Working with high risk young prisoners with emerging personality disorders Jake Shaw Consultant Forensic Psychologist Dr Owen Forster Clinical Psychologist ----- Meeting Notes (06/03/15 06:51) ----- Introductions Talk about AYOI Pathways Service for HRHH Emerging PD

The next 20 minutes The needs of high risk prisoners with PD at HMYOI Aylesbury Aylesbury Pathways Service Core principles Service model Future Directions Discuss needs of client group

HMYOI Aylesbury – 1847 to present day Opened as a county gaol in 1847 Operational Capacity 440 Since 1989 designated long term YOI Currently holds longest sentenced young adults (18-21) in English prison system Reputation for taking behaviourally challenging young prisoners

Inside through the times

Renovation

The challenges of adolescence A period of profound change in social and emotional development Increase in impulsivity, stimulation seeking, risk taking, conflict with authority, peer focused interactions Internal world an emotional rollercoaster Fragile and fluctuating self-esteem Avoidant behavior and impulsive acting out are common When coupled with problematic attachment experiences, trauma, deprivation and negative peer influences can be a period of particular vulnerability Spend few moments thinking about the particular needs of hrhh young adult prisoners with emerging personality disorders Let’s start by thinking about normal adolescent development, Fe

Emerging personality disorders in adolescence and young adulthood Many young people presenting with PD had significant impairments in adulthood when followed up 20 years later (Crawford et al., 2008) Higher levels of psychosocial adversity associated with more persistent personality difficulties more frequent antisocial behaviour more serious convictions (Vizard et al., 2007) Young adulthood is therefore a critical point for intervention The social, relational, occupational and criminal consequences of emerging PD in adolescence can shape later life course trajectories The social, relational, occupational and criminal consequences of emerging PD can shape later life course trajectories Early onset PD associated with psychosocial adversity, antisocial behaviour, convictions and 88% of young male sentenced prisoners meet criteria for PD 81% ASPD(ONS, 2000)

Needs of high risk young prisoners with emerging PD at HMYOI Aylesbury (McMurran et al, 2013) High risk, complex cases (N=54, 17%) 54% self-harm 70% childhood behavioural problems 89% early onset offending 37% excessive violence/sadism in offence 98% impulsive 98% reckless/risk taking 43% difficulties coping But - hard to reach group Exemplified by recent needs analysis which was completed prior to our service being set up

HRHH PD group sig. more likely to have the following offending related needs Emotional difficulties (OR 13.5) Drug misuse (OR 4.0) Relationships problems (OR 4.8) Accommodation (OR 2.5) Criminal Attitudes (OR 2.3) Anecdotally we can add that this population are also both frequent perpetrators and victims of assaults Quite severe trauma histories High proportion of gang affiliations Often pend protracted periods in segregation Presenting with a number of co-morbid conditions Including ADHD/ASD For the longer term incarcerated youths there is often a serious lack of general life skills Surface level hostility is often driven by very low levels of confidence in their abilities outside of a delinquent peer group

Aylesbury Pathways Service Direct work with individuals Case formulation Enabling environment + Workforce development One of two sites for high risk high harm young adult prisoners in the OPD strategy Delivered by London Pathways Partnership (LPP) in partnership with NOMS Integrated treatment model Delivered within an attachment framework AMBIT, MBT + Schema models, self-harm support groups Service User Involvement central to the service model, design and delivery Consistent focus on engagement and motivation with young people, the broader prison and also the Recognising the importance of the broader system Accommodate frequently co-morbid conditions ADHD/ASD Diverse staff group, mixed NOMS/NHS staff, employ ex-service users – working with Emergence, with extensive use of 3rd sector agencies. Diverse range of activities, including formal therapy, creative sessions, music production, Art therapy, life skills workshops.

Pathways Service Design Tier 1 For all staff & prisoners Prison wide training Tier 2 Service support Consultation Signposting/ liaison Tier 3 Enabling Environments x 2 Case ID & Assessment Outreach Clients x 20 Enhanced supervision & training Tier 4 Intervention Service Clients x 20 Formulation Evidence based intervention Social, creative & occupational activities

Service Delivery: Tier 1 & Tier 2 To deliver training to all prison staff (including KUF training) Enhance all prisoners understanding of available support & services Tier 1 Provision Supporting existing services in management of prisoners Provide consultation to the prison on management & progression of problematic prisoners Signposting & Liaison for prisoners to help them access existing services or for progressive moves onwards. Tier 2 Provision

Tier 3 Provision Working towards awards on F & G wing 10 standards set by the RCPsych Joint working between Pathways Service, Wing Staff and Prisoners Enabling Environments Accept referrals from all sources in the prison including self-referral Joint assessment by Clinical and Operational staff If suitable devise initial treatment plan & Initial formulation Case ID & Assessment 20 prisoners, fortnightly contact from staff Focus on engagement, motivation & stabilisation Help to access existing services & programmes or to progress into the Intervention Service Outreach Clients Individual & Group supervision offered to all Pathways staff KUF training Individual development including CBT, Schema Therapy & AMBIT Enhanced Training & Supervision

Tier 4 Provision 15-20 prisoners, weekly contact from staff Participation in Individual & Group sessions Liaison & joint working with other prison services Intervention Service Full formulation of offending, risk & difficulties across the lifespan Narrative understanding for prisoners & staff Developed in conjunction with psychology staff Formulation Individual psychotherapy Group therapy including Schema, Mentalization Based Therapy & R&R 2 Co-facilitated groups including Self-Harm, Hearing Voices & Managing License Evidence Based Intervention A large range of group and individual activities aimed at reducing isolation, promoting self-esteem and building skills Including Life Skills, Art, Social Skills, Well-being, Mindfulness & Yoga Social, Creative & Occupational Activity

Pathways Staffing Group Clinical Staff Group 1 x 8c Clinical Lead (0.6 wte) 2 x 8a/Band 8 Clinical Psychologist (2.0 wte) 1 x 7 Occupational Therapist (1.0 wte) 1 x 6 Occupational Therapist (1.0 wte) Operational Staff Group 1 x Band 4 Supervising Officer - Service Lead(1.0 wte) 1 x Band 4 Supervising Officer – EE Lead (1.0 wte) 4 x Band 3 Prison Officers (4.0 wte) Additional Staff 1 x Admin Support (1.0 wte) 2 x Service User Consultants (0.4 wte) 1 x Consultant Forensic Psychiatrist (0.2 wte) Sessional workers including systemic therapist, art therapist, SLT & Yoga teacher.

Thanks for listening