Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Services for People with Personality Disorder What progress have we made? The Traditional and the Radical Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Content Traditional Forensic Network Report on Services for People with Personality Disorder in Scotland 2005 [DSPD] Radical Serious Offender Liaison Service National Prison Healthcare Network Mental Health Report Order of Lifelong Restriction Forensic Psychological Matrix Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality Disorder Deeply ingrained maladaptive patterns of behaviour recognisable in adolescence or earlier which continue throughout adult life though may be less noticeable or disabling in later years, but which lead to suffering on the part of the patient or others and have an adverse effect on the individual or society. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Diagnostic Guidelines Evidence that the individuals characteristic and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culture expected and accepted range (or norm). Deviation in more than one of : 1. Cognition 2. Affectivity 3. Control over impulses and gratification of needs 4. Manner of relating and handling interpersonal situations Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Diagnostic Guidelines (cont) Behaviour is inflexible, maladaptive or otherwise dysfunctional across a range of personal+social situations. There is personal distress and/or adverse impact on a social environment. There is evidence that deviation is stable and of long duration, having its onset in late childhood or adolescence. Deviation not explained by other mental disorders or organic brain disease. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Specific Personality Disorders Paranoid Schizoid Dissocial Emotionally unstable - impulsive type - borderline type Histrionic Anankastic Anxious (avoidant) Dependent Mixed Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network LegislationMH(C&T)(S)A 2003 Definition of Mental DisorderMental 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 orientation Sexual deviancy Transsexualism Transvestism Alcohol or drug dependence or use Behaviour that causes, or is likely to cause, harassment, alarm or distress to any other person Acting as no prudent person would act. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Criteria for Detention Mental disorder Significantly impaired ability to make decisions about treatment[Not for MDOs] Significant risk to health, safety or welfare; or safety of others Available treatments likely to prevent mental disorder from worsening or alleviate symptoms or effects Necessity Underlying principles Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Epidemiology Community Casey and Tyrer (1986) n=200PAS PD4% Combined PD3% Severe PD3.5% Gross PD0.5% Primary Care Moran et al (1999) n=303 Prevalence29% Hospital Outpatients30-40% Inpatients40-50% Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Background: Prevalence of ASPD Prison population 80% State Hospital - primary diagnosis 5.4% - secondary diagnosis 27-42% - psychopathy: PCL-R 30+ 0% : PCL-R % ISD 5.1% of discharges in 2000 primary or secondary dx Subtypes: ASPD, Paranoid, Schizoid, Borderline, (Narcissistic) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network NHS: Comorbid Schizophrenia and Anti social Personality disorder Feighner Criteria (DSMIII): school disciplinary; running away; offending; poor work; poor relationships; rage; sexual problems; vagrancy; lying. Based on behavioural patterns. Greater emphasis on Factor 2 traits Schizophrenia and no antisocial personality disorder 113 (67%) Schizophrenia and antisocial personality disorder 56 (33%) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network PCL-R scores Retrospective scoring of case notes up to 1993 (n=161) Mean PCL-R score 14.5, SD 6.9, Range 1-31 Score over patient Score over 25 9 patients Score over 15 87 patients Feighner positive Mean 18.4, SD 6.2, Range 3-31 Feighner negative Mean 12.7, SD 6.4, Range 1-25 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network ASPD History Offending Violent offending Arson and drug offending Substance dependence Outcome out of high security Incidents Self harm No symptom difference No greater number of serious incidents or convictions Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Logistic Regression Model Model to differentiate ASPD and Non ASPD groups (80.4% accuracy) Variables greater in ASPD Previous self harm Previous convictions Higher social functioning Higher PCL-R score Comorbidity changes outcomes Clinical Forum: PD and Problem Behaviours 9 th May 2014 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 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. Clinical Forum: PD and Problem Behaviours 9 th May 2014 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. Clinical Forum: PD and Problem Behaviours 9 th May 2014 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. No longer HMP Grendon - therapeutic community Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Summary 2005 Report No longer a diagnosis of exclusion Training Sharing of Risk Community pilots Prison based pilots Inpatient initiatives Patient engagement Staff engagement Improved patient care Improved public safety Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Diagnosis of Exclusion 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Training Fatal Accident Inquiry Death in Custody Evidence Expertise Clinical Forum: PD and Problem Behaviours 9 th May 2014 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Sharing of Risk Multi-Agency Public Protection Arrangements MAPPA Management of Offenders etc. (Scotland) Act 2005 Health service: Duty to co-operate for all offenders Responsible authority for restricted patients Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network MAPPA Types of Offenders Registered Sex Offenders April 2007 Restricted patients 30 April 2008 Violent Offenders 2015? Category 3 others with a conviction posing a risk of serious harm Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network MAPPA Levels Level 1 no specific review meeting Level 2 regular review meetings considering a number of cases Level 3 dedicated Multi-Agency Public Protection Panel (MAPPP) considers an individual case Level based on complexity of multi-agency risk management, not risk assessment. Clinical Forum: PD and Problem Behaviours 9 th May 2014 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 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality Disorder: Pilots and Initiatives Problem Behaviours Problem Behaviour Clinic Stalking Threatening Fire Setting Violent Offending Persistent Complaining Morbid Jealousy Problem Gambling Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Perpertrator Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Management of High Risk Offenders MacLean Committee Report Dealing with serious violent and sexual offenders, including those with personality disorders Scottish Executive 2000 Risk Management Authority Risk Assessment Order Order of Lifelong Restriction Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Role of Risk Management Authority - Assessment and minimisation of risk or serious violent and sexual offending in Scotland - Setting standards, guidelines and guidance for offender risk assessment and management - Training and accreditation of risk assessors - Policy advice to Ministers - Appraising risk management plans for those on OLR - Monitoring of research - Promotion of evidence based practice Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Risk Assessment Order I 90 (maximum 180) day period of assessment to allow preparation of risk assessment report To assist the court in determining if the nature of, or the circumstances of the commission of, the offence of which the convicted person is being found guilty either in themselves or as part of a pattern of behaviour are such as to demonstrate that there is a likelihood that he, if at liberty, would seriously endanger the lives, or physical or psychological wellbeing, of members of the public at large. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Risk Assessment Order II Offender convicted of a serious violent or sexual offence, or an offence that endangers life Emphasis on clinical risk assessment Risk assessor appointed by court Structured professional judgement RMA structure Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Order for Lifelong Restriction (OLR) Indeterminate detention and lifelong risk management of serious violent and sexual offenders assessed as posing an ongoing high risk of serious harm. Court - balance of probabilities that risk criteria are met Punishment period set by court Risk management plan prepared and submitted to RMA within 9 months Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network High Risk Offenders: Risk Assessment Orders N=63 over first 4 years Male 62 (98.4%) Previous convictions: Any 61 (96.8%) Non sexual violence 48 (76.2%) Age (N=57) Less than to Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network High Risk Offenders: Index Offences Homicide / attempted homicide 13 (20.6%) Others non sexual violence 20 (31.7%) Sexual offending 41 (65.1%) Fire raising 2 (3.2%) Other offences 4 (1.6%) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network High Risk Offenders: Diagnoses Psychopathy (PCL-R >=30) 8 (14%) PCL-R >=25 20 (35.1%) Personality disorder 29 (50.9%) Learning disability 7 (12.3%) Paraphilia 27 (47.4%) Severe mental illness 2 (3.5%) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network High Risk Offenders: Risk Risk conclusion High 49 (77.8%) Medium 14 (22.2%) Low 0 Darjee and Russell, 2011 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network High Risk Offenders: OLR Outcome OLR 49 (77.8%) Discrepancy between risk conclusion and sentencing 5 (2 high and 3 medium) (7.9%) Defence reports commissioned 12 (19%) Oral evidence given in court 7 (11.1%) Subject refused to be interviewed 2 (3.2%) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Indeterminate Sentence for Public Protection Criminal Justice Act years + Convicted of serious specified violent or sexual offence Max penalty 10years+ Court considers poses a significant risk of harm to the public Scotland 72 v England and Wales x8 The State Hospital 29 October 2004 Dr Lindsay Thomson A Problem Behaviour and Personality Disorder Service to Support Criminal Justice Agencies Rajan Darjee, Consultant Forensic Psychiatrist Katharine Russell, Consultant Forensic Clinical Psychologist Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality disorder Criminal justice liaison Problem behaviour Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality disorder in violent and sexual offenders PERSONALITY DISORDER IS PRESENT IN THE MAJORITY OF VIOLENT AND SEXUAL OFFENDERS: % of prisoners 50 60% of sexual offenders 60 70% of violent offenders > 50% of homicide offenders 50 60% of stalkers > 50% of domestic violence perpetrators 80 90% of repeat violent or sexual offenders PERSONALITY DISORDER ASSOCIATED WITH POOR OUTCOMES: RECIDIVISM, SERIOUS HARM NON-COMPLIANCE, RECALL, FAILURE OF STANDARD CRIMINAL JUSTICE APPROACHES STAFF STRESS & BURN-OUT, INTER-AGENCY DISPUTES POOR HEALTH AND SOCIAL OUTCOMES Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality disordered offenders Mental Health Services Criminal Justice Services Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Criminal justice agencies: Police and Criminal Justice Social Work (CJSW) Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network No mental illness! 18 month waiting list! Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Personality disordered offenders Joint working between Criminal Justice and Mental Health Services Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network The problem 30-60% of sexual offenders have personality disorders Almost all complex, high risk or difficult to manage sex offenders have personality disorders Specialist clinical services in Scotland non-existent Forensic mental health services focus on the case management of offenders with mentally illness and learning disability Personality disordered sex offenders managed by criminal justice agencies with little, if any, clinical input Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network The solution 30-60% of sexual offenders have personality disorders Almost all complex, high risk or difficult to manage sex offenders have personality disorders Specialist clinical services in Scotland non-existent Forensic mental health services focus on the case management of offenders with mentally illness and learning disability Personality disordered sex offenders managed by criminal justice agencies with little, if any, clinical input Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Commenced in 2007 with introduction of Multi Agency Public Protection Arrangements (MAPPA) in Scotland Psychology and psychiatry input to help criminal justice social work and the police manage difficult cases Consultation liaison model Integrated working between criminal justice and forensic mental health services Key clinical issues: structured professional judgement, personality dysfunction/disorder, formulation, practical management advice Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Serious Offender Liaison Service Consultant Psychologist Consultant Psychiatrist Psychology Assistant Senior Social Worker Secretary Personality disordered offenders Sexual harm Domestic abuse StalkingArson Other serious violence Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Attend all MAPPA meetings Available for telephone consultation and advice Regular meetings with police sex offender management units and criminal justice social work services Detailed case consultation meetings with case manager Full clinical assessment Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Referral Criteria Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Psychology vs. Psychiatry Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Understand interpersonal, emotional and sexual functioning Understand context, motivation and method of offending Project this into the future to understand risk Understand how personality will impact on risk management approaches Formulation Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Evaluation of utility of SOLS input (Judge et al. 2013) Informing risk managementConfirming what was known and giving weightUnderstanding personalityTreatmentUsefulness and limitations of risk assessment Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network The story so far Positively viewed by CJSW and police Key factors in success: Relationships with partner agencies Integrated, supportive, practical working with CJSW and police Specialist expertise in the assessment and management of high risk personality disordered offenders Focus on interpersonal relationships Awareness of team dynamics Training and clinical supervision Not based on referral criteria, protocols etc Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Outputs 1/10/12-30/9/13 Referrals117 Case Consultations117 Full Assessment 27 Source CJSW74% Police21% NHS 4% Diagnosis: MMI3, LD5, ASD1 ASPD1/2 Narcissistic 1/3 Borderline1/3 Paranoid 1/5 Schizoid1/5 Psychopathy 8 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network The Future: Regional Model North Grampian, Highlands & Islands, & Tayside South & East Lothian, Fife Forth Valley & Borders West Glasgow & Clyde, Lanarkshire, Ayrshire & Arran and Dumfries & Galloway Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network National Prisoner Healthcare Network - Mental Health Working Group Report April 2013 Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network OBJECTIVES To create an equitable mental health and learning disability service where the provision of care for prisoners is similar to the care received for those patients in the community. Nine specific objectives. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network RECOMMENDATIONS Problem Behaviours -A problem behaviour service should be developed within Scottish Prisons in line with the Serious Offender Liaison Service in the Community. -The mentalisation based service for female offenders should be evaluated and extended to male services if appropriate. Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network Other Developments Scottish Government PD Consultation Service for Restricted Patients The Forensic Mental Health Matrix A Guide to Delivering Evidence Based Psychological Therapies in Forensic Mental Health Services in Scotland Forensic Network PD Forum Training N2PTS, MBT, PD in Prisons [England DSPD] Reflective Practice Groups Mentalisation Therapy CBT CAT DBT Schema Focused Therapy Evaluation Clinical Forum: PD and Problem Behaviours 9 th May 2014 Forensic Network 2014 Progress Shared risk MAPPA Joint working with SPD Network Forensic Network PD Group Reflective Practice Specific Therapies SOLS NPHN-MH Report Make the Diagnosis! Future Extension of SOLS Similar Prison Service Agreed model Outcome Studies and Evaluation