 1,511
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
MENTAL DISORDER AND STALKERS
• Symptomatic Pathologies of love - schizophrenia, dementia
• Pure Pathologies of love - erotomanic delusional disorder
• Continuum morbid infatuation Delusions of love
• Personality Disorder
• Substance Abuse
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
CLASSIFICATION OF STALKERS
• Rejected - pursues ex-intimates for reconciliation, revenge or both
• Intimacy seekers - seeking love from someone they love
• Incompetent - inappropriate intrusion, seeking a date or sexual encounter
• Resentful - pursue victims as revenge for actual or perceived injury
• Predatory - for sexual offending
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Stalking
• Stalking is as prevalent in Scotland as in the rest of the Western World
• Legislation exists in response to this issue• Research has focussed on legal matters• There is little clinical input in this area• Treatment: CJSW/Prisons +/- Mental Health input
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network
Progress 2008
• Scottish Government Tripartite Group
Pilot projects within CJSW Services and SPS for
joint health, social services and criminal justice
assessment and management of “problem clients”.
• Shared risk – MAPPA
• Joint working with SPD Network
• Forensic Network MAPPA and Sex Offender lead
Personality Disorder: A Risky Business?
Forensic Network & SPDN 13th June 2008 L.D.G.Thomson@ed.ac.uk
Forensic Network