Welcome Hugh Hamill Deputy Director PBNI Chair PPANI SMB
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Anthony Harbinson Director of Safer Communities Department of
Justice
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Geraldine OHare Head of Psychology PBNI Chair PPANI SMB
Education and Training Subgroup
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Dr Richard Bunn Consultant Psychiatrist Belfast HSCT
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Ramada Plaza Belfast 18 th December 2013
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Dr Richard Bunn Consultant in Forensic Psychiatry Shannon
Clinic, Regional Secure Unit.
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Who am I really?
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Public Protection
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Violence and Mentally Disordered Offenders Mentally ill
offenders are more violent than the general population. They commit
more homicides. Medication is irrelevant. Severe personality
disorder is not associated with violent offending.
Slide 13
Violence and Mentally Disordered Offenders Mentally ill
offenders are not more violent than the general population. They do
not commit more homicides. Breakdown in medication regimes can be a
trigger factor. [Boyd Committee] Boyd Committee: A Preliminary
Report on Homicide - A Report of the Steering Committee of the
Confidential Inquiry into Homicide and Suicide of Mentally Ill
Persons. London: Boyd Committee. Severe personality disorder has
been associated with violent offending, and requires specific
assessment.
Slide 14
Most violence is committed by people WITHOUT mental
illness
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mental health, violence and homicide
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Slide 18
Schizophrenic who killed Jonathan Zito set to be moved from
high-security prison By Daily Mail Reporter Christopher Clunis, who
stabbed Jonathan Zito through the eye, is being moved to a
medium-security unitDaily Mail Reporter Christopher Clunis, a
schizophrenic,was jailed indefinitely after stabbing Jonathan Zito,
27, through the eye at a packed Finsbury Park tube station in
December 1992. The case caused outrage when it was revealed that
Clunis, now 45, who had a history of violent behaviour, had been
released under the controversial 'care in the community' programme
just weeks before the killing. Eight days before the attack,
Clunis, who had stopped taking his medication, was found wandering
the streets with a screwdriver and breadknife, threatening
children. Sources at Rampton high security hospital, in
Nottinghamshire, have said there are plans to move 18st Clunis to a
medium-secure unit in Northamptonshire. One source told the Evening
Standard: 'Clunis will be transferred on a trial-leave basis for
six months with a view to him staying put if all goes to plan. 'It
is hugely significant and the beginning of a stage-by-stage process
designed to prepare patients for eventual release back into the
community. 'It shows experts feel Clunis is responding to treatment
and he could have his freedom sooner than anyone ever expected.'
Clunis was diagnosed as a paranoid schizophrenic in 1986. An
inquiry after Mr Zito's death found a 'catalogue of failure and
missed opportunity' by professionals who should have been
monitoring him.
Slide 19
The National Confidential Inquiry 9% of all homicides in
England and Wales are committed by mentally ill persons. The rate
is approximately 50 per year or one a week.
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The National Confidential Inquiry Mentally ill persons who
commit homicide are more likely to have a history of previous
violence. 25% of mentally ill persons who committed homicide were
non-compliant with medication in the month preceding the event. 1
in 20 homicides are committed by persons with schizophrenia. In the
week prior to the homicide 29% of patients were seen by services;
and only 9% were thought to be of short-term moderate or high risk
of violent behaviour.
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Mental Health
Slide 22
Question 1. Mental Illness is rare. False As many as 1 in 6
adults are affected at any one time and up to 1 in 4 consultations
with a GP concern mental health issues. (Source - Sainsbury Centre
for Mental Health) Question 2. People with mental illness are more
likely to kill strangers than people who do not suffer from mental
illness. False Those suffering from mental illness are less likely
to kill than the General population. (Source - National
Confidential Inquiry into Homicide and Suicide) Question 3. The
rate of homicide committed by people suffering from mental illness
is increasing. False There is evidence of an absolute decline.
(Source - Mental Health and Serious Harm to Others, NHS National
Programme on Forensic Mental Health Research and Development)
Question 4. The rate of serious violence committed by those
suffering from mental illness is increasing. True & False. The
rate is rising but not as much as in the general population.
(Source - Mental Health and Serious Harm to Others, NHS National
Programme on Forensic Mental Health Research and Development)
Question 5. Young people are likely to understand the
discrimination associated with mental health problems. True. A
survey in 2001 found that 80% of young people believe that having a
mental health problem will lead to discrimination. 65% also
identified young people as major perpetrators of discrimination.
(Source - Dept. of Health Press Release 11.3.2001)
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Mental illness can lead directly to or create a vulnerability
to crime. People with mental illness, whether or not they have
committed a serious offence, may be more likely... to be
compromised or damaged by the criminal justice system. For example,
they may be: More vulnerable to arrest. More vulnerable to
injustice within the criminal justice system. At more risk of other
harm by the system, for example adverse effects of custodial care
and/or other institutions, e.g. an elevated suicide rate among
prisoners. Susceptible people without mental illness on entry to
the criminal justice system may develop it. People with mental
illness may be more vulnerable to becoming a victim of crime
through: Direct victimisation. Becoming victims of press and/or
public fear and hostility whether having offended or not, and,
where they have, at a disproportionate level compared to offenders
without mental illness.
Slide 25
Outline: Classification of Mental Disorders
Slide 26
Violence & Schizophrenia 1 st episode schizophrenia 52/253
violent in 1992 study 36 violent in preceding year 16 > 1 year
after admission Humphreys, et al (1992) Dangerous behavior
preceding first admissions for schizophrenia Br J Schiz 161:501-505
Violence & Mental Illness Violence was greater only with acute
symptoms Schizophrenia lower rates of violence than depression or
Bipolar Disorder Substance Abuse > than Mental Illness Monahan,
1997 Actuarial support for the clinical assessment of violence
risk. International Review of psychiatry 176:312-319.
Slide 27
Violence & Paranoia Paranoid psychotic patients Violence
well-planned and in-line with beliefs Relatives or friends are
usual targets Paranoid in community more dangerous than
institutionalized given weapons access Krakowski et al., (1986)
Psychopathology and Violence: a review of the literature. Compr
Psych 27 (2): 131-148
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Violence & Delusions Delusions conflicting data Factors to
consider Threat/control override symptoms Non-delusional
suspiciousness If delusions make people unhappy, frightened or
angry. Whether they have acted on previous delusion Borum et al.,
1996
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Violence & hallucinations In general, AVH not inherent risk
Certain types increase risk Hallucinations that generate negative
emotions If pts. have not developed coping strategies Command
Hallucinations 7 studies that showed no relationship MacArthur
study (2001) showed general hallucinations were not associated but
there was a relationship between command hallucinations to commit
violence
Slide 30
Violence & Mania High percentage of assaultive or
threatening behavior Serious violence is rare Violence with
restraints Violence with limit setting Tardiff (1980) Assault,
suicide, and mental illness. Arch Gen Psych 37 (2): 164-169
Slide 31
Violence & Depression Depression May strike out in despair
Depressed mothers who kill their children Most common diagnosis in
murder-suicide Extension of suicide In couples, associated with
feelings of jealousness and possessiveness Resnick (1969) Child
murder by parents: a psychiatric review of filicide. Am J Psych 126
(3): 325- 334 Rosenbaum (1990) The role of depression in couples
involved in murder-suicide and homicide. Am J Psych 147 (8):
1036-1039
Slide 32
Violence & Brain Injury Brain Injury Aggressive features:
Trivial triggering stimuli Impulsivity No clear aim or goals
Explosive outbursts Concern and remorse following episode Geriatric
senile organic psychotic disease More assaultive than ANY other
diagnosis Kalunian (1990) Violence by geriatric patients who need
psychiatric hospitalization. J Clin Psych 51 (8): 340-343
Slide 33
Violence & Personality Personality Disorders Borderline
somewhat associated Antisocial personal disorder most common
Violence is cold and calculated Motivated by revenge Occurs during
periods of heavy drinking Combined with low IQ very ominous
combination
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Violence & personality Personality Traits Impulsivity
Inability to tolerate criticism Repetitive antisocial behavior
Reckless driving A sense of entitlement and superficiality Typical
Violence paroxysmal, episodic Borum (1996)
Slide 35
Violence & Psychopathy Originally described by Cleckley
(1941) in The Mask of Sanity Operationalized by Hare (1980, 1991,
2003): The Psychopathy Checklist- Revised (PCL-R) Unique
interpersonal, affective, and behavioral traits Not in the DSM-IV
or ICD-10 The most important factor in the risk of predatory
violence.
Slide 36
Violence &: PTSD Domestic Violence Intellectual disability
ADHD Substances - 50-80% involved in violent crimes are under the
influence of alcohol at the time of the offense.
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Violence & Substances 50-80% involved in violent crimes are
under the influence of alcohol at the time of the offense. "..
people with a mental disorder are at least as likely to use
substances as anyone else and people with anti-social personality
disorder are significantly more likely than average to drink too
much. The combination of an anti-social personality disorder and
use of alcohol is strongly associated with a high risk of harm to
other people." De Montfort University (2007) Substance Use, Mental
Health and Crime. BA (Hons.) Community and Criminal Justice Module
Guide. Leicester, De Montfort University, p. 96.
Slide 38
Mental Health Services available for Offenders Voluntary Sector
Community Mental Health Teams (CMHTs) Community Forensic Mental
Health Teams (CFMHT) Psychiatric Hospital Regional Secure Units
People with mental health problems who are caught up in the
criminal justice system may be admitted into a regional secure
unit. They may be: Admitted from the courts under an order of the
Mental Health Order, Transferred from an ordinary hospital because
it is thought they need to be in a more secure setting, Transferred
from prison under the Mental Health Order, or Transferred from a
special hospital because they no longer need to be under maximum
security. Special Hospitals People with a major mental disorder,
who are detainable under mental health law and who are considered
to pose a risk to others, may be admitted to a high security
special hospital. Ashworth, Broadmoor, Carstairs and Rampton.
Hospital orders and the transfer of prisoners to hospital for
mental health treatment. It is important for those dealing with
offenders being compulsorily detained in these and similar
circumstances to understand the legal position.
Slide 39
Offenders and Mental Health The numbers of offenders with
mental health both in the community and in prison are
disproportionate to the numbers of people in the general
population. This is particularly true in relation to female and
young offenders. Prisoners have significantly higher rates of
mental health problems than the general public (see table below
from ).
Slide 40
Briefing No 39: Mental health care and the criminal justice
system Sainsbury Centre for Mental Health gives these figures: Up
to 90% of prisoners have some form of mental health problem
(Singleton et al. 1998). 10% of male and 30% of female prisoners
have previously experienced a psychiatric acute admission to
hospital (DOH 2007). Most prisoners with mental health problems
have common conditions, such as depression or anxiety. A smaller
number have more severe conditions such as psychosis. Some Black
communities are overrepresented in secure mental health forensic
hospitals (Rutherford & Duggan 2007). A study of 500 women
prisoners found that "women in custody are five times more likely
to have a mental health concern than women in the general
population" (University of Oxford, cited in Prison Reform Trust
2008). Young people in custody have an even greater prevalence of
poor mental health, with 95% of 16 to 20 year olds having at least
one mental health problem and 80% having more than one (Lader et
al. 2000). The Office for National Statistics (ONS) study showed
78% of male remand prisoners with personality disorder, 64% of male
sentenced prisoners and 50% of female prisoners. Anti-social
personality disorder had the highest prevalence of any category of
personality disorder. (Bradley review). A disproportionate 28% of
Mental health treatment requirements made in 2006 were made in
relation to non-white ethnic groups. (Seymour & Rutherford
Sainsbury centre for mental health 2008). A third of women subject
to community supervision by the Probation Service said they had a
mental disorder. During the same period the figure for men was one
in five (Mair and May 1997, quoted in Seymour & Rutherford). By
2006 research In London demonstrated that 48 per cent of offenders
in touch with the London probation Service were experiencing mental
health concerns and that as many as a third of offenders in the
community also had a personality disorder (Solomon and Rutherford
2007 quoted in Seymour & Rutherford).
Slide 41
Promoting Quality Care Improve Safety Promote consistency
Support services & Interfaces Regional Learning Promote good
practice Principles Work with service users and carers Team working
Risk Management Communication Recovery & Positive Risk taking
Collaborative working AHPs, users, et al Understand roles &
responsibilities Risk management Effective communication
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Promoting Quality Care Care Planning Contingency & Crises
plan Level of risk Frequency of review Comprehensive Risk
Assessment Key worker responsibilities Care coordination
responsibilities Recording of information Manage transfer &
transitions - NCISH Discharge planning RQIA AUDIT
Slide 43
Why do we do it? Tarasoff v. The regents of the University of
California, 1976.
Slide 44
Considering Mental Health
Slide 45
For further sources on mental disorder and violent crime:
Blumenthal, S. and Lavender, T. (2001) Violence and mental
disorder: A critical aid to the assessment and management of risk.
Jessica Kingsley Publishers, published for the Zito Trust. Bonta,
J., Law, M. and Hanson, K. (1998) The prediction of criminal and
violent recidivism among mentally disordered offenders.
Psychological Bulletin, Vol. 123, pp. 123-142. Coid, J. et al.
(2007) Predicting and understanding risk of re-offending: the
Prisoner Cohort Study. Home Office Research Summary 6/07, Ministry
of Justice, London. Doyle, M. and Dolan, M. (2006) Predicting
community violence from patients discharged from mental health
services. British Journal of Psychiatry, Vol. 189, pp. 520-526.
Monahan, J. (1992) Mental disorder and violent behaviour. American
Psychologist, Vol. 47, pp. 511-521. Monahan, J. et al. (2001)
Rethinking risk assessment: The MacArthur Study of Mental Disorder
and Violence. Oxford University Press. Prins, H. (2005) Mental
disorder and violent crime: a problematic relationship. Probation
Journal, Vol. 52 (4), pp. 333-357. Snowden, R. J., Gray, N.,
Taylor, J. and MacCulloch, M. J. (2007) Actuarial prediction of
violent recidivism in mentally disordered offenders. Psychological
Medicine, Vol. 37, pp. 1539-1549. Taylor, P. and Gunn, J. (1999)
Homicides by People with Mental Illness: Myth and Reality. British
Journal of Psychiatry, Vol. 174, pp. 9-14.
Slide 46
For guidance see: Ministry of Justice - Mentally disordered
offenders. Ministry of Justice - Mentally disordered offenders,
guidance. Best Practice in Managing Risk: Principles and evidence
for best practice in the assessment and management of risk to self
and others in mental health services. (Dept of Health 2007)
Avoidable deaths: five year report of the national confidential
inquiry into suicide and homicide by people with mental illness
(2006). The National Confidential Inquiry into Suicide and Homicide
by People with a Mental Illness is a national research project
carried out at the University of Manchester since 1996 with
periodic updates. The inquiry collects detailed clinical
information on all suicides and homicides that occur under mental
health services in England, Wales, Scotland and Northern Ireland.
Morgan S. (2000) Clinical Risk Management: A Clinical Tool and
Practitioners Manual. The Sainsbury Centre for Mental Health.
Giving up the culture of blame: risk assessment and risk management
in psychiatric practice. Prepared for the Royal College of
Psychiatrists, by Dr John F. Morgan (2007). The Mental Health
Policy Implementation Guide. Dual Diagnosis Good Practice Guide.
(Dept of Health, 2002) advises that the possible association
between substance misuse and increased risk of aggressive or
anti-social behaviour forms an integral part of the risk
assessment, and should be explicitly documented. MAPPA Guidance
2009, version 3, sections mental health paragraphs
24.9-24.9.7.
Slide 47
Additional Materials: Fernando, S. (1991) Mental Health, Race
and Culture. Basingstoke: Macmillan. Madden, A. (2009) Treating
Violence a guide to risk management in mental health. Oxford:
Oxford University Press. (Anthony Madden is a practicing
psychiatrist with a very pro-active view on risk assessment in
mental health). Prins, H. (2005) Offenders, Deviants or Patients?
London, Routledge. Prison Inspectorate (2007) The mental health of
prisoners: A thematic review of the care and support of prisoners
with mental health needs. These websites are useful sources of more
information: Department of Health Royal College of Psychiatrists.
Mind (National Association for Mental Health). Personality Disorder
Website.
PERSONALITY DISORDER AND MANAGEMENT OF RISK Dr. Ian
Bownes.
Slide 51
WHAT IS PERSONALITY DISORDER? - a personality disorder is an
enduring pattern of inner experience and behaviour that deviates
markedly from the expectations of the individuals culture, is
pervasive and inflexible, has onset in adolescence or early
adulthood, is stable over time and leads to distress and/or
impairment. - a personality disorder is an enduring pattern of
inner experience and behaviour that deviates markedly from the
expectations of the individuals culture, is pervasive and
inflexible, has onset in adolescence or early adulthood, is stable
over time and leads to distress and/or impairment.
Slide 52
SPECTRUM OF DISORDER DANGEROUS SEVERE PERSONALITY DISORDER
CATEGORICAL DISORDER OF PERSONALITY AS CATEGORISED BY 1CD- 10
PERSONALITY BASED DEFICITS AND DEFICIENCIES CHARACTEROLOGICAL
TRAITS ODD/ECCENTRIC/NON-CONFORMING
Slide 53
EPIDEMIOLOGY OF PERSONALITY DISORDER - Around 14% of General
Population will have a categorical personality disorder diagnosis.
- Around 14% of General Population will have a categorical
personality disorder diagnosis. - 0.6 2% general population will
have ASPD - 0.6 2% general population will have ASPD - But 50 70 %
of CJS Clientele will have ASPD - But 50 70 % of CJS Clientele will
have ASPD - Combination of ASPD and Emotionally Unstable
Personality Traits most associated with harm to self and others. -
Combination of ASPD and Emotionally Unstable Personality Traits
most associated with harm to self and others.
Slide 54
POINTS ABOUT PERSONALITY DISORDER - Common in society
generally. - Common in society generally. - High incidence in
forensic populations. - High incidence in forensic populations. -
Acquired in significant personal adversity - Acquired in
significant personal adversity - No comprehensive legislative
framework. - No comprehensive legislative framework. - Not proven
to be untreatable or fully treatable - Not proven to be untreatable
or fully treatable - Core Symptoms/ behaviours fluctuate over time.
- Core Symptoms/ behaviours fluctuate over time. - Highly co-morbid
- to psychosocial dysfunction, mental illness, self-harm and
suicide. - Highly co-morbid - to psychosocial dysfunction, mental
illness, self-harm and suicide.
Slide 55
WHY WORRY ABOUT SEVERE P.D.? - PUBLIC PERCEPTION OF RISK FROM
MEDIA. - PUBLIC PERCEPTION OF RISK FROM MEDIA. - A MAJOR COMPONENT
OF C.J. S. WORKLOAD - A MAJOR COMPONENT OF C.J. S. WORKLOAD -
ASSOCIATED WITH PERSONAL DISTRESS. - ASSOCIATED WITH PERSONAL
DISTRESS. - MAJOR FINANCIAL BURDEN TO TRUSTS - A&E SELF HARM. -
POPULATE PSYCHIATRIC ADMISSION WARDS DUE TO PSYCHIATRIC
COMORBIDITIES. - NEED TREATMENT FOR SUBSTANCE MISUSE. - REQUIRE
SOCIAL SERVICES INTERVENTION.
Slide 56
CHARACTERISTICS OF PERSONALITY DISORDERED History of Childhood
Deprivation and abuse. History of Childhood Deprivation and abuse.
Familial Dysfunctionality/Criminality/Paramilitarism. Familial
Dysfunctionality/Criminality/Paramilitarism. Exposure to violent
role models. Exposure to violent role models. Punishment
Beatings/shootings for ASPD. Punishment Beatings/shootings for
ASPD. Use Instrumental Violence to own ends. Use Instrumental
Violence to own ends. Interpersonal alienation. Interpersonal
alienation. Abuse Drugs and Alcohol. Abuse Drugs and Alcohol.
Non-Compliance with therapeutic Interventions. Non-Compliance with
therapeutic Interventions. External Attribution of Blame. External
Attribution of Blame. See Statutory Services as oppressive agents
of Social Control. See Statutory Services as oppressive agents of
Social Control.
Slide 57
INEVITABLE CONSEQUENCES OF PERSONALITY DISORDER - Severe family
disharmony. - Severe family disharmony. - School drop out. - School
drop out. - Employment problems. - Employment problems. - Extremely
hazardous lifestyle. - Extremely hazardous lifestyle. - Associated
with Substance Misuse. - Associated with Substance Misuse. -
Associated with Criminality. - Associated with Criminality. -
Associated with Mental & Physical Ill health. - Associated with
Mental & Physical Ill health. - Associated with frequent
episodes of DSH. - Associated with frequent episodes of DSH. - High
proportion commit Suicide. - High proportion commit Suicide. -
Associated with impulsive aggressive behaviours. - Associated with
impulsive aggressive behaviours.
Slide 58
PERSONALITY DISORDERED OFFENDERS - All ICD-10 CATEGORIES ARE
REPRESENTED. - All ICD-10 CATEGORIES ARE REPRESENTED. - ASPD AND
BPD MOST CLOSELY LINKED TO VIOLENCE. - ASPD AND BPD MOST CLOSELY
LINKED TO VIOLENCE. - TEND TO HAVE LONG CRIMINAL CAREERS - TEND TO
HAVE LONG CRIMINAL CAREERS - HIGH LEVELS OF RECIDIVISM - HIGH
LEVELS OF RECIDIVISM - TEND TO DROP OUT OF TREATMENT PREMATURELY -
TEND TO DROP OUT OF TREATMENT PREMATURELY - TEND TO SHOW SOME
RELIEF WITH TIME - TEND TO SHOW SOME RELIEF WITH TIME - NEED 4-8
YEARS OF TREATMENTTO MAKE DIFFERENCE - NEED 4-8 YEARS OF
TREATMENTTO MAKE DIFFERENCE
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PSYCHOPATHOLOGY IN PERSONALITY DISORDERED. PSYCHOPATHY -
MANIPULATIVE INSTRUMENTAL VIOLENCE MOOD SWINGS IMPULSIVE BEHAVIOUR
ACTING OUT OPPOSITIONAL & DEFIANT BEHAVIOUR ANXIETY STATES POOR
SLEEP WORRIES ABOUT FAMILY/PERSONAL SECURITY STAYING IN CELL
Slide 60
ORIGINS OF RISK IN THE PERSONALITY DISORDERED
Slide 61
TRAUMATIC CHILDHOOD EXPERIENCES - UP TO 80% OF PERSONALITY
DISORDERED - UP TO 80% OF PERSONALITY DISORDERED ABANDONMENT
ABANDONMENT TERRORISATION TERRORISATION CRUELTY CRUELTY HUMILIATION
HUMILIATION - CAUSES ATTACHMENT INSECURITY - CAUSES ATTACHMENT
INSECURITY - IMPEDES SELF-REFLECTIVE FUNCTION - IMPEDES
SELF-REFLECTIVE FUNCTION - LIMITS CAPACITY TO ARTICULATE DISTRESS -
LIMITS CAPACITY TO ARTICULATE DISTRESS - IMPEDES DEVELOPMENT OF
EMPATHY - IMPEDES DEVELOPMENT OF EMPATHY - INCREASES SENSITIVITY TO
THREAT - INCREASES SENSITIVITY TO THREAT - LEADS TO HYPERAROUSAL -
LEADS TO HYPERAROUSAL
Slide 62
DISORGANISED ATTACHMENT IN PERSONALITY DISORDERED - ASSOCIATED
WITH CHILDHOOD ABUSE - ASSOCIATED WITH CHILDHOOD ABUSE - INCREASED
MENTAL DISORDER - INCREASED MENTAL DISORDER - DISSOCIATION WHEN
STRESSED - DISSOCIATION WHEN STRESSED - INCREASED SENSE OF THREAT -
INCREASED SENSE OF THREAT - FRANTIC RE-ATTACHMENT EFFORTS - FRANTIC
RE-ATTACHMENT EFFORTS - TOXIC/PATHOLOGICAL ATTACHMENT -
TOXIC/PATHOLOGICAL ATTACHMENT - CONTROLLING BEHAVIOURS -
CONTROLLING BEHAVIOURS - RE-ENACTMENT OF TRAUMA - RE-ENACTMENT OF
TRAUMA
Slide 63
ATTACHMENT AND THE PERSONALITY DISORDERD - WEAKENING OF
ATTACHEMENT LEADS TO: - DISCHARGE OF EMOTION - ABANDONMENT FEARS -
ANNIHILATION FEAR - RESENTMENT - SENSE OF BETRAYAL - SENSE OF LOSS
- VIOLENCE
Slide 64
PATHOLOGICAL ATTACHMENTS - DISMISSIVE OR ENMESHING -
COMPENSATORY FOR RECENT LOSS - EMOTIONALLY CHARGED/CONTRADICTORY -
FEELINGS OF LOVE OR HATE - FEELINGS OF BEING CONTROLLED - FEELINGS
OF BEING EXPLOITED - FEELINGS OF BEING UNDER THREAT - DEVOID OF
FEELINGS OF TENDERNESS - NEW ATTACHMENTS MIRROR OLD ONES - RISK OF
VIOLENCE MAY INCREASE
Slide 65
RISK AND PERSONALITY DISORDER
Slide 66
WHAT IS RISK? risk is simply the probability or likelihood of a
particular event occurring. risk is simply the probability or
likelihood of a particular event occurring.
Slide 67
How dangerous is it that this man go loose? How dangerous is it
that this man go loose? HAMLET HAMLET
Slide 68
Risk Assessment is not about making an accurate prediction -
but about making informed defensible decisions. Risk Assessment is
not about making an accurate prediction - but about making informed
defensible decisions. (Grounds, 1995)
Slide 69
CHARACTERISTICS OF RISK - CHANGES WITH TIME. - CHANGES WITH
TIME. - CAN INCREASE OR DECREASE. - CAN INCREASE OR DECREASE. - IS
UNCERTAIN ONLY RELATIVE PROBABILITIES CAN BE ESTIMATED. - IS
UNCERTAIN ONLY RELATIVE PROBABILITIES CAN BE ESTIMATED. - OPERATES
ALONG A CONTINUUM. - OPERATES ALONG A CONTINUUM. - THRESHOLDS OF
RISK ARE DIFFICULT TO ESTABLISH. - THRESHOLDS OF RISK ARE DIFFICULT
TO ESTABLISH. - DIFFERENCES BETWEEN LOW MODERATE HIGH OFTEN MINIMAL
- DIFFERENCES BETWEEN LOW MODERATE HIGH OFTEN MINIMAL
Slide 70
GENERAL CHARACTERISTICS OF AT RISK PERSONALITY DISORDERED
Diagnosis frequently unclear. Diagnosis frequently unclear. Mix of
Treatable and Untreatable Symptoms. Mix of Treatable and
Untreatable Symptoms. Neuropsychological deficits.
Neuropsychological deficits. History of Childhood Deprivation and
abuse. History of Childhood Deprivation and abuse. Familial
Dysfunctionality/Criminality. Familial
Dysfunctionality/Criminality. Exposure to violent role models
Exposure to violent role models Use Instrumental Violence to own
ends. Use Instrumental Violence to own ends. Interpersonal
alienation. Interpersonal alienation. Abuse Drugs and Alcohol.
Abuse Drugs and Alcohol. Non-Compliance with therapeutic
Interventions. Non-Compliance with therapeutic Interventions.
Hostile Attribution of Blame. Hostile Attribution of Blame. See
Statutory Services as oppressive agents of Social Control. See
Statutory Services as oppressive agents of Social Control.
Slide 71
Settings where At Risk Personality Disordered clients are
Located. HIGH SECURITY MEDIUM SECURITY PSYCHIATRIC INTENSIVE CARE
LOW SECURE SERVICES COMMUNITY HOSTELS SOCIAL SERVICES PROBATION
SERVICES FORENSIC OUTPATIENTS CLINICS
Slide 72
P.D. RISK MANAGEMENT INTERFACES. CRIMINAL JUSTICE SYSTEM
PRISONS POLICE COURTS PROBATION SERVICE COMMUNITY SERVICES SOCIAL
SERVICES PRIMARY CARE VOLUNTARY CARE HOSTELS COMMUNITY PSYCHIATRY
THE PERSONALITY DISORDERED CLIENT HOSPITAL SERVICES HIGHER SECURE
SERVICES P.I.C.U. PSYCHIATRY PSYCHOLOGY OCCUPATIONAL THERAPY
Slide 73
AREAS OF DEFICIT AND DEFICIENCY IN THE PERSONALITY DISORDERED
THAT CAN LEAD TO RISK.
PERSISTENT CONDUCT DISORDER DSM IV - Frequent Bullying -
Frequent Bullying - Starting physical fights - Starting physical
fights - Using weapons - Using weapons - Physical cruelty to people
and animals - Physical cruelty to people and animals - Theft with
victim confrontation - Theft with victim confrontation - Staying
out late without permission - Staying out late without permission -
Truanting from school - Truanting from school - Vandalism -
Vandalism - Breaking and Entering - Breaking and Entering -
Manipulative lying - Manipulative lying - Covert Stealing - Covert
Stealing - Forced sex - Forced sex - Deliberate fire setting to
cause harm - Deliberate fire setting to cause harm - Running away
from home overnight - Running away from home overnight
Slide 76
PRESENCE OF VIOLENT ATTITUDES PRESENCE OF VIOLENT ATTITUDES
Present from childhood. Present from childhood. Fantasises about
violence Fantasises about violence Use of instrumental violence.
Use of instrumental violence. Sees violence as empowering Sees
violence as empowering Premeditates violence. Premeditates
violence. Associates with violent peers. Associates with violent
peers. Denies/minimises seriousness. Denies/minimises seriousness.
Not modified by legal sanction or social shame. Not modified by
legal sanction or social shame.
Slide 77
PERPETRATOR ATTITUDES. - MACHO PERSONALITY.. - MACHO
PERSONALITY.. - Belief that violence is manly. - Belief that
violence is manly. - Belief that danger is exciting. - Belief that
danger is exciting. - Belief in concept of sexual entitlement. -
Belief in concept of sexual entitlement. - Minimisation of harm
experienced by victim. - Minimisation of harm experienced by
victim. - Association with like minded others - Association with
like minded others - Syntoncity of ideas re: criminality. -
Syntoncity of ideas re: criminality.
Slide 78
HISTORY OF VIOLENCE Instigated fights from an early age.
Instigated fights from an early age. Fights across a range of
settings. Fights across a range of settings. Threats of Harm with
weapons. Threats of Harm with weapons. Serious injury to victims.
Serious injury to victims. Family and friends equal threats or
assaults. Family and friends equal threats or assaults. Reports
buzz or sense of excitement. Reports buzz or sense of excitement.
Evidence of sexual gratification. Evidence of sexual gratification.
Urge to repeat behaviour. Urge to repeat behaviour.
Slide 79
DISTORTED THINKING - ABNORMAL SCHEMA. - ABNORMAL SCHEMA. -
COMPLETE DENIAL - COMPLETE DENIAL - PARTIAL DENIAL - PARTIAL DENIAL
- DENIAL OF A PROBLEM - DENIAL OF A PROBLEM - MINIMISATION OF THE
NATURE OF OFFENCE - MINIMISATION OF THE NATURE OF OFFENCE -
DENYING/MINIMISING PLANNING - DENYING/MINIMISING PLANNING -
DENYING/MINIMISING FANTASY - DENYING/MINIMISING FANTASY -
MINIMISING HARM - MINIMISING HARM - MINIMISING RESPONSIBLITY -
MINIMISING RESPONSIBLITY
Slide 80
ABNORMAL SCEMA - Ingrained thinking/assumptions. - Ingrained
thinking/assumptions. - I have to look out for myself no one else
will. - I have to look out for myself no one else will. - Society
cares nothing of me. - Society cares nothing of me. - People admire
strength (violence). - People admire strength (violence). - Being
violent is the only way to get things done. - Being violent is the
only way to get things done. - no ones doing nothing for me... - no
ones doing nothing for me... - The weak in society are mugs. - The
weak in society are mugs.
Slide 81
PROBLEMS WITH SELF- AWARENESS - LACK OF INSIGHT - LACK OF
INSIGHT - IMPAIRED SELF-REFLECTIVITY - IMPAIRED SELF-REFLECTIVITY -
FAILURE TO UNDERSTANDONES CRIME - FAILURE TO UNDERSTANDONES CRIME -
FAILURE TO UNDERSTAND OFFENCE CYCLE - FAILURE TO UNDERSTAND OFFENCE
CYCLE - DEFICITS IN KNOWLEDGE - DEFICITS IN KNOWLEDGE - DISTORTED
ATTITUDES - DISTORTED ATTITUDES - PROBLEMS WITH ANGER AND
IMPULSIVENESS - PROBLEMS WITH ANGER AND IMPULSIVENESS
Slide 82
PROBLEMS WITH STRESS OR COPING - MALADAPTIVE COPING MECHANISMS
- MALADAPTIVE COPING MECHANISMS - STRESS VULNERABILITY - STRESS
VULNERABILITY - CHRONIC NEGATIVE AFFECT - CHRONIC NEGATIVE AFFECT -
POOR SELF-REGULATION - POOR SELF-REGULATION - CHANGES IN EMPLOYMENT
- CHANGES IN EMPLOYMENT - DIFFICULTIES IN INTIMATE RELATIONSHIPS -
DIFFICULTIES IN INTIMATE RELATIONSHIPS - CHANGES OF RESIDENCE. -
CHANGES OF RESIDENCE.
Slide 83
History of problems with relationships. No evidence of
long-term comittment. No evidence of long-term comittment. Stormy,
unstable or conflictual. Stormy, unstable or conflictual.
Controlling, domineering, manipulative and subugating. Controlling,
domineering, manipulative and subugating. Frequent
break-ups/infidelity. Frequent break-ups/infidelity. Escalating
abuse and violence. Escalating abuse and violence.
Gratuitous/ego-boosting violence which is repeated.
Gratuitous/ego-boosting violence which is repeated.
Slide 84
History of problems with substance misuse. Use starts in
childhood or early adolescence. Use starts in childhood or early
adolescence. Heavy sustained use of multiple substances. Heavy
sustained use of multiple substances. Use in controlled settings
Care/prisons/hospitals, Use in controlled settings
Care/prisons/hospitals, Involvement in drug trade. Involvement in
drug trade. Associated with risky /dangerous behaviour and
criminality. Associated with risky /dangerous behaviour and
criminality. Affects education, work, relationships Affects
education, work, relationships
Slide 85
History of problems with employment. Poor educational
attainment. Poor educational attainment. School drop out before
exams sat. School drop out before exams sat. Long periods of
unemployment. Long periods of unemployment. Frequent sackings for
absenteeism, poor time keepings, alcoholism, fights or dishonesty.
Frequent sackings for absenteeism, poor time keepings, alcoholism,
fights or dishonesty. Failure to adhere to financial comittments
due to unemployment. Failure to adhere to financial comittments due
to unemployment.
Slide 86
History of Problems with Major Mental Disorder. Interfers with
Education, work, employment, ADL and relationships. Interfers with
Education, work, employment, ADL and relationships. Deteriorating
with time. Deteriorating with time. Multiple Hospitalisations.
Multiple Hospitalisations. Poor response to medication and other
therapies. Poor response to medication and other therapies.
Positive symptoms. Positive symptoms. Evidence of
agitation/distress. Evidence of agitation/distress. Evidence of
illness linked to violence. Evidence of illness linked to
violence.
RISK IN BORDERLINE PERSONALITY DISORDER. Extreme Reactions to
Extreme Reactions to - Stress. - Stress. - Demand. - Demand. -
Provocation. - Provocation. - Irritating situations, - Irritating
situations, - Abandonment real or perceived. - Abandonment real or
perceived. - Changes of plans. - Changes of plans.
Slide 89
RISK IN BORDERLINE PERSONALITY DISORDER. IMPULSIVITY leading to
IMPULSIVITY leading to - Spending Sprees. - Spending Sprees. -
Unsafe sex. - Unsafe sex. - Hazardous driving. - Hazardous driving.
- Experimental drug use. - Experimental drug use. - binge eating. -
binge eating. - Self Harm or Suicide. - Self Harm or Suicide.
Slide 90
RISK IN BORDERLINE PERSONALITY DISORDER. MOOD DISORDER that is
MOOD DISORDER that is - Chronically Disturbed. - Chronically
Disturbed. - Rapidly changing. - Rapidly changing. - Usually
negative. - Usually negative. - Changes last hours or minutes. -
Changes last hours or minutes. - Associated with anger outbursts. -
Associated with anger outbursts. - Paranoid thoughts. - Paranoid
thoughts. - Denigration of professionals. - Denigration of
professionals.
Slide 91
PSYCHOPATHY PSYCHOPATHY
Slide 92
EMOTIONAL DEFICIENCY IN PSYCHOPATHY - DECREASED ELECTRODERMAL
RESPONSIVENESS - DECREASED ELECTRODERMAL RESPONSIVENESS - LESS
FACIAL EXPRESSION - LESS FACIAL EXPRESSION - ABSENCE OF AFFECTIVE
STARTLE MODULATION - ABSENCE OF AFFECTIVE STARTLE MODULATION - LACK
OF FEAR IN RESPONSE TO AVERSIVE EVENTS - LACK OF FEAR IN RESPONSE
TO AVERSIVE EVENTS - POOR CONDITIONING - POOR CONDITIONING -
GENERAL UNDERAROUSAL - GENERAL UNDERAROUSAL
Slide 93
PSYCHOPATHY PREDICTS PSYCHOPATHY PREDICTS - Desire to dominate.
- Desire to dominate. - Hostile Attributions - Hostile Attributions
- Absence of Empathy - Absence of Empathy - Absence of Anxiety -
Absence of Anxiety - Recklessness - Recklessness - Impulsivity -
Impulsivity - No concern for future - No concern for future -
Antisocial attitudes. - Antisocial attitudes.
Slide 94
PSYCHOPATHY AND VIOLENCE - LINKED TO CORE TRAITS OF: - LINKED
TO CORE TRAITS OF: - GRANDIOSITY - GRANDIOSITY - CALLOUSNESS -
CALLOUSNESS - MANIPULATION - MANIPULATION - LACK OF EMPATHY - LACK
OF EMPATHY - Lack of guilt/remorse. - Lack of guilt/remorse. -
TENDS TO BE COLD BLOODED AND INSTRUMENTAL IN NATURE. - TENDS TO BE
COLD BLOODED AND INSTRUMENTAL IN NATURE. - LACK OF EMOTION. - LACK
OF EMOTION. - ABNORMAL RESPONSE TO PUNISHMENT. - ABNORMAL RESPONSE
TO PUNISHMENT.
Slide 95
UNPREMEDITATED ATTACKS IN PSYCHOPATHIC INDIVIDUALS - External
Locus of Control. - External Locus of Control. - No physical
evidence of pre-planning. - No physical evidence of pre-planning. -
Attackers have not set out to harm. - Attackers have not set out to
harm. - Have a previous history of instability/violence. - Have a
previous history of instability/violence. - Attack occurs following
exposure to stress or provocation. - Attack occurs following
exposure to stress or provocation. - Attack usually occurs in
similar contexts. - Attack usually occurs in similar contexts. -
Usually involves acquaintances rather than strangers. - Usually
involves acquaintances rather than strangers.
Slide 96
PREMEDITATED ATTACKS IN PSYCHOPATHIC INDIVIDUALS. - Victim,
setting and method of attack already determined in attackers mind.
- Victim, setting and method of attack already determined in
attackers mind. - May follow period of rehearsal in fantasy. - May
follow period of rehearsal in fantasy. - Believes successful attack
will bring rewards. - Believes successful attack will bring
rewards. - Start attack sequence with level of self- control. -
Start attack sequence with level of self- control. - Self-control
may lessen during the attack. - Self-control may lessen during the
attack.
Slide 97
CHARACTERISTICS - Systematic - may follow script from T.V.,
Film or Pornography. - Systematic - may follow script from T.V.,
Film or Pornography. - May have special knowledge of martial
arts/arson/poisoning. - May have special knowledge of martial
arts/arson/poisoning. - Self-control may degenerate into frenzy. -
Self-control may degenerate into frenzy. - Site of attack may have
special significance. - Site of attack may have special
significance. - May keep post-attack trophy or diary. - May keep
post-attack trophy or diary. - Attacks again after certain
interval. - Attacks again after certain interval.
Slide 98
ASSESSMENT OF RISK IN PERSONALITY DISORDERED INDIVISUALS.
ASSESSMENT OF RISK IN PERSONALITY DISORDERED INDIVISUALS.
Slide 99
DEFENSIBILITY OF ASSESSMENT OF RISK - All reasonable steps have
been taken. - All reasonable steps have been taken. - Reliable
assessment methods have been used. - Reliable assessment methods
have been used. - Information is collected and thoroughly
evaluated. - Information is collected and thoroughly evaluated. -
Decisions are recorded. - Decisions are recorded. - Staff work
within Agency Policies and Procedures. - Staff work within Agency
Policies and Procedures. - Staff communicate with others to seek
the information they do not have. - Staff communicate with others
to seek the information they do not have.
Slide 100
CORE RISK FACTORS - Attitudes that support or condone violence.
- Attitudes that support or condone violence. - Problems with
self-awareness. - Problems with self-awareness. - Problems with
stress and coping. - Problems with stress and coping. -
Psychopathic personality disorder. - Psychopathic personality
disorder. - Major mental illness. - Major mental illness. -
Problems with substance misuse. - Problems with substance misuse. -
Problems with intimate relationships. - Problems with intimate
relationships. - Sexual deviance. - Sexual deviance. - Diversity of
offending. - Diversity of offending. - Escalation of offending. -
Escalation of offending.
Slide 101
AIMS AND OBJECTIVES RISK MANAGEMENT IN P.D. To comprehensively
assess the specific components of risk. To comprehensively assess
the specific components of risk. To differentiate between mental
health related issues of risk and those that are not. To
differentiate between mental health related issues of risk and
those that are not. To express a view regarding To express a view
regarding -Whom is at risk. -Whom is at risk. -Why they are at
risk. -Why they are at risk. -Immediacy of the risk. -Immediacy of
the risk. To suggest risk reducing strategies. To suggest risk
reducing strategies. To monitor efficacy of risk reducing
strategies. To monitor efficacy of risk reducing strategies.
HCR-20: HISTORICAL SCALE - H1- PREVIOUS VIOLENCE - H1- PREVIOUS
VIOLENCE - H2- YOUNG AGE AT FIRST VIOLENT INCIDENT - H2- YOUNG AGE
AT FIRST VIOLENT INCIDENT - H3 - RELATIONSHIP INSTABILITY - H3 -
RELATIONSHIP INSTABILITY - H4 EMPLOYMENT PROBLEMS - H4 EMPLOYMENT
PROBLEMS - H5 SUBSTANCE USE PROBLEMS - H5 SUBSTANCE USE PROBLEMS -
H6 MAJOR MENTAL ILLNESS - H6 MAJOR MENTAL ILLNESS - H7 PSYCHOPATHY
- H7 PSYCHOPATHY - H8 EARLY MALADJUSTMENT - H8 EARLY MALADJUSTMENT
- H9 PERSONALITY DISORDER - H9 PERSONALITY DISORDER - H10 PRIOR
SUPERVISION FAILURE. - H10 PRIOR SUPERVISION FAILURE.
Slide 104
HCR-20: CLINICAL SCALE - C1 LACK OF INSIGHT - C1 LACK OF
INSIGHT - C2 NEGATIVE ATTITUDES - C2 NEGATIVE ATTITUDES - C3 ACTIVE
SYMPTOMS OF MAJOR MENTAL ILLNESS - C3 ACTIVE SYMPTOMS OF MAJOR
MENTAL ILLNESS - C4 IMPULSIVITY - C4 IMPULSIVITY - C5 UNRESPONSIVE
TO TREATMENT - C5 UNRESPONSIVE TO TREATMENT
Slide 105
WHAT IS RISK MANAGEMENT ?
Slide 106
GENERAL PRINCIPLES OF MANAGING RISK IN PERSONALITY DISORDER
Stratify patients according to the risk they present. Stratify
patients according to the risk they present. Avoid Inappropriate
Placements. Avoid Inappropriate Placements. Ensure Whole Systems
Approach. Ensure Whole Systems Approach. Ensure Interagency
Cooperation. Ensure Interagency Cooperation. Avoid creation of
artificial barriers to Service Delivery. Avoid creation of
artificial barriers to Service Delivery. Ensure Continuity of
Care/Responsibility. Ensure Continuity of Care/Responsibility.
Ensure Least Restrictive, Safe, Homely local settings. Ensure Least
Restrictive, Safe, Homely local settings. Ensure Client Centred
Approach. Ensure Client Centred Approach. Ensure good Communication
and transfer of important information. Ensure good Communication
and transfer of important information.
Slide 107
RISK ASSESSMENT FRAMEWORK IN P.D. - Define the behaviour to be
predicted. - Define the behaviour to be predicted. - Distinguish
between the probability and the cost of the behaviour. -
Distinguish between the probability and the cost of the behaviour.
- Be aware of possible sources of error. - Be aware of possible
sources of error. - Take into account internal as well as external
factors. - Take into account internal as well as external factors.
- Check all necessary information is available. - Check all
necessary information is available. - Predict factors that will
decrease as well as increase risk. - Predict factors that will
decrease as well as increase risk. - Identify ALL key professionals
or agencies from the start involved. - Identify ALL key
professionals or agencies from the start involved. - Plan key
interventions jointly. - Plan key interventions jointly.
Slide 108
Risk Management Goals Provide Support/practical advice. Provide
Support/practical advice. Facilitate monitoring and Supervision.
Facilitate monitoring and Supervision. Crises Intervention. Crises
Intervention. Increase motivation. Increase motivation. Improve
Thinking Skills. Improve Thinking Skills. Reduce distress. Reduce
distress. Improve problem Solving. Improve problem Solving. Improve
Social Skills. Improve Social Skills.
HCR-20: RISK MANAGEMENT SCALE - R1 - PLANS LACK FEASIBILITY -
R1 - PLANS LACK FEASIBILITY - R2 EXPOSURE TO DESTABILISERS - R2
EXPOSURE TO DESTABILISERS - R3 LACK OF PERSONAL SUPPORT - R3 LACK
OF PERSONAL SUPPORT - R4 NON-COMPLIANCE WITH REMEDIATION ATTEMPTS -
R4 NON-COMPLIANCE WITH REMEDIATION ATTEMPTS - R5 - STRESS - R5 -
STRESS
Slide 111
MANAGING THE RISK - Record roles and responsibilities of each
professional/agency involved with patient. - Record roles and
responsibilities of each professional/agency involved with patient.
- Audit any adverse incidents as they arise. - Audit any adverse
incidents as they arise. - Have predetermined plans of action. -
Have predetermined plans of action. - Keep good quality records. -
Keep good quality records. - Assure open communications. - Assure
open communications. - Comply with statutory requirements. - Comply
with statutory requirements. - Adhere to organisational protocols.
- Adhere to organisational protocols. - Provide adequate trained
staff. - Provide adequate trained staff. - Spread the risk. -
Spread the risk.
Slide 112
THERAPEUTIC INTERVENTIONS.
Slide 113
STAGES OF INTERVENTION - SAFETY. - SAFETY. - CONTAINMENT. -
CONTAINMENT. - CONTROL AND REGULATION. - CONTROL AND REGULATION. -
EXPLORATION AND CHANGE. - EXPLORATION AND CHANGE. - INTEGRATION AND
SYNTHESIS - INTEGRATION AND SYNTHESIS LIVESLEY, 2003 LIVESLEY,
2003
Slide 114
AIMS OF INTERVENTION - NOT TO CURE PERSONALITY DISORDER - NOT
TO CURE PERSONALITY DISORDER - BUT TO - BUT TO - AMELIORATE
DISTRESSING SYMPTOMS - AMELIORATE DISTRESSING SYMPTOMS - TO
STABILISE IN THE HERE AND NOW. - TO STABILISE IN THE HERE AND NOW.
- TO ENCOURAGE ADAPTIVE FUNCTIONING. - TO ENCOURAGE ADAPTIVE
FUNCTIONING. - TO INSTIL PROSOCIAL ATTITUDES. - TO INSTIL PROSOCIAL
ATTITUDES. - TO REDUCE STIGMA/ALIENATION. - TO REDUCE
STIGMA/ALIENATION. - TO ENCOURAGE EMOTIONAL AND PRACTICAL
INVESTMENT IN SOCIETY. - TO ENCOURAGE EMOTIONAL AND PRACTICAL
INVESTMENT IN SOCIETY.
Slide 115
Features of a Successful Management Plan. Instil order as a
central feature. Instil order as a central feature. Individualised.
Individualised. Explicit Goals. Explicit Goals. Prioritised Goals.
Prioritised Goals. Long term time frame. Long term time frame.
Consistency. Consistency. Insistency. Insistency. Persistency.
Persistency. Tolerance. Tolerance.
Slide 116
MULTIDIMENSIONAL TREATMENT - INSTIL PSYCHOLOGICAL AND LIFESTYLE
STABILITY. - INSTIL PSYCHOLOGICAL AND LIFESTYLE STABILITY. - SOCIAL
SUPPORT/MONITORING - SOCIAL SUPPORT/MONITORING - ADDRESS COGNITIVE
DISTORTIONS - ADDRESS COGNITIVE DISTORTIONS - ENCOURAGE EMPATHIC
CONCERN - ENCOURAGE EMPATHIC CONCERN - MANAGEMENT OF NEGATIVE
EMOTIONAL STATES - MANAGEMENT OF NEGATIVE EMOTIONAL STATES - ANGER
MANAGEMENT - ANGER MANAGEMENT - SOCIAL SKILLS TRAINING/COPING
STRATEGIES - SOCIAL SKILLS TRAINING/COPING STRATEGIES
Slide 117
HIERARCHY OF THERAPEUTIC INTERVENTIONS SPECIALISED FORENSIC
PSYCHOTHERAPY COGNITIVE BEHAVIOUR THERAPY ENHANCED THINKING SKILLS
MENTALISATION THERAPY OFFENCE FOCUSSED WORK PROBLEM SOLVING SKILLS
SOCIAL SKILLS TRAINING ANGER MANAGEMENT ANXIETY MANAGEMENT
ANTI-SOCIAL SCHEMA WORK STRUCTURED DAY
Slide 118
RISK SCENARIO PLANNING - Consider more than one scenario. -
Consider more than one scenario. - Consider nature of future harm.
- Consider nature of future harm. - Severity of future harm. -
Severity of future harm. - Imminence - Imminence - Frequency or
duration - Frequency or duration - Likelihood - Likelihood
Slide 119
BARRIERS TO EFFECTIVE INTERAGENCY WORKING - LACK OF FORMAL
PROTOCOLS FOR COOPERATION. - LACK OF FORMAL PROTOCOLS FOR
COOPERATION. - INCOMPATIBLE SYSTEMS OF DATA STORAGE. - INCOMPATIBLE
SYSTEMS OF DATA STORAGE. - DIFFICULTIES IN INFORMATION ACCESS AND
RETRIEVAL. - DIFFICULTIES IN INFORMATION ACCESS AND RETRIEVAL. -
PROFESSIONAL MISTRUST AND RIVALRIES. - PROFESSIONAL MISTRUST AND
RIVALRIES. - MISPLACED CONFIDENTIALITY. - MISPLACED
CONFIDENTIALITY.
Slide 120
IMPEDIMENTS TO CHANGE 1) The presence of untreated
Dysfunctional Schema (ingrained automatic patterns of thinking.)
The presence of untreated Dysfunctional Schema (ingrained automatic
patterns of thinking.) Alienation from and absence of a need to
invest emotionally in society coupled with Alienation from and
absence of a need to invest emotionally in society coupled with
Unquestioning and non-judgemental practical and emotional support
from his/her dysfunctional substance abusing peer grouping.
Unquestioning and non-judgemental practical and emotional support
from his/her dysfunctional substance abusing peer grouping.
Slide 121
IMPEDIMENTS TO CHANGE 2) A perception that he/she has status
within his sub-cultural fringe that has to date not been afforded
him by mainstream society. A perception that he/she has status
within his sub-cultural fringe that has to date not been afforded
him by mainstream society. An inherent tendency to impulsivity and
sensation seeking behaviours. An inherent tendency to impulsivity
and sensation seeking behaviours. Failure of normal society to
provide individual with challenging and exciting legal activities.
Failure of normal society to provide individual with challenging
and exciting legal activities.
Slide 122
IMPEDIMENTS TO CHANGE 3) Absence of a wholesome, non-
criminogenic and supportive social network that he could readily
identify with. Absence of a wholesome, non- criminogenic and
supportive social network that he could readily identify with. Poor
academic attainment and failure to build up a skills base. Poor
academic attainment and failure to build up a skills base. Fear of
ridicule, fear of failure and fear of the unfamiliar if he was to
leave his to date well tried and tested comfort zone of a
dysfunctional peer grouping. Fear of ridicule, fear of failure and
fear of the unfamiliar if he was to leave his to date well tried
and tested comfort zone of a dysfunctional peer grouping.
Slide 123
PERSONAL QUALITIES OF P.D. PRACTITIONERS - Good clinical
skills/Clarity of thought. - Good clinical skills/Clarity of
thought. - Sound experience in General Psychiatry. - Sound
experience in General Psychiatry. - Natural curiosity regarding
unusual behaviours. - Natural curiosity regarding unusual
behaviours. - Ability to think multi-dimensionally. - Ability to
think multi-dimensionally. - Tolerance for difficult patients. -
Tolerance for difficult patients. - Capacity to accept patients
characteristics but not condone/collude. - Capacity to accept
patients characteristics but not condone/collude. - Willingness to
be flexible. - Willingness to be flexible.
Slide 124
Dr Maria OKane Consultant Psychiatrist Belfast HSCT
Slide 125
Personality Disorder A Diagnosis for Inclusion Dr Maria OKane
Consultant Psychiatrist / Clinical Lead BHSCT PD Service
Slide 126
Background Population of NI 1.8 million, Belfast 420k GHQ
(DHSSPSNI, 2001) prevalence of mental illness 20% higher than
England and Scotland No validated epidemiological stats for
Personality Disorder in NI Suicide rates in deprived areas of the
city x2 average UK, Self harmx4 (Protect Life Strategy review 2012-
PD levels not identified ) Benzodiazepine and Antidepressant usage
x2 average UK POMH-PD Audit 2012 95% on medications Unemployment
rate 30% higher than remainder of UK 30 years of civil unrest (
1968-1998) continued paramilitary violence Personality Disorder
Strategy adopted Winter 2010 1.5 million regionally
Slide 127
Context to PD Services in N. Ireland Legal Context & Mental
Health Legislation in N. Ireland Bamford Review of Mental Health
& Learning Disability (N. Ireland) (2007) Forensic & Adult
Mental Health Reports Public Protection Arrangements N. Ireland
(PPANI) Health & Criminal Justice Provision
Slide 128
Overview Personality Disorder Strategy N. Ireland
Recommendations New Developments to date Partnership Working . is
it working? Personality Disorder Treatments & Interventions
Future plans for Personality Disorder Services in N. Ireland
Slide 129
Why is PD important? 5 13% general population 20 50% substance
misuse attenders 50 78% of prisoners 47 77% of people who commit
suicide 50% of children with conduct disorder and many care
leavers
Slide 130
What is it ? GENERAL DIAGNOSTIC CRITERIA FOR A PERSONALITY
DISORDER DEFINITION ICD 10 / DSMIV/V An enduring pattern of inner
experience and behaviour that deviates markedly from the
expectations of the individuals culture. This pattern is manifested
in two (or more) of the following areas. Cognition (I.e. ways of
perceiving and interpreting, self, other people and events)
Affectivity (I.e. the range, intensity, lability and
appropriateness of emotional response) Interpersonal functioning
Impulse control The enduring pattern is inflexible and pervasive
across a broad range of personal and social situations. The
enduring pattern leads to clinically significant distress or
impairment in social, occupational or other important areas of
functioning. The pattern is stable and of long duration and its
onset can be traced back to at least to adolescence or early
adulthood. The enduring pattern is not better accounted for as a
manifestation or consequence of another mental disorder. The
enduring pattern is not due to the direct physiological effects of
a substance or general medical condition
Slide 131
Clusters A/Paranoid Personality Disorder 4% of pop A /Schizoid
Personality Disorder < 1% A/ Schizotypal Personality Disorder 2%
B/Anti-social Personality Disorder 1.5% pop B/Emotionally Unstable
Personality Disorder 2% pop B/Histrionic Personality Disorder 2%
pop B/Narcissitic Personality Disorder C/Anxious / Avoidant
Personality Disorder C/Dependent Personality Disorder
Slide 132
Recorded Common Historical Themes YesNoTotal number Difficult
parent/ caregiver patient relationship/attachment documented 21930
Exposure to violence (domestic & troubles) 20 ( 5 troubles in
N.Ireland) 1030 Involved in care system6 ( All before age 9)2430
Childhood familial sexual abuse 22 (1 unknown male)8 (1 rape as
adult) 30 Convictions History Forensic History 2 24 28 6 30 Family
History of mental illness / disorder 21728 (2 adopted)
Slide 133
The Team Staff Composition 0.5 Consultant Psychiatrist 1 Band 7
Team Leader 2 Band 7 Nurse Therapists 1 Junior Doctor CT3 2 Band 6
Social Workers 1 Band 3 Job-share Carer Advocate 1 Band 3 Advocate
( vacant) 1Band 3 Mental Health Support Worker Administrative
support The Service Integrated Health and Social Care Model MBT
Keywork once engaged Progression and review through treatment
programme Twice weekly and individual staff supervision
Slide 134
The Belfast Self Harm and PD Service Referral 10 per week
Information session 50% attendance Assessment 95% opt in 6 weeks
psychoeducatio n group 12 weeks MBT group 18 months MBT Group &
1:1 Self Activation OPD
Slide 135
Slide 136
A strategic approach to comprehensive services for PD
Commissioning approaches Specialist commissioning Collaborative
commissioning (wider geography ) Mental Health partnership
commissioning Wider partnership Primary care Employment Housing
Social care TIER 1 consultation, support, education PCMH, gateway,
services A&E liaison, crisis services Community mental health
services Assertive outreach Acute care Secure care High secure care
Mental Health Services PD services Youth agencies TIER 4 specialist
services TIER 3 Intensive day services TIER 2 case management &
treatment
Slide 137
Personality Disorder Strategy N.I. A Diagnosis for Inclusion
Core Principles Service Model User & Carer Involvement Training
Provision in N. Ireland for PD Services
Slide 138
Strategy Recommendations 17 Recommendations Commissioning of PD
Services/Multi-Agency Lead Trust Tiered Approach Criminal Justice
PD Unit Prison Based Services PD Network across Health/Criminal
Justice Integrated Care Pathways
Slide 139
N.I. Personality Disorder Strategy Recommendations
Recommendations 1 - 5: Commissioning services Recommendations 6 -
8: Specialist Units & Criminal Justice Services Recommendations
9 - 12:PD Network & Pathways of Care & Training
Recommendations 13 - 17:Research & Evaluation
Slide 140
Background NICE Guidelines Bradley Review Knowledge and
Understanding Framework Recognising Complexity Personality Disorder
is everybodys business Implementation
Slide 141
Recognising Complexity Potential cost benefits Community PD
services (Tiers 1 to 3) appropriate use of Primary care Reduced
Prescribing Reduced harm from drug and alcohol abuse Reduced risk
of offending Reduction in A&E use Improved Family life,
education and employment Improved staff retention
Slide 142
Recognising Complexity Potential cost benefits Severe and
complex PD (Tier 4) Less escalation to more secure/intensive
services Reduced risk to self or others Managing the challenge to
services
Slide 143
Recognising Complexity Potential cost benefits Severe PD, high
risk of harm to others (Tier 5) Less escalation to prison,
segregation, secure or forensic placements Strengthened community
management More rational use of high cost placements
Slide 144
Recognising Complexity Commissioning guidance for PD services
Aims to support commissioners to work collaboratively to address
need and improve outcomes for people with PD
Slide 145
Recognising Complexity Commissioning for complexity Recognising
overlapping client groups with: learning disability substance
misuse offending behaviour think PD Encouraging effective pathways
think cooperation, co-production As part of other required duties
and needs assessments think PD Equalities matter think PD
Slide 146
Cases Transferred Out Of N. Ireland for Treatment Analysis of
Independent Funding Requests (IFRs) for Personality Disorder at
November 12 = 15 cases Total cost = 2.76million per annum 6 had
forensic needs identified All had secure needs: 5 low 1 low to
medium 8 medium 1 high 11 detained & 4 voluntary patients
Slide 147
Length of Stay Time SpanNumber of Cases 1 Year 2 1-3 Years7 3-5
Years3 5+ Years1 No Admission Date1
Slide 148
Length of Stay (contd) Personality Disordered Providers
NumberAverage Cost Per Day Private Hospital4472 - 548 Independent
Hospital4635 - 656 Independent Hospital2534 - 545 Private
Hospital2515 - 566 Private Hospital1375 NHS Hospital1523 NHS High
Secure Hospital1970
Slide 149
Progress To Date Commissioning of PD Services Development of PD
Teams within Trust areas Lead Trust (Belfast Health & Social
Care Trust) Service Delivery Model/Carers & Users Prison based
service Care Pathway Multi-Agency Training Implementation
Group
Slide 150
Partnership Working .. is it working? Who is responsible?
Pathways across services Criminal Justice & Health Interface
Integrated Model Challenges & Opportunities
Slide 151
Future Plans for Personality Disorder Services in N. Ireland
Strategic approach Collaborative working/shared vision Effective
partnerships Joint training Effective practice/outcomes Evaluation
& Research Leaders in this area of work
Slide 152
Challenges at the Interface Diagnosis/ Misdiagnosis/
Overdiagnosis of PD Drugs- Illicit/ prescribed Alcohol Misuse Lack
of awareness of Community options/ Tier 1-2/ Pathway Collusion /
Expectation / Entitlement/ Impulsivity/ Threats 3 week window
Slide 153
QUESTIONS?
Slide 154
Lunch
Slide 155
PPANI Special Interest Seminar Offenders with Mental Health
Problems December 18 th 2013
Slide 156
Primary Research: England and Wales (Birmingham); Scotland
(Edinburgh); Northern Ireland (Belfast)and the Republic of Ireland
(Dublin) 51 semi-structured interviews with Statutory agencies inc
police, prisons, probation, HSS Voluntary sector agencies
Independents inc forensic and clinical psychologists
Slide 157
To examine official, public and academic discourses on grooming
To deconstruct the term grooming and examine its role in the onset
of sexual offending against children, and how in turn it may be
prevented
Slide 158
Access Compliance Secrecy But also about normalisation &
huge impact on victims
Difficulties of defining/identifying grooming Limited to known
risk - conviction/serious concern about future harm Complement with
a PHA - early intervention at primary & secondary levels of
prevention
Slide 161
Similarities & differences Easier to police on-line
grooming due to digital chain of evidence, but problems with
advancing technology Each poses their own sets of challenges for
preventing, targeting and criminalising grooming & abuse
Slide 162
Differences between first time & subsequent offending
Offending as a combination of offender motivation, victim
vulnerability, and opportunity Psychological & environmental
factors preferential, opportunist, situational offending Variations
with age or gender of perpetrator The victim-offender
continuum
Slide 163
Complexities of onset environment/others Apt to describe
deliberate/conscious course of conduct Short hand reference but
less appropriate with intra-familial abuse Less appropriate for SOs
with learning difficulties/MDOs/poor social skills Complexity means
a multi-layered approach to prevention/intervention/
protection
Slide 164
Children/young people grooming others Interactions between
offenders in group treatment settings
Slide 165
older adult offenders grooming younger offenders Implications
for treatment settings Dynamics of group work settings Individual
offender progress Effectiveness/outcomes of treatment Training for
professionals
Slide 166
There was an older guy in the group and his orientation was
young males.... I was really taken aback. This [young] guy, he
suffers from Aspergers,... and the other man was a teacher. And one
day the young guy had a book and I said, thats a very interesting
book and he said, yeah, the other guy gave it to me.... he asked me
for my number a couple of weeks ago and phoned me, and said he had
it, so once I had read it wed meet for coffee and chat about it. So
I could see it, you know, in exactly the same format he used to get
young guys into his house... So it was like it was happening
actually in front of us. RI 3 (16 th May 2011) (Treatment
Professional).
Slide 167
Grooming within child care institutions by those in position of
trust Grooming of assessment, treatment and management
professionals
Slide 168
Interactions between offenders and professionals Professional
Grooming a sense of being tested... [or] being pulled into some
sort of relationship dynamic that really shouldnt be going on (SC
11, 7 th September 2011 assessment/treatment professional) an
occupational hazard Impact on assessment/ treatment/ management
Prisons and prison staff The therapeutic alliance Police/social
services and suspect offenders
Slide 169
The experience of the offender? Greater occurrence of
professional grooming among offenders who had gone through
treatment I tend to find that I am groomed more by those people who
have been through the programmes than those who havent, because
they have learned the language of change (NI 8, 6 th July 2011-
police). they would be very conscious of what responses they need
to give.... So I think any institutionalised delivery of
programmes, they are going to know how to tick the box (NI 5, 22 nd
June 2011 voluntary sector).
Slide 170
Impact on assessment/management? impression
management/transference How ascertain whether change is genuine
rather than false or manipulative? Tension between human and
emotional/professional and detached side of work with sex offenders
Play professionals off against each other = the watering down of
evidence/losing sight of the risk that someone poses Importance of
going back to the offence & balancing victim and offender
perspectives:
Slide 171
one of the most difficult things in forensic work is trying to
stay in the middle all the time... not over identifying with
victims; not over indentifying with offenders. It is not being
drawn into... completely seeing the side that the offender wants
you to see, but also seeing the other side (SC 9, 24 th August 2011
forensic psychologist)
Slide 172
Work with the offenders family/partner Ultimately, when all the
agencies pull away, those are the individuals that will be
responsible for standing over whether that adult or young person is
applying the learning in their day to day life. (NI 12, 26 th July
2011, treatment professional).
Slide 173
Work with First-time offenders there is a whole gap in service
provision about engaging perpetrators who are outside of the court
criminal system (NI 14, 3 rd August 2011, social services
professional). I dont think we offer enough before the abuse has
actually happened. (RI 4, 13 th June 2011, social services
professional).
Slide 174
Training of professionals around the dynamics of abuse e.g.
education & health sector on new and emerging forms of grooming
e.g. law enforcement agencies on sexual exploitation and impact on
victim e.g. judiciary on pre-abuse/pro-offence behaviours
Slide 175
Extremely complex and nuanced nature of sexual offending
against children Multi-layered approach - Interventions with
potential victims, as well as offenders and families how do we
couple monitoring, management and the building in of protective
factors? (RI 8, 23 rd June 2011 Probation)
Slide 176
Balance victim and offender focus - address victim
vulnerability and offender opportunity Blended protection
(Kemshall) protective and reintegrative strategies Proactive
management of risk, plus strengths- and needs- Offender-focused as
well as offence- focused strategies
Slide 177
A confessional v a bio-psycho social approach Balance between
future focus and pro- offending behaviour Correlation between
grooming and recidivism (e.g. Scalora and Garbin, 2003)
Slide 178
we need to have a very sensitised and nuanced view of grooming
and we need to spend our time looking at the seemingly
insignificant decisions made by offenders (RI 11, 5 th July 2011
assessment professional) BUT... If you dont concentrate on the
skills and strengths and other things, then I think all we are
doing is reinforcing an offenders negative views of himself (SC 11,
7 th September 2011 assessment & treatment professional)
Slide 179
Marcella Leonard PPANI Coordinator
Slide 180
Summary of PPANI Audits 2013
Slide 181
Audit team consists of: PSNI Managers Public Protection Team /
PPANI Links PBNI Manager PPT / LAPPP Chair NIPS Governor Trust
Principal Officer PPANI Lay Advisors PPANI Co-ordinator
Slide 182
Audit Team meets 4 times a year and reviews 100% Category 3
LAPPP papers 5% Category 2 5% Those reduced to Category 1 Specific
theme in each audit: SA07 Integration, DV, Prison LAPPP Risk
Management Plans Report provided to Chair of Policy and Practice
Subgroup Report provided to quarterly PPANI SMB meeting
Slide 183
Introduction of new LAPPP Forms which have evidenced improved
quality of information and structure from LAPPP meeting Record of
multiagency discussion provides more accurate reflection of the
depth of discussion at the LAPPP meeting Challenge posed by
domestic violence cases due to lack of assessment tool and where
there is no legal mandate to enforce cooperation with PPANI Risk
Management Plan Audit team acknowledges continued improvement in
the quality of the LAPPP papers Summary of Audits Findings
Slide 184
Summary of Audit Findings Audit which focused on quality of the
Risk Management Plans identified the risks identified were not
correlated with the risk management plan. Risk Management Plans
were too generic and lacked specific risk posed by individual
offender Risk Management Plans not including the findings of the
Sa07 Lack of clarity and context to some statements in LAPPP papers
could lead to misunderstanding
Slide 185
Summary of Audit Findings Lack of clarity between the PSNI DRM
role and the visiting officer role could lead to confusion re
accountability for RMP When agency / professional involvement with
offender ceases explanation should be provided to LAPPP Lack of
reports from external agencies /professionals providing assessments
or treatment to PPANI offenders Challenges for DRMs where no
statutory orders are in place Significant improvement in quality of
information for prison LAPPPs
Slide 186
Summary of Audits Recommendations DRMs to provide analysis of
SA07 assessments DRMs to provide analysis of their intervention
with offender since previous LAPPP DRMs to provide outline as to
how offenders specific risks are being addressed including within
any treatment programmes Where LAPPP makes decision to reduce
offender to Category 1, a summary of risk posed and areas to be
addressed must be provided
Slide 187
Summary of Audits Recommendations DRMs must ensure sharing of
information with all relevant agencies and personnel Guidance to be
developed for DRMs to assist in risk management of domestic
violence cases Impact on the links with victims when they do not
register with victim information schemes, all relevant agencies to
improve the uptake of victims accessing the scheme All relevant
agencies / professionals involved in the management and treatment
of PPANI offenders must provide written report at least 2 days
before LAPPP to DRM and if possible attend the LAPPP
Slide 188
Summary of Audits Recommendations All resources, interventions
and treatments must be evidenced in the DRM report Any dissent in
the LAPPP meeting regarding category of risk should be recorded in
the LAPPP papers Child and Vulnerable Adult protection concerns
should be added to the LAPPP agenda Risks identified need to be
evidenced in specific Risk Management Plans
Slide 189
Summary of Audits Recommendations DRMs must identify what is
the risk posed by associates not naming the individuals LAPPP
Chairs need to be mindful of Data Protection issues when
referencing others in LAPPP papers Guidance for agencies regarding
the sharing of soft intelligence within the LAPPP with other
agencies Consideration should be given to inclusion of offences
which are left on the books in the risks posed by the
offender.
Slide 190
When DRM refers to any agency assessments context must be given
to the scoring analysis within the DRM report for explanation for
other agency representatives. NIPS LAPPP papers should provide EDR
on the front of LAPPP papers. All Audit findings and
recommendations are overseen by Policy and Practice subgroup on
behalf of PPANI SMB Summary of Audits Recommendations