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? What we’ve been doing?

"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)

Heterogeneity

No such thing as a stereotypical sex offender

Mental disorder in sex offenders Fazel et al. (2007)

Mental disorder in sex offenders Alden et al Mental disorder in sex offenders Alden et al. (2007) comorbid personality disorder v comorbid substance misuse v no comorbidity

Mental disorder in ‘paedophilic sex offenders’ Raymond et al. (1999)

Mental disorder in elderly sex offenders Fazel et al. (2002)

Mental disorder in referrals to specialist residential treatment Dunsieth et al. (2004)

Mental disorder in sexual murderers Stone (2001), Firestone et al (1998), Proulx & Sauvetre (2007)

PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

SEXUAL OFFENDERS PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

Personality disorder in sex offenders 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

Stable dynamic domains SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION

Stable dynamic domains SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION

‘Personality disorder service’ Wider personality issues Psychopathy Paraphilia Sexual dysfunction Gender identity Mood disorders Developmental disorders

SUPPORTING CRIMINAL JUSTICE AGENCIES Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

Stable dynamic factors Risk Assessment Static factors Stable dynamic factors Acute dynamic factors Triggers OFFENCE

RISK ASSESSMENT Structured Professional Judgement Multi-agency Integrated Complex & unusual cases RMA Guidance Clinical understanding essential

Tiered approach to risk assessment and management Specialist assessment and risk management Assessment & supervision of stable & dynamic risk Risk screening & monitoring Needs assessment

SUPPORTING CRIMINAL JUSTICE AGENCIES Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

SUPPORTING CRIMINAL JUSTICE AGENCIES Part of the MAPPA team Available for advice Clinical understanding of offending Clinical perspective on management Linking offenders in with services SUPPORTING CRIMINAL JUSTICE AGENCIES Another view

SUPPORTING CRIMINAL JUSTICE AGENCIE Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIE TREATMENT

TREATMENT Pharmacological 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

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

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?

Understanding and managing personality disordered offenders Risk Need Responsivity

Forensic mental health service A ONE TRICK PONY?

Taking responsibility for patient’s behaviour

Forensic mental health services working with criminal justice: SEARCH AND RESCUE

Section 328 definition of mental disorder includes personality disorder

Traditional multi-agency working model

Criminal justice agencies

Forensic mental health services working with criminal justice: WORKING TOGETHER

Multi-Agency Public Protection Arrangements (MAPPA)

SACRO HOUSING OFFENDER CRIMINAL JUSTICE SOCIAL WORK POLICE MENTAL HEALTH

X 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

How we’re doing it 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

How we’re doing it 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

How we’re doing it Provide training to NHS staff on MAPPA MAPPA now extends to restricted patients as well as sex offenders which has impact on psychiatric colleagues

Sex Offender Liaison Service (SOLS) 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

Sex Offender Liaison Service (SOLS) 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

Referral Referrals from CJSW and Police Assessment only Risk Assessment Medication potential Most cases are 2:1 Supervision is provided

Referrals 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

Risk Assessment Psychiatry and Clinical Psychology One or two interviews is normal Review of notes Discussion with case workers Two staff allows for element of supervision

Medication A more recent addition to the service Seen by Psychiatry First service of its kind in Scotland Follow-up provided

Medication Psychiatry Review notes Interview Review of Symptoms Prescription of anti-androgens/SSRIs Follow-up

Reports Background information PCL-R RSVP (HCR-20 if appropriate) Marshall/Hucker Sadism scale Offence Analysis Formulation Recommendations

Follow-up 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

SOLS assessments Number of referrals Referred by 23 CJSW 14 Police 2 MAPPA 2 Court 2 NHS 3

SOLS assessments Offence (most serious sexual offence) Victims 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

SOLS assessments MAPPA level 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

SOLS assessments Number of staff carrying out assessment Tools used One 5 Two 18 Tools used PCL-R 10 RSVP 10 HCR-20 3 SSS (Marshall/Hucker) 1

SOLS assessments 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

SOLS assessments Paraphilia (n=23) Specific paraphilias Definite 7 Possible 2 None 14 Specific paraphilias Paedophilia 9 Non-sadistic rape fantasies 1 Fetishism 1 Exhibitionism 1

Mr Z 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

Mr Z #2 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

Mr Z #3 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

Mr Z #4 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

Mr Z #5 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

Mr Z #6 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

Sex Offender Liaison Service (SOLS) What 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

Future developments 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

Dr Rajan Darjee Consultant Forensic Psychiatrist Dr Katharine Russell Chartered Clinical Psychologist The Orchard Clinic Royal Edinburgh Hospital Morningside Terrace Edinburgh EH10 5HF 0131 537 5866 rajan.darjee@nhs.net katharine.russell@nhs.net