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Personality Disorder in Forensic Settings “them and us?” Dr Jon Patrick

Personality Disorder in Forensic Settings “them and us?” Dr Jon Patrick Consultant Forensic Psychotherapist. Mad?. Bad?. Patient?. Prisoner?. How does society see diagnosis?. Simplified views are simple If they’re a “beast” then throw away the key and punish them.

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Personality Disorder in Forensic Settings “them and us?” Dr Jon Patrick

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  1. Personality Disorder in Forensic Settings “them and us?” Dr Jon Patrick Consultant Forensic Psychotherapist

  2. Mad? Bad? Patient? Prisoner? How does society see diagnosis? • Simplified views are simple • If they’re a “beast” then throw away the key and punish them. • If they’re a “victim” then let them out early and give them a cuddle. • Both views are - • Dangerous • Lose sight of whole picture

  3. Major mental illness Personality Disorder Bipolar Affective Disorder Schizophrenia Depression Borderline Antisocial Narcissistic How do we see diagnosis? • Illness • Vulnerable • In need of care • Easier to see these MDOs as patients? • Not illness - “it’s personality isn’t it?” • Not vulnerable - “at it?” • Harder to care for • Harder to see these MDOs as patients?

  4. Engage patients Improve rehab Risk manage Reduce offending Stay professional Survival? The numero uno concern… The Therapeutic Relationship

  5. Major mental illness Personality Disorder And a relationship is two or more people • It happened to them? • It’s the illness? • They’re ill? • Easier maintain? • It’s who they are? • It’s behavioural? • By definition PD = relationship problems. • Harder to maintain? Therapeutic relationships • So it’s not just the patients… • It’s US and the patients…

  6. A term of abuse? Difficult Less deserving More manipulative Attention seeking Annoying Anxiety provoking PD and Therapeutic Relationships Patients with PD

  7. Offences and therapeutic relationships? • Some offences are easier for us… • SOTP and therapist • Me and murderers • Have to be aware of our feelings or risk getting into tricky situations… • Revenge and punishment • vs • Limit-setting and care Sex Violence

  8. Abuse • Neglect • Intrusion • Deprivation Patients’ lives and therapeutic relationships? Virtually all patients with disastrous early experiences

  9. 1. Battered wives 2. Violent husbands 3. Sexually abused / abuser Patients’ lives and therapeutic relationships? 4 examples… 4. Health care professionals?

  10. But we do need to acknowledge that it does happen… • If we do then there’s the chance for a different experience to occur.. Thoughtful Reflective Not caught up in it! Therapeutic relationships are unconscious • They don’t know they’re doing it… • We don’t know we’re doing it…

  11. Custodial vs Care • Set limits • Keep your word • Observe response • Fair to all • Honesty • Consistency • At least half the battle • Ask for it • Make space for it • Use it • Having feelings is normal • It will keep you safe • It will keep patients safe • It will keep others safe Boundaries Supervision So what do we do? Understand your role….

  12. In long-term relationships with our patients Aggro More complex than short-term! Neglect Rejection Overcloseness Sexual violations Splitting And what if we don’t? • Patients (like everyone) will always try to recreate their early lives in the here-and-now • So will try and push, without knowing, into these situations that are familiar for them • These pushes can lead to problems…

  13. ThoughtsQuestionsExamples

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