Special Interest Seminar 2013

1. Special Interest Seminar 2013

2. Welcome Hugh Hamill Deputy Director PBNI Chair PPANI SMB

3. Anthony Harbinson Director of Safer Communities Department of Justice

4. Geraldine O’Hare Head of Psychology PBNI Chair PPANI SMB Education and Training Subgroup

5. Offenders with Mental Health ProblemsPresentation to PPANI Special Interest Seminar18 December 2013Geraldine O’HareHead of Psychology Services & Interventions

6. Overview  Mental Health & the Criminal Justice System: Prevalence  Findings from Strategic Reports Towards a shared Criminal Justice & Health Strategy  The Vision

7. Mental Health & Criminal Justice 70% of prisoners have psych osis, a personality disorder or a substance misuse problem  Specific concerns about women and young offenders  Self-harm and suicide rates increased  10% male & 30% female previous psychiatric acute admission  20-50% male prisoners have a learning difficulty (Sainsbury Centre, 2011)

8. Prevalence  70% of sentenced prisoners suffer from two or more mental health problems  64% sentenced males & 50% female prisoners have personality disorder  78% male prisoners on remand have personality disorder  20% of prisoners have four or five major mental health disorders  16% arrested into custody meet one or more of the assessment criteria for mental disorder  11% some form of physical disability (Sainsbury Centre, 2011)

9. Women Offenders Increased three fold in last 10 years (Corston, 2007)  Psychosis rates 14%, compared to 0.5% general population (Singleton et. al) 50% received mental health treatment before custody 30% psychiatric admissions  Personality Disorder, particularly Borderline PersonalityDisorder most prevalent  Self-harm & suicide attempts greatly exceeds general population  Twice as likely as men to have received help for mental health problems in 12 months prior to custody.  44% have communication difficulties

10. Young Offenders  Three times higher rates of mental health problems (Hagall, ‘02)  10% psychosis in sentenced males60% female remands10% self-harmed (Baker et al, ’03)  84% personality disorder on remand 88% sentenced (Lader, 2000)  Survey by YJB (2006) (E&W) found 59% of YJA (N.I.) signs of mental health issues  Over 60% speech, language and communication difficulties.

11. Substance Misuse Problems  73% PBNI cases assessed as having substance misuse problems  15% male sentenced prisoners convicted of drug offences  26% sentenced female prisoners (MoJ, ‘07)  63% sentenced males39% sentenced females classed as hazardous drinkers prior to imprisonment

12. Mental Health Problems in Prisons & the General Population Singleton et al, 2000

13. Probation and Mental Illness  Prevalence study (Brooker ‘12) of 39% mental illness, anxiety disorder most common. (PBNI 34%)  60% Substance misuse(PBNI 73%)  48% Personality Disorder (PBNI 60%)  Ongoing research studies for Mental Illness and Personality Disorder within PBNI.

14. Types of Mental Health Issues Cognitive functioning Hallucinations Delusions Recognition of emotion Flat Affect/Mood incongruence S/L difficulties Social isolation Paranoia Flashbacks Unstable lifestyle Dependency Guilt/Anger Dissociation Antisocial Self harm/Suicidal ideation Avoidant Low mood/Tearful Safety behaviours Hopelessness and helplessness Hyper vigilance/arousal Mania

15. Prevalence of Personality Disorder within Criminal Justice System  70% male prisoners (47% Anti-Social PD)  42% female prisoners (41% Anti-Social PD) Anti-Social Personality Disorder (APD) commonest Paranoid Personality Disorder, second most common in men Borderline Personality Disorder, second most common in women  Comorbidity most common in women (Singleton et al, 2000)

16. Strategic Reports on Mental Health & Criminal Justice  Bamford (2007): Forensic Services ReportCorston (2007): On Women Offenders & Mental Health Issues Bradley Report (2009): Review of Mental Health & Learning Disability within CJS in England & Wales CJINI: Not a Marginal Issue (2010) N. Ireland Personality Disorder Strategy (2010) Owers Report (2011) From Bradley, Bamford & Beyond …..

17. What The Reports Found  Some good practice, but …..  A range of deficiencies in provision across the CJS  Poor continuity of care Poor identification at early stages  Diversion too late  Convergence between CJ & Health too late  Access to services inconsistent  Improve partnership arrangements  Improve accommodation provision  Inadequate services for personality disordered offenders (in N. Ireland)

18. CJINI ‘Not a Marginal Issue’ (2010) “Mental Health problems are prevalent and imprisonment may not be the best response to their offending behaviour; it frequently does them no good and risks further harming their mental health, making them more likely to reoffend”

19. CJINI Recommendations 18 Recommendations for all CJ agencies, including  Training  MDO Scheme  Sentencers access to specialist advice in interpreting reports Flagging to Courts  Extended time for reports  Access to high secure hospital  Accommodation  Research  Personality Disorder Strategy resourced  Review of Prison Health Care  Joint Health/CJ Board be established

20. Independent Review of the N. Ireland Prison Service Final Report October 2011 Recommendation 13 which states: “There should be a joint Healthcare & Criminal Justice Strategy covering all Health & Social Care Trusts, with a joint Board overseeing commissioning processes within & outside prisons, to ensure that services exist to support diversion from custody & continuity of care” (Owers, 2011)

21. Towards a Shared Mental Health Strategy for Criminal Justice & Health in N. Ireland  Benefits of a joint strategy - significant  An integrated & responsive approach to mental health issues within the CJINI  From many models of service to an agreed joined up model From single practitioners, to whole team & agency approach  From single agency challenges to joint opportunities  From reliant on champions to strategic & planned  Mental health & psychological wellbeing of offenders to reduce the number of future victims & ultimately protection of the public

22. Joint Healthcare & CriminalJustice Strategy  Four Workstreams:-1.Prevention & Early Identification2. Offenders in the Community3.Offenders in Custody4. Reintegration & Rehabilitation into the Community  Outcomes of Strategy

23. Towards a Criminal Justice Mental Health Strategy: Key Themes Identified  Early identification  Places of safety  Diversionary options Information sharing Integration of Assessment, Management & Discharge with Community Services  Personality Disorder Services  Dual diagnosis & substance misuse  Public Protection Sentences  Legislation

24. Joint Health Care and Criminal justice Strategy: Key Themes Identified  Provision for over 65’s  Provision for under 18’s  Ethnic Minorities & Foreign Nationals Gender specific care provision Learning disability & communication difficulties  Access to primary care services  Evaluation of effectiveness of mental health interventions  Research strategy  Resources

25. All-Stages Diversion within CJS Early Intervention

26. All-Stages Diversion within CJS Criminal Justice Decision Making

27. All-Stages Diversion within CJS Through Care & Recovery

28. Voluntary & Community Groups Learning & Communication Difficulties Discharge &Resettlement Early Identification Provision forOver 65s Places of Safety Diversion YoungPeople Health & Criminal Justice Strategy Provision forUnder 18s Evaluation & Research Information Sharing Women PersonalityDisorderServices SubstanceMisuse Dual Diagnosis Resources Legislation PublicProtectionServices Ethnic Minorities Research &Evaluation

29. The Vision

30. Thank You Geraldine O’Hare Head of Psychology Services & Interventions Tel. No: 028 90 262400Email: geraldine.ohare@pbni.gsi.gov.uk

31. Dr Richard Bunn Consultant Psychiatrist Belfast HSCT

32. PPANI Ramada Plaza Belfast 18th December 2013

33. Who Am I? Dr Richard Bunn Consultant in Forensic Psychiatry Shannon Clinic, Regional Secure Unit.

34. Who am I really?

35. Who am I really?

36. Public Protection

38. 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.

39. 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.

40. Caution: Most violence is committed by people WITHOUT mental illness

41. mental health, violence and homicide

44. 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 unit 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.

45. 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. • <2/year NI • Random killings have not increased in the last 30 years. • Methods of homicide were similar to the general population, but they were ‘significantly more likely to use a sharp instrument’ (p. 106). • Mentally ill persons who commit homicide are more likely to have a drugs and/or alcohol dependence (p. 133).

46. 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.

47. Mental Health

48. 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)

50. 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.