1. Dr Nuwan Galappathie MBChB MRCPsych MMedSc LLM Consultant Forensic Psychiatrist St Andrew’s Healthcare, Birmingham Visiting Researcher, Institute of Psychiatry, Kings College, London Mental Health and the Criminal Justice System What to do if your client has a mental health problem

2. Contents Recognise mental health problems in offenders Manage offenders with mental health problems Instruct an Expert Witness A charity leading innovation in mental health

3. Mental Disorder and Offending A charity leading innovation in mental health

4. Mental Disorder and Offending A charity leading innovation in mental health Small link between mentally disorder and violence (Walsh et al 2002) Violent acts against strangers are rare but attract large amounts of media interest More likely to assault family members MDOs more likely to be victims of violence, homelessness and financial abuse (Walsh et al 2003)

5. Diagnosis using an Internationally Recognised Classificatory System

6. Schizophrenia in films A charity leading innovation in mental health

7. Schizophrenia in the news A charity leading innovation in mental health

8. Schizophrenia A charity leading innovation in mental health – A syndrome characterised by abnormalities in thinking, perception, inappropriate or blunted affect and bizarre behaviour.

9. Schizophrenia A charity leading innovation in mental health – Positive Symptoms Hallucinations / Command hallucinations Delusions Thought Disorder – Negative Symptoms Blunted affect/emotion Low motivation, Avolition Poor social skills, impaired self care

10. Schizophrenia A charity leading innovation in mental health Presentation: prodromal, acute then chronic Prevalence 1% Link with substance misuse

11. Major Mood Disorders A charity leading innovation in mental health Depression – Mild depression – Moderate depression – Severe depression – Severe depression with psychotic symptoms Bipolar Affective Disorder – Hypomania – Mania with psychotic symptoms

12. Depression A charity leading innovation in mental health Low mood Reduced energy Poor concentration Guilt / unworthiness Bleak views re: future Disturbed sleep eg initial, middle or late insomnia Thoughts / acts of self harm

13. Depression A charity leading innovation in mental health Anhedonia Reduced emotional reactivity Early morning wakening Mood worse in morning Psychomotor retardation / agitation Loss of appetite Weight loss Loss of sexual interest

14. Psychotic depressive symptoms A charity leading innovation in mental health Hallucinations – Mood congruent Delusions – Nihilistic delusions – Delusions of poverty – Hypochondriacal delusions

15. Bipolar affective disorder A charity leading innovation in mental health A major mood disorder: Symptoms include: – Significant disturbance in mood, elevation of mood, low mood, decreased energy and activity – Irritability – Dis-inhibition – Promiscuity – Insomnia – Overspending – Mood congruent psychotic symptoms Auditory hallucinations Grandiose delusions

16. Personality Disorder A charity leading innovation in mental health Deeply engrained and enduring patterns of behaviour Develops in childhood / adolescence and continues into adulthood Not diagnosed before age 16 / 17 / 25 Pervasive Significant personal / occupational / social distress

17. Personality Disorder A charity leading innovation in mental health Paranoid Schizoid Dissocial Emotionally unstable Histrionic Anankastic Anxious (avoidant) Dependent nb Narcissistic (DSM) / Psychopathic disorder

18. Learning Disability A charity leading innovation in mental health Arrested / incomplete development of the mind Arises within the developmental period Global impairment of skills acquired within the developmental period IQ below 70

19. Autistic Spectrum Disorder A charity leading innovation in mental health Pervasive Developmental Disorder Impaired communication, social interaction, restricted & repetitive activities and interests – Impaired eye contact – Abnormal / excessive gesturing – Lack of social awareness – Can be high functioning

20. ADHD – Hyperkinetic Disorder A charity leading innovation in mental health Hyperactivity Inattention Impulsivity Childhood / Adult

21. PTSD – Post Traumatic Stress Disorder A charity leading innovation in mental health Trauma Hyper vigilance Flashbacks Avoidance Anxiety / Depression Alcohol / Substance misuse

22. Alcohol & Substance Misuse A charity leading innovation in mental health Dependence Syndrome – Compulsion – Control – Tolerance – Reduced activities – Withdrawal symptoms – Psychological / physical harm

23. Sleep Disorders

24. Managing Offenders with Mental Health Problems – Where to get help with treatment In the Community – GP / AE – Community Mental Health Team – Drug & Alcohol Services At the Police Station – Force Medical Examiner – Criminal Justice Liaison Service – Appropriate adult (for police interview) A charity leading innovation in mental health

25. Managing Offenders with Mental Health Problems – Where to get help with treatment In Prison – Prison Medical Officer – Prison Mental Health Inreach Team – Visiting Psychiatrist In Hospital – Responsible Clinician A charity leading innovation in mental health

26. Managing Offenders with Mental Health Problems – Medico Legal Issues Fitness to plead and stand trial – The common law test for fitness to plead remains that set down in the case R v Pritchard 1836 A charity leading innovation in mental health

28. M (John) [2003] EWCA Crim 3452, [2003] All ER (D) 199. See the CP, paras 2.53 to 2.56, A charity leading innovation in mental health Defendant should be found unfit to plead if any one or more of the following was beyond his capability: – (1) understanding the charge(s); – (2) deciding whether to plead guilty or not; – (3) exercising his or her right to challenge jurors; – (4) instructing solicitors and/or advocates; – (5) following the course of proceedings; and – (6) giving evidence in his or her own defence.

29. Court Adaptations A charity leading innovation in mental health Intermediary Court – Increased breaks – Sit out of dock – Special measures: advice to counsel – Youth offenders – Live links

30. Sentencing – offenders under disability A charity leading innovation in mental health If found to have committed the act or made the omission – No prison sentence – Nb – “proceeds of crime” – Section 35 MHA 1983 admission for report – Section 38 Interim Hospital Order 5A CPIA

31. Sentencing – offenders under disability A charity leading innovation in mental health If found to have committed the act or made the omission – Section 37 Hospital Order / CPIA – Section 37 Hospital Order + Section 41 Restriction Order / CPIA – Supervision Order (+/- condition treatment / residence – Absolute Discharge

32. Managing Offenders with Mental Health Problems – Medico Legal Issues Mental State at the time of the offence Psychiatric defences – Diminished Responsibility (partial defence to Murder) – Insanity – Automatism ( Sane/ Insane ) Capacity to form intent A charity leading innovation in mental health

33. Managing Offenders with Mental Health Problems Sentencing Recommendations Risk Assessment – Violence – Sexual offending – Fire setting Community Disposal – Mental health treatment in the community – Condition of Mental Health Treatment A charity leading innovation in mental health

34. Managing Offenders with Mental Health Problems Sentencing Recommendations A charity leading innovation in mental health Hospital Order – High Secure Hospitals – Medium Security – Low Security – Specialist Services Eg Autistic Spectrum Disorder Service Learning Disability Service Brain Injury Service

35. Managing Offenders with Mental Health Problems Sentencing Recommendations - Hospital REMAND: – S35 (Remand to Hospital by Court for psychiatric report) – S36 (Remand to Hospital by Court for treatment) – S48 (Transfer of Remanded Prisoner to Hospital for urgent treatment) DISPOSAL by COURT: – S37 (hospital order and applies to the transfer of individuals from prison to hospital) – S37/ S41 (Restriction order) – S38 (interim treatment order) – S45A (Hybrid - Hospital Order and Prison Sentence) SENTENCED PRISONER – S47 (hospital treatment) / S49 (Restriction order) A charity leading innovation in mental health

36. Managing Offenders with Mental Health Problems Sentencing Recommendations A charity leading innovation in mental health Prison – Effects of Prison Sentence on Mental Health – Ability to benefit from treatment and rehabilitation within prison – Risk of self harm / suicide within prison

37. Instructing an Expert Email: consultancyservice@standrew.co.ukconsultancyservice@standrew.co.uk Instruction Enquiries should include: Patient details – Initials, age, gender. Any diagnosis of Personality Disorder, mental health condition or Learning Disability. Brief outline of the case background and what you want the report to assess. The location where the assessment will need to take place – is the client on remand or can they travel to St Andrew’s? The submission date for the report. A charity leading innovation in mental health

38. Instructing an Expert Instructions should be posted to: Consultancy Service, St Andrew’s, Billing Road, Northampton, NN1 5DG or sent via the email address: consultancyservice@standrew.co.ukconsultancyservice@standrew.co.uk We need a full letter of instruction, the full prosecution bundle (Charge sheet, MG5 case summary, witness statements, PNC report) and copies of any previous psychiatric or psychological reports, as well as any medical records. In most instances medical records will need to be seen by the clinician, so please request these as soon as possible. If you have any queries about instructing St Andrew’s Consultancy Service, please call us on 01604 616070 A charity leading innovation in mental health