Transcript A Network for Practitioners Involved in the Assessment and

The Role of Mental Health
Services in the Management
of Personality Disordered
Offenders in the Community
Dr Rajan Darjee
Consultant Forensic Psychiatrist
Dr Katharine Russell
Chartered Clinical Psychologist
Overview
• Why we’re doing what we’re doing?
• How we’re doing it?
• What we’ve been doing?
"It's time frankly that the
psychiatric profession seriously
examined their own practices
and tried to modernise them in a
way that they have so far failed
to do."
Jack Straw (Home Secretary)
Heterogeneity
No such thing as a
stereotypical sex offender
Mental disorder in sex offenders
Fazel et al. (2007)
Learning disability
Personality disorder
Alcohol/drug related disorders
Anxiety
Depression
Other psychosis
Bipolar disorder
Schizophrenia
0
5
10
15
20
25
Adjusted Odds Ratio
30
35
Mental disorder in sex offenders
Alden et al. (2007)
comorbid personality disorder v comorbid substance misuse v no comorbidity
Any psychosis
Other psychosis
Affectiv e
Organic
Schizophrenia
0
2
4
6
Odds Ratio
8
10
Mental disorder in ‘paedophilic
sex offenders’
Raymond et al. (1999)
Personality disorder
Sexual Dysfunction
Other Paraphilias
Alcohol/drug related
disorders
Anxiety
Mood
0
10
20
30
40
Percentage
50
60
70
80
Mental disorder in elderly sex
offenders
Fazel et al. (2002)
Dementia
Personality disorder
Depression
Psychosis
0
5
10
15
20
Percentage
25
30
35
Mental disorder in referrals to
specialist residential treatment
Dunsieth et al. (2004)
Personality disorder
Paraphilias
Alcohol/drug related
disorders
Anxiety
Mood
0
20
40
60
Percentage
80
100
Mental disorder in sexual
murderers
Stone (2001), Firestone et al (1998), Proulx & Sauvetre (2007)
Personality disorder
Alcohol/drug related
Paraphilia
Anxiety
Mood disorder
Psychosis
0
20
40
60
Percentage
80
100
PERSONALITY
PERSONALITY
DISORDER
PSYCHOPATHY
ANTISOCIAL
PERSONALITY
DISORDER
SEXUAL OFFENDERS
PERSONALITY
PERSONALITY
DISORDER
PSYCHOPATHY
ANTISOCIAL
PERSONALITY
DISORDER
Personality disorder in sex
offenders
• Personality disorder of various types
common
• Personality pathology in sex offenders is
heterogeneous
• Psychopathy associated with adult rape
and sexual homicide
• Obsessive-compulsive and avoidant
personality associated with child offences
• Personality pathology linked to dynamic risk
domains
Stable dynamic domains
SEXUAL
PREOCCUPATION
/ DEVIATION
SOCIO-AFFECTIVE
FUNCTIONING
ATTITUDES
SELF REGULATION
Stable dynamic domains
SEXUAL
PREOCCUPATION
/ DEVIATION
SOCIO-AFFECTIVE
FUNCTIONING
ATTITUDES
SELF REGULATION
‘Personality disorder service’
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Personality disorder
Wider personality issues
Psychopathy
Paraphilia
Sexual dysfunction
Gender identity
Mood disorders
Developmental disorders
Clinical input
RISK ASSESSMENT
SUPPORTING
CRIMINAL JUSTICE
AGENCIES
TREATMENT
Clinical input
RISK ASSESSMENT
SUPPORTING
CRIMINAL JUSTICE
AGENCIES
TREATMENT
Clinical input
RISK ASSESSMENT
SUPPORTING
CRIMINAL JUSTICE
AGENCIES
TREATMENT
Risk Assessment
Static factors
Stable dynamic
factors
Acute dynamic
factors
Triggers
OFFENCE
RISK ASSESSMENT
Structured
Professional
Judgement
Multi-agency
Integrated
Complex &
unusual cases
RMA Guidance
Clinical
understanding
essential
Tiered approach to risk
assessment and
management
Needs
assessment
Risk screening
& monitoring
Assessment &
supervision of
stable &
dynamic risk
Specialist
assessment
and
risk
management
Clinical input
RISK ASSESSMENT
SUPPORTING
CRIMINAL JUSTICE
AGENCIES
TREATMENT
Part of the
MAPPA team
Available for
advice
Clinical
understanding
of offending
Clinical
perspective on
management
SUPPORTING
CRIMINAL JUSTICE
AGENCIES
Linking
offenders in
with services
Another view
Clinical input
RISK ASSESSMENT
SUPPORTING
CRIMINAL
JUSTICE AGENCIE
TREATMENT
Specific therapies
for personality
disorder
Tailored sex
offender
programme
Pharmacological
treatment
Specialist
psychological
treatment of
offending behaviour
Attention to the
context and
relationships
Supporting use of
criminal justice
treatment
TREATMENT
Treatment
Psychological treatment of sex offenders
Sex offenders with personality disorders
or sexual deviation
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More flexible programmes
Emphasis on motivation and engagement
Deal with issues as they arise
Take into account and address core beliefs
Less rigid adherence to timetable/manual
Integrated with other aspects of
management
= MENTAL HEALTH LED JOINT PROGRAMMES
Treatment
Pharmacological treatment of sex offenders
• Part of sex offender programmes in all developed
countries … except Scotland!!
• Medications include SSRIs and anti-libidinals
• Important consideration for a significant minority
of sex offenders (5-10%)
• Who will assess? Who will treat? Who will pay?
Understanding and managing
personality disordered offenders
• Risk
• Need
• Responsivity
Forensic mental health
service
A ONE TRICK
PONY?
Taking responsibility for
patient’s behaviour
Forensic mental health services working with
criminal justice: SEARCH AND RESCUE
Section 328 definition of mental
disorder includes personality disorder
Traditional multi-agency working
model
Criminal justice agencies
Forensic mental health services working
with criminal justice: WORKING TOGETHER
Multi-Agency Public Protection
Arrangements (MAPPA)
SACRO
HOUSING
OFFENDER
CRIMINAL
JUSTICE
SOCIAL WORK
POLICE
MENTAL HEALTH
Forget the nonsense
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Responsibility
“Not mentally ill”
No formal mental disorder
Undeserving
“Untreatable”
Mental health services have nothing to offer
If something goes wrong we’ll get the blame
Detention in hospital
How we’re doing it
• MAPPA Health Representatives for
Lothian
• Attending Level 2 and Level 3 meetings
• Available for phone consultation
• Point of liaison between NHS Lothian
colleagues and MAPPA colleagues
How we’re doing it
• Provide basic input to MAPPA on the
NHS contacts patients are having or
have had
• HOWEVER provide additional input in
terms of consultancy on cases, e.g.
interpreting previous clinic reports,
advising on risk, advising on available
treatments and suitability
How we’re doing it
• Provide training to NHS staff on MAPPA
• MAPPA now extends to restricted
patients as well as sex offenders which
has impact on psychiatric colleagues
Sex Offender Liaison Service
(SOLS)
• Established in April 2007 to support MAPPA
• Referrals from Criminal Justice Social Work,
Police and MAPPA
• Sex offenders with personality disorders or
sexual deviation
• Assessments to help criminal justice
agencies manage risk in community
• NOT route to standard mental health
involvement
Sex Offender Liaison Service
(SOLS)
• Staff
– Psychiatrist, psychologist, nurse, OT
– MAPPA clinical representatives
• Referrals
– 25 referrals
– Internet offences – sexual homicide
• Assessments
– 2 staff
– Long and thorough
– Structured professional judgement
• Resources
– None
• Treatment
– Not primarily a treatment service
– Medication
Referral
• Referrals from CJSW and Police
• Assessment only
• Risk Assessment
• Medication potential
• Most cases are 2:1
• Supervision is provided
Referrals
• Some referrals come via our direct input to
MAPPA
• Letters sent to Police and CJSW re our
service
• Now getting increased rate of referral as
word of mouth increases
Risk Assessment
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Psychiatry and Clinical Psychology
One or two interviews is normal
Review of notes
Discussion with case workers
Two staff allows for element of supervision
Medication
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A more recent addition to the service
Seen by Psychiatry
First service of its kind in Scotland
Follow-up provided
Medication
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Psychiatry
Review notes
Interview
Review of Symptoms
Prescription of anti-androgens/SSRIs
Follow-up
Reports
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Background information
PCL-R
RSVP (HCR-20 if appropriate)
Marshall/Hucker Sadism scale
Offence Analysis
Formulation
Recommendations
Follow-up
• Following risk assessment we may refer onto
other health services, e.g. psychology,
sexual dysfunction, psychotherapy
• No treatment provided by our service due
to lack of resources
SOLS assessments
• Number of referrals
– 23
• Referred by
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CJSW
Police
MAPPA
Court
NHS
14
2
2
2
3
SOLS assessments
• Offence (most serious sexual offence)
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Homicide
Rape
Sexual assault
Incest
Internet
Other non-contact
• Victims
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Adult female only
Adult male only
Child only
Adult and child
2
7
6
1
3
3
11
1
10
1
SOLS assessments
• Reason for referral (not mutually exclusive)
– Risk assessment
– Diagnosis and implications
– Assessment/treatment of sexual problems
• MAPPA level
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3
2
1
N/A
4
13
0
6
12
11
4
SOLS assessments
• Number of staff carrying out assessment
– One
– Two
5
18
• Tools used
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PCL-R
RSVP
HCR-20
SSS (Marshall/Hucker)
10
10
3
1
SOLS assessments
• Personality disorder (n=17)
– Definite
– Traits
– None
11
4
2
• Personality diagnoses (not
mutually exclusive)
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Antisocial
Narcissistic
Borderline
Schizotypal
Paranoid
Schizoid
Avoidant
Dependent
8
8
3
2
3
1
1
1
SOLS assessments
• Paraphilia (n=23)
– Definite 7
– Possible 2
– None
14
• Specific paraphilias
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Paedophilia
Non-sadistic rape fantasies
Fetishism
Exhibitionism
9
1
1
1
Mr Z
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Murder of man – query sexual element
Served 11 years of life sentence
Been in community on licence for 4 years
Recently causing concerns with social work
re voicing extreme anger at men he is in
relationships with which mirrored index
offence
Mr Z #2
• Info at interview differed drastically from file
info
• He was very open about this – stated it
would be stupid to be truthful while trying to
get out on parole from prison
• Presented as hostile towards women – both
in self-report and in reaction to female
interviewer
Mr Z #3
• Very controlling in interview – had his own
agenda about what he wanted to convey
• Gave detailed gruesome recall of index
offence
• No sign of remorse
• Left us no clearer as to why currently
presenting with more issues to social work
• Continues to deny sexual element to
offence
Mr Z #4
• Index offence followed near strangulation of
his wife and grievance re victim
• 90th Percentile on PCL-R Factor 1
• Openly admits to using violence when he
has a grievance
• Has had sexual relationship with vulnerable
female recently leaving him ‘enraged’.
• Following this he harmed himself
Mr Z #5
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Grave concerns about this man
Likely to have breached his licence
Report back to Social Worker
GP has seen him re Anxiety and Depression
Scored off the scale on HADS
Telephone discussion with Psychiatrist who
was referred Mr Z by GP
Mr Z #6
• Attended Risk management Case
Conference (RMCC)
• Gave clinical advice to GP re
diagnosis
• Added significantly to understanding
of case
• Risk formulation influenced decisions
about potential victims and housing
Sex Offender Liaison Service (SOLS)
What we’d like to do?
• See far more referrals for assessment
• Offer treatment programme for high risk /
high needs sex offenders (=personality
disorder)
• Develop treatment for sexually deviant
offenders
• Make clinical input more readily available to
criminal justice social work and police
• Retain criminal justice / MAPPA framework
• See people who present before they offend
• BUT ALL OF THIS NEEDS RESOURCES
Future developments
FUNDING
• NHS Lothian
• Scottish Government
LOCALLY (NHS Lothian - as part of MAPPA/community
forensic developments)
• Increased capacity to see referrals
• Referrals from NHS as well as criminal justice
• Develop treatment
• Evaluate as community forensic PD pilot
NATIONALLY (Forensic Network)
• Developing role of forensic mental health in MAPPA
• Teaching and training – PD, sex offending, risk
• Developing assessment and treatment of sex offenders
Dr Rajan Darjee Consultant Forensic Psychiatrist
Dr Katharine Russell Chartered Clinical Psychologist
The Orchard Clinic
Royal Edinburgh Hospital
Morningside Terrace
Edinburgh EH10 5HF
0131 537 5866
[email protected]
[email protected]