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The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community. Dr Rajan Darjee Consultant Forensic Psychiatrist Dr Katharine Russell Chartered Clinical Psychologist. Overview. Why we’re doing what we’re doing? How we’re doing it?

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The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community

Dr Rajan Darjee

Consultant Forensic Psychiatrist

Dr Katharine Russell

Chartered Clinical Psychologist


Overview l.jpg
Overview Personality Disordered Offenders in the Community

  • Why we’re doing what we’re doing?

  • How we’re doing it?

  • What we’ve been doing?


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"It's time frankly that the psychiatric profession seriously examined their own practices and tried to modernise them in a way that they have so far failed to do."

Jack Straw (Home Secretary)


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Heterogeneity examined their own practices and tried to modernise them in a way that they have so far failed to do."


No such thing as a stereotypical sex offender l.jpg
No such thing as a stereotypical sex offender examined their own practices and tried to modernise them in a way that they have so far failed to do."


Mental disorder in sex offenders fazel et al 2007 l.jpg
Mental disorder in sex offenders examined their own practices and tried to modernise them in a way that they have so far failed to do." Fazel et al. (2007)


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Mental disorder in sex offenders examined their own practices and tried to modernise them in a way that they have so far failed to do." Alden et al. (2007)comorbid personality disorder v comorbid substance misuse v no comorbidity


Mental disorder in paedophilic sex offenders raymond et al 1999 l.jpg
Mental disorder in ‘paedophilic sex offenders’ examined their own practices and tried to modernise them in a way that they have so far failed to do." Raymond et al. (1999)


Mental disorder in elderly sex offenders fazel et al 2002 l.jpg
Mental disorder in elderly sex offenders examined their own practices and tried to modernise them in a way that they have so far failed to do." Fazel et al. (2002)



Mental disorder in sexual murderers stone 2001 firestone et al 1998 proulx sauvetre 2007 l.jpg
Mental disorder in sexual murderers treatment Stone (2001), Firestone et al (1998), Proulx & Sauvetre (2007)


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PERSONALITY DISORDER treatment

PERSONALITY

ANTISOCIAL PERSONALITY DISORDER

PSYCHOPATHY


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SEXUAL OFFENDERS treatment

PERSONALITY DISORDER

PERSONALITY

ANTISOCIAL PERSONALITY DISORDER

PSYCHOPATHY


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Personality disorder in sex offenders treatment

  • Personality disorder of various types common

  • Personality pathology in sex offenders is heterogeneous

  • Psychopathy associated with adult rape and sexual homicide

  • Obsessive-compulsive and avoidant personality associated with child offences

  • Personality pathology linked to dynamic risk domains


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Stable dynamic domains treatment

SEXUAL PREOCCUPATION / DEVIATION

ATTITUDES

SOCIO-AFFECTIVE FUNCTIONING

SELF REGULATION


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Stable dynamic domains treatment

SEXUAL PREOCCUPATION / DEVIATION

ATTITUDES

SOCIO-AFFECTIVE FUNCTIONING

SELF REGULATION


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‘Personality disorder service’ treatment

  • Personality disorder

  • Wider personality issues

  • Psychopathy

  • Paraphilia

  • Sexual dysfunction

  • Gender identity

  • Mood disorders

  • Developmental disorders


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Clinical input treatment

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES

TREATMENT


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Clinical input treatment

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES

TREATMENT


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Clinical input treatment

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES

TREATMENT


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Risk Assessment treatment

Staticfactors

Stable dynamic factors

Acute dynamic factors

Triggers

OFFENCE


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RISK ASSESSMENT treatment

Structured Professional Judgement

Multi-agency

Integrated

Complex & unusual cases

RMA Guidance

Clinical understanding essential


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Tiered approach to risk assessment and management treatment

Specialist

assessment

and

risk

management

Assessment &

supervision of

stable &

dynamic risk

Risk screening

& monitoring

Needs

assessment


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Clinical input treatment

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES

TREATMENT


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Part of the MAPPA team treatment

Available for advice

Clinical understanding of offending

Clinical perspective on management

Linking offenders in with services

SUPPORTING CRIMINAL JUSTICE AGENCIES

Another view


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Clinical input treatment

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIE

TREATMENT


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Pharmacological treatment treatment

Tailored sex offender programme

Specific therapies for personality disorder

Specialist psychological treatment of offending behaviour

Attention to the context and relationships

TREATMENT

Supporting use of criminal justice treatment


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Treatment treatment Psychological treatment of sex offenders

Sex offenders with personality disorders or sexual deviation

  • More flexible programmes

  • Emphasis on motivation and engagement

  • Deal with issues as they arise

  • Take into account and address core beliefs

  • Less rigid adherence to timetable/manual

  • Integrated with other aspects of management

    = MENTAL HEALTH LED JOINT PROGRAMMES


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Treatment treatment Pharmacological treatment of sex offenders

  • Part of sex offender programmes in all developed countries … except Scotland!!

  • Medications include SSRIs and anti-libidinals

  • Important consideration for a significant minority of sex offenders (5-10%)

  • Who will assess? Who will treat? Who will pay?



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Forensic mental health service treatment

A ONE TRICK PONY?






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Criminal justice agencies personality disorder




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SACRO justice: WORKING TOGETHER

HOUSING

OFFENDER

CRIMINAL

JUSTICE

SOCIAL WORK

POLICE

MENTAL HEALTH


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X justice: WORKING TOGETHER

Forget the nonsense

  • Responsibility

  • “Not mentally ill”

  • No formal mental disorder

  • Undeserving

  • “Untreatable”

  • Mental health services have nothing to offer

  • If something goes wrong we’ll get the blame

  • Detention in hospital


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How we’re doing it justice: WORKING TOGETHER

  • MAPPA Health Representatives for Lothian

    • Attending Level 2 and Level 3 meetings

  • Available for phone consultation

  • Point of liaison between NHS Lothian colleagues and MAPPA colleagues


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    How we’re doing it justice: WORKING TOGETHER

    • Provide basic input to MAPPA on the NHS contacts patients are having or have had

    • HOWEVER provide additional input in terms of consultancy on cases, e.g. interpreting previous clinic reports, advising on risk, advising on available treatments and suitability


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    How we’re doing it justice: WORKING TOGETHER

    • Provide training to NHS staff on MAPPA

    • MAPPA now extends to restricted patients as well as sex offenders which has impact on psychiatric colleagues


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    Sex Offender Liaison Service (SOLS) justice: WORKING TOGETHER

    • Established in April 2007 to support MAPPA

    • Referrals from Criminal Justice Social Work, Police and MAPPA

    • Sex offenders with personality disorders or sexual deviation

    • Assessments to help criminal justice agencies manage risk in community

    • NOT route to standard mental health involvement


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    Sex Offender Liaison Service (SOLS) justice: WORKING TOGETHER

    • Staff

      • Psychiatrist, psychologist, nurse, OT

      • MAPPA clinical representatives

    • Referrals

      • 25 referrals

      • Internet offences – sexual homicide

    • Assessments

      • 2 staff

      • Long and thorough

      • Structured professional judgement

    • Resources

      • None

    • Treatment

      • Not primarily a treatment service

      • Medication


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    Referral justice: WORKING TOGETHER

    • Referrals from CJSW and Police

    • Assessment only

      • Risk Assessment

      • Medication potential

  • Most cases are 2:1

  • Supervision is provided


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    Referrals justice: WORKING TOGETHER

    • Some referrals come via our direct input to MAPPA

    • Letters sent to Police and CJSW re our service

    • Now getting increased rate of referral as word of mouth increases


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    Risk Assessment justice: WORKING TOGETHER

    • Psychiatry and Clinical Psychology

    • One or two interviews is normal

    • Review of notes

    • Discussion with case workers

    • Two staff allows for element of supervision


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    Medication justice: WORKING TOGETHER

    • A more recent addition to the service

    • Seen by Psychiatry

    • First service of its kind in Scotland

    • Follow-up provided


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    Medication justice: WORKING TOGETHER

    • Psychiatry

    • Review notes

    • Interview

    • Review of Symptoms

    • Prescription of anti-androgens/SSRIs

    • Follow-up


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    Reports justice: WORKING TOGETHER

    • Background information

    • PCL-R

    • RSVP (HCR-20 if appropriate)

    • Marshall/Hucker Sadism scale

    • Offence Analysis

    • Formulation

    • Recommendations


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    Follow-up justice: WORKING TOGETHER

    • Following risk assessment we may refer onto other health services, e.g. psychology, sexual dysfunction, psychotherapy

    • No treatment provided by our service due to lack of resources


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    SOLS assessments justice: WORKING TOGETHER

    • Number of referrals

      • 23

    • Referred by

      • CJSW 14

      • Police 2

      • MAPPA 2

      • Court 2

      • NHS 3


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    SOLS assessments justice: WORKING TOGETHER

    • Offence (most serious sexual offence)

      • Homicide 2

      • Rape 7

      • Sexual assault 6

      • Incest 1

      • Internet 3

      • Other non-contact 3

    • Victims

      • Adult female only 11

      • Adult male only 1

      • Child only 10

      • Adult and child 1


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    SOLS assessments justice: WORKING TOGETHER

    • Reason for referral (not mutually exclusive)

      • Risk assessment 12

      • Diagnosis and implications 11

      • Assessment/treatment of sexual problems 4

    • MAPPA level

      • 3 4

      • 2 13

      • 1 0

      • N/A 6


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    SOLS assessments justice: WORKING TOGETHER

    • Number of staff carrying out assessment

      • One 5

      • Two 18

    • Tools used

      • PCL-R 10

      • RSVP 10

      • HCR-20 3

      • SSS (Marshall/Hucker) 1


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    SOLS assessments justice: WORKING TOGETHER

    • Personality disorder (n=17)

      • Definite 11

      • Traits 4

      • None 2

    • Personality diagnoses (not mutually exclusive)

      • Antisocial 8

      • Narcissistic 8

      • Borderline 3

      • Schizotypal 2

      • Paranoid 3

      • Schizoid 1

      • Avoidant 1

      • Dependent 1


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    SOLS assessments justice: WORKING TOGETHER

    • Paraphilia (n=23)

      • Definite 7

      • Possible 2

      • None 14

    • Specific paraphilias

      • Paedophilia 9

      • Non-sadistic rape fantasies 1

      • Fetishism 1

      • Exhibitionism 1


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    Mr Z justice: WORKING TOGETHER

    • Murder of man – query sexual element

    • Served 11 years of life sentence

    • Been in community on licence for 4 years

    • Recently causing concerns with social work re voicing extreme anger at men he is in relationships with which mirrored index offence


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    Mr Z #2 justice: WORKING TOGETHER

    • Info at interview differed drastically from file info

    • He was very open about this – stated it would be stupid to be truthful while trying to get out on parole from prison

    • Presented as hostile towards women – both in self-report and in reaction to female interviewer


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    Mr Z #3 justice: WORKING TOGETHER

    • Very controlling in interview – had his own agenda about what he wanted to convey

    • Gave detailed gruesome recall of index offence

    • No sign of remorse

    • Left us no clearer as to why currently presenting with more issues to social work

    • Continues to deny sexual element to offence


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    Mr Z #4 justice: WORKING TOGETHER

    • Index offence followed near strangulation of his wife and grievance re victim

    • 90th Percentile on PCL-R Factor 1

    • Openly admits to using violence when he has a grievance

    • Has had sexual relationship with vulnerable female recently leaving him ‘enraged’.

    • Following this he harmed himself


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    Mr Z #5 justice: WORKING TOGETHER

    • Grave concerns about this man

    • Likely to have breached his licence

    • Report back to Social Worker

    • GP has seen him re Anxiety and Depression

    • Scored off the scale on HADS

    • Telephone discussion with Psychiatrist who was referred Mr Z by GP


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    Mr Z #6 justice: WORKING TOGETHER

    • Attended Risk management Case Conference (RMCC)

    • Gave clinical advice to GP re diagnosis

    • Added significantly to understanding of case

    • Risk formulation influenced decisions about potential victims and housing


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    Sex Offender Liaison Service (SOLS) justice: WORKING TOGETHERWhat we’d like to do?

    • See far more referrals for assessment

    • Offer treatment programme for high risk / high needs sex offenders (=personality disorder)

    • Develop treatment for sexually deviant offenders

    • Make clinical input more readily available to criminal justice social work and police

    • Retain criminal justice / MAPPA framework

    • See people who present before they offend

    • BUT ALL OF THIS NEEDS RESOURCES


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    Future developments justice: WORKING TOGETHER

    FUNDING

    • NHS Lothian

    • Scottish Government

      LOCALLY (NHS Lothian - as part of MAPPA/community forensic developments)

    • Increased capacity to see referrals

    • Referrals from NHS as well as criminal justice

    • Develop treatment

    • Evaluate as community forensic PD pilot

      NATIONALLY (Forensic Network)

    • Developing role of forensic mental health in MAPPA

    • Teaching and training – PD, sex offending, risk

    • Developing assessment and treatment of sex offenders


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    Dr Rajan Darjee justice: WORKING TOGETHERConsultant Forensic Psychiatrist

    Dr Katharine RussellChartered Clinical Psychologist

    The Orchard Clinic

    Royal Edinburgh Hospital

    Morningside Terrace

    Edinburgh EH10 5HF

    0131 537 5866

    [email protected]

    [email protected]


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