Personality disordered offenders in the community

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Personality disordered offenders in the community

• What is the role of mental health services?
• Dr Rajan Darjee
• State Hospital
• rajan.darjee_at_tsh.scot.nhs.uk

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Overview

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

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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

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• Her Majestys Institution for Personality
  Disorders
• Senior Forensic Nurses description of
• H.M.P. Cornton Vale
• Could you tell me if theyre ill or if theyre a
  personality disorder wasting everyones time?
• Defence Solicitor requesting a report

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Media High profile cases
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Personality disordered offenders in the community
PRISON
HOSPITAL
Personality disordered offenders in the
community
COURT
NOT YET OFFENDED
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Personality disorder and offending

• Prison
• Violent offenders
• Sexual offenders
• Mentally disordered offenders in hospital

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Antisocial personality disorder
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PERSONALITY DISORDER
PERSONALITY
ANTISOCIAL PERSONALITY DISORDER
PSYCHOPATHY
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VIOLENT SEXUAL OFFENDERS
PERSONALITY DISORDER
PERSONALITY
ANTISOCIAL PERSONALITY DISORDER
PSYCHOPATHY
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Hare Psychopathy Checklist- Revised (PCL-R)

• promiscuous sexual behaviour
• 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

• 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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Heterogeneity - studies

• Violent offenders
• Sex offenders
• Mentally disordered offenders
• Non-offenders

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Heterogeneity
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Diagnosis versus formulation

• Making diagnosis using ICD-10, DSM-IV or PCL-R is
  of little practical use if youre 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

• 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

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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

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What happens at the moment in Scotland?
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Should mental health be the lead agency?

• Resources
• Risk management
• Responsibility
• Lack of expertise and experience

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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

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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

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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

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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

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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

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Criminal justice agencies
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Forensic mental health services working with
criminal justice SEARCH AND RESCUE
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Forensic mental health services working with
criminal justice WORKING TOGETHER
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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

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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

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Problems of personality disordered offenders in
standard offending behaviour programmes

• Readiness
• Motivation
• Engagement
• Drop-out
• Lack of flexibility
• Integration
• Interpersonal dynamics
• Core schema

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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

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Future developments

• Pilot Forensic Mental Health Personality Disorder
  Services
• Multi Agency Public Protection Arrangements

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Multi-Agency Public Protection Arrangements
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PERSONALITY DISORDERED OFFENDERS
CRIMINAL JUSTICE
HEALTH
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CRIMINAL JUSTICE
HEALTH
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CRIMINAL JUSTICE
HEALTH
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CRIMINAL JUSTICE
HEALTH
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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

?
??
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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

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