A Forensic Perspective

1. A Forensic Perspective • The Risks of Excluding Offenders with Personality Disorder

2. 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.

3. 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

4. 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% • ISD5.1% of discharges in 2000 primary or secondary dx

5. 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

6. Prison State Hospital Recidivism Rate Violent Recidivism Duration 60% - 2 years 31% (20%) 19% (12%) 11 (2) Recidivism Rates

7. 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

8. 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.

9. 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.

10. 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

11. Forensic Network Report on Services for People with Personality Disorder • Dr Fiona Biggam Forensic Clinical Psychologist • Dr Derek Chiswick Consultant Forensic Psychiatrist • Dr Raj Darjee Lecturer in Forensic Psychiatry • Prof. Kate Davidson Consultant Clinical Psychologist • Caroline Doyle Lead Nurse, DSPD Unit, HMP Frankland • Dr Edward Duncan Clinical Specialist Occupational Therapist • Prof. Don Grubin Professor of Forensic Psychiatry • Prof. Roisin Hall Chief Executive, Risk Management Authority • Formerly Director of Psychological Services, SPS • Annie McGeeney Social Worker • Diane Perera Registered Mental Nurse, HMP Perth • Dr Maureen Sturrock Psychiatric Adviser, The Scottish Executive

12. No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety Summary 2005

13. 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

14. 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

15. No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety Summary 2005

17. Fatal Accident Inquiry • Death in Custody • Evidence • Expertise

19. 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

20. No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety Summary 2005

21. Multi-Agency Public Protection ArrangementsMAPPA • Management of Offenders etc. (Scotland) Act 2005 • Health service: • Duty to co-operate for all offenders • Responsible authority for restricted patients

22. MAPPA – Types of Offenders • Registered Sex Offenders – April 2007 • Restricted patients – 30 April 2008 • Violent Offenders – 2009 or 2010? • ‘Category 3’ – others with a conviction • posing a risk of serious harm

23. 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.

24. No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety Summary 2005

25. Problem Behaviour Clinic • Stalking • Threatening • Fire Setting • Violent Offending • Persistent Complaining • Morbid Jealousy • Problem Gambling

27. Perpertrator

28. “Persistent and unwanted attention” : 17% women ]: 7% men] lifetime: 5% women]: 2% men] in last year “Stalked” : 10% women]: 4% men] lifetime 2002 Non harassment orders 37PROTECTION FROM HARASSMENT ACT 1997 Interdicts 1,511 PREVALENCE OF STALKING IN SCOTLAND

29. 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

30. 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

31. 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

32. 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