Transcript Personality disordered offenders in the community

Personality disordered
offenders in the
community
What is the role of mental health services?
Dr Rajan Darjee
State Hospital
[email protected]
Overview
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Who are personality disordered offenders in the
community?
What is the current policy context?
What should forensic mental health services do
and how?
Attitudes to personality disorder in
forensic mental health services
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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
 ‘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
Media – High profile cases
Personality disordered offenders in
the community
PRISON
HOSPITAL
Personality disordered
offenders
in the community
COURT
NOT YET OFFENDED
Personality disorder and offending
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Prison
Violent offenders
Sexual offenders
Mentally disordered offenders in hospital
Antisocial personality disorder
PERSONALITY
PERSONALITY
DISORDER
PSYCHOPATHY
ANTISOCIAL
PERSONALITY
DISORDER
VIOLENT & SEXUAL OFFENDERS
PERSONALITY
PERSONALITY
DISORDER
PSYCHOPATHY
ANTISOCIAL
PERSONALITY
DISORDER
Hare Psychopathy Checklist- Revised
(PCL-R)
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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
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promiscuous sexual behaviour
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early behaviour problems
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
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Heterogeneity - studies
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Violent offenders
Sex offenders
Mentally disordered offenders
Non-offenders
Heterogeneity
Diagnosis versus formulation
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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
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Services for personality disordered
offenders in England and Wales
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DSPD
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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
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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
What happens at the moment in
Scotland?
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NHS Forensic inpatient units
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SPS
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State Hospital
Orchard Clinic
Low secure forensic units
Offending behaviour programmes
Risk
Segregation units
Vulnerable prisoner units
Community
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Criminal Justice Social Work
Mental Health Services
What happens at the moment in
Scotland?
Should mental health be the lead
agency?
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Resources
Risk management
Responsibility
Lack of expertise and experience
Should there be hospital treatment
for personality disordered offenders?
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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
Legislation and Policy
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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
Forensic Network Working Groups
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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
Forensic Network Working Group on
Personality Disorder
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Not a diagnosis of exclusion
Proper assessment
Better training
Pilot community services
Pilot prison services
No change to hospital practice
Issues to address
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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
Criminal justice agencies
Forensic mental health services working with
criminal justice: SEARCH AND RESCUE
Forensic mental health services working with
criminal justice: WORKING TOGETHER
Multi Agency Public Protection
Arrangements (MAPPA)
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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
Offending behaviour programmes
Accreditation criteria:
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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
Problems of personality disordered offenders
in standard offending behaviour programmes
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Readiness
Motivation
Engagement
Drop-out
Lack of flexibility
Integration
Interpersonal dynamics
Core schema
Forensic mental health role
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Personality Assessment
Case Formulation
Context for relationships
Treatment
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Engagement, motivation, education
‘Basic’ skills
Offending behaviour programmes
Specific psychological interventions for personality
dysfunction
Medication
Risk assessment and management
Future developments
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Pilot Forensic Mental Health Personality
Disorder Services
Multi Agency Public Protection Arrangements
Multi-Agency Public Protection
Arrangements
HEALTH
PERSONALITY
DISORDERED
OFFENDERS
CRIMINAL JUSTICE
HEALTH
CRIMINAL JUSTICE
HEALTH
CRIMINAL JUSTICE
HEALTH
CRIMINAL JUSTICE
The way forward
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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
?
??
Summary
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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
Can you work in forensic
mental health without
being able to deal
appropriately with
offenders with personality
disorders?