Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008...

Personality Disorder: A Risky Business?

Forensic Network & SPDN 13th June 2008 [email protected]

Forensic Network

A Forensic Perspective

The Risks of Excluding Offenders with Personality Disorder



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.



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



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



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



Forensic Network

Recidivism Rates

Prison

State Hospital

Recidivism Rate Violent Recidivism Duration

60% - 2 years

31% (20%) 19% (12%) 11 (2)



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



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.



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.



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



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



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



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



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



Forensic Network

Summary 2005


exclusion

• Training

• Sharing of Risk



•Community pilots







Forensic Network



Forensic Network

Fatal Accident Inquiry

• Death in Custody• Evidence• Expertise



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.



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



Forensic Network

Summary 2005


exclusion

• Training

• Sharing of Risk



•Community pilots







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



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



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.



Forensic Network

Summary 2005


exclusion

• Training

• Sharing of Risk



•Community pilots







Forensic Network

Problem Behaviour Clinic

• Stalking • Threatening • Fire Setting • Violent Offending• Persistent Complaining • Morbid Jealousy • Problem Gambling



Forensic Network



Forensic Network

Perpertrator



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



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



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



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



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



Forensic Network

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Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008...

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