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Personality Disorder: A Risky Business? Forensic Network A Forensic Perspective The Risks of Excluding Offenders with Personality Disorder Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Conference Aims • To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk. • To consider the aetiology of PD as a route to both engagement and management, in particular the issue of disadvantage. • To discuss current progress and future plans for services for people with PD who offend • To present a model of assessment and management based on shared risk and to examine this in community, hospital and prison settings. Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Conference Aims: Outline • To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk. - Prevalence - Current service & practice - Recidivism - Current issues • To discuss current progress and future plans for services for people with PD who offend Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Background: Prevalence of ASPD • General population 2-3% • Prison population 80% • State Hospital - primary diagnosis 5.4% - secondary diagnosis 27-42% - psychopathy : PCL-R 30+ 0% : PCL-R 25+ 15% • ISD 5.1% of discharges in 2000 primary or secondary dx Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Background: SPS • Identify problem behaviours and needs • 3 principal structures: Sentence Management Risk Management groups Mental Health teams. • CBT interventions - focus on violent behaviour and sexual offending behaviour Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Recidivism Rates Prison State Hospital Forensic Network & SPDN Recidivism Rate Violent Recidivism Duration 60% 2 years 31% (20%) 19% (12%) 11 (2) 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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 Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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. Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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. Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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: HMP Grendon - therapeutic community Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Forensic Network Report on Services for People with Personality Disorder Dr Fiona Biggam Dr Derek Chiswick Dr Raj Darjee Prof. Kate Davidson Caroline Doyle Dr Edward Duncan Prof. Don Grubin Prof. Roisin Hall Annie McGeeney Diane Perera Dr Maureen Sturrock Forensic Network & SPDN Forensic Clinical Psychologist Consultant Forensic Psychiatrist Lecturer in Forensic Psychiatry Consultant Clinical Psychologist Lead Nurse, DSPD Unit, HMP Frankland Clinical Specialist Occupational Therapist Professor of Forensic Psychiatry Chief Executive, Risk Management Authority Formerly Director of Psychological Services, SPS Social Worker Registered Mental Nurse, HMP Perth Psychiatric Adviser, The Scottish Executive 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Summary 2005 • No longer a diagnosis of exclusion • Training • Sharing of Risk •Prison based pilots • Inpatient initiatives •Community pilots Forensic Network & SPDN • Patient engagement • Staff engagement • Improved patient care • Improved public safety 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network 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 Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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 Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Summary 2005 • No longer a diagnosis of exclusion • Training • Sharing of Risk •Prison based pilots • Inpatient initiatives •Community pilots Forensic Network & SPDN • Patient engagement • Staff engagement • Improved patient care • Improved public safety 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Fatal Accident Inquiry • Death in Custody • Evidence • Expertise Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Legislation MH(C&T)(S)A 2003 Definition of Mental Disorder Mental 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. Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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 Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Summary 2005 • No longer a diagnosis of exclusion • Training • Sharing of Risk •Prison based pilots • Inpatient initiatives •Community pilots Forensic Network & SPDN • Patient engagement • Staff engagement • Improved patient care • Improved public safety 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network 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 Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network MAPPA – Types of Offenders Registered Sex Offenders Restricted patients Violent Offenders ‘Category 3’ Forensic Network & SPDN – April 2007 – 30 April 2008 – 2009 or 2010? – others with a conviction posing a risk of serious harm 13th June 2008 [email protected] Personality Disorder: A Risky Business? 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. Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Summary 2005 • No longer a diagnosis of exclusion • Training • Sharing of Risk •Prison based pilots • Inpatient initiatives •Community pilots Forensic Network & SPDN • Patient engagement • Staff engagement • Improved patient care • Improved public safety 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Problem Behaviour Clinic • Stalking • Threatening • Fire Setting • Violent Offending • Persistent Complaining • Morbid Jealousy • Problem Gambling Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Perpertrator Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network PREVALENCE OF STALKING IN SCOTLAND • “Persistent and unwanted attention” : 17% women ] : 7% men] : 5% women] : 2% men] • “Stalked” : 10% women] : 4% men] lifetime in last year 2002 •Non harassment orders 37 PROTECTION FROM HARASSMENT ACT 1997 •Interdicts 1,511 lifetime Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network MENTAL DISORDER AND STALKERS • Symptomatic Pathologies of love - schizophrenia, dementia • Pure Pathologies of love - erotomanic delusional disorder • Continuum morbid infatuation Delusions of love • Personality Disorder • Substance Abuse Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network CLASSIFICATION OF STALKERS • Rejected - pursues ex-intimates for reconciliation, revenge or both • Intimacy seekers - seeking love from someone they love • Incompetent - inappropriate intrusion, seeking a date or sexual encounter • Resentful - pursue victims as revenge for actual or perceived injury • Predatory - for sexual offending Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Stalking • Stalking is as prevalent in Scotland as in the rest of the Western World • Legislation exists in response to this issue • Research has focussed on legal matters • There is little clinical input in this area • Treatment: CJSW/Prisons +/- Mental Health input Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Progress 2008 • Scottish Government Tripartite Group Pilot projects within CJSW Services and SPS for joint health, social services and criminal justice assessment and management of “problem clients”. • Shared risk – MAPPA • Joint working with SPD Network • Forensic Network MAPPA and Sex Offender lead Forensic Network & SPDN 13th June 2008 [email protected] Personality Disorder: A Risky Business? Forensic Network Forensic Network & SPDN 13th June 2008 [email protected]
