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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
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Overview Why we’re doing what we’re doing? How we’re doing it?
What we’ve been doing?
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"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)
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Heterogeneity
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No such thing as a stereotypical sex offender
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Mental disorder in sex offenders Fazel et al. (2007)
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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
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Mental disorder in ‘paedophilic sex offenders’ Raymond et al. (1999)
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Mental disorder in elderly sex offenders Fazel et al. (2002)
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Mental disorder in referrals to specialist residential treatment Dunsieth et al. (2004)
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Mental disorder in sexual murderers Stone (2001), Firestone et al (1998), Proulx & Sauvetre (2007)
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PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY
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SEXUAL OFFENDERS PERSONALITY DISORDER PERSONALITY
ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY
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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
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Stable dynamic domains
SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION
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Stable dynamic domains
SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION
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‘Personality disorder service’
Wider personality issues Psychopathy Paraphilia Sexual dysfunction Gender identity Mood disorders Developmental disorders
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SUPPORTING CRIMINAL JUSTICE AGENCIES
Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT
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SUPPORTING CRIMINAL JUSTICE AGENCIES
Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT
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SUPPORTING CRIMINAL JUSTICE AGENCIES
Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT
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Stable dynamic factors
Risk Assessment Static factors Stable dynamic factors Acute dynamic factors Triggers OFFENCE
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RISK ASSESSMENT Structured Professional Judgement Multi-agency
Integrated Complex & unusual cases RMA Guidance Clinical understanding essential
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Tiered approach to risk assessment and management
Specialist assessment and risk management Assessment & supervision of stable & dynamic risk Risk screening & monitoring Needs assessment
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SUPPORTING CRIMINAL JUSTICE AGENCIES
Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT
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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
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SUPPORTING CRIMINAL JUSTICE AGENCIE
Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIE TREATMENT
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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
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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
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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?
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Understanding and managing personality disordered offenders
Risk Need Responsivity
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Forensic mental health service
A ONE TRICK PONY?
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Taking responsibility for patient’s behaviour
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Forensic mental health services working with criminal justice: SEARCH AND RESCUE
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Section 328 definition of mental disorder includes personality disorder
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Traditional multi-agency working model
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Criminal justice agencies
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Forensic mental health services working with criminal justice: WORKING TOGETHER
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Multi-Agency Public Protection Arrangements (MAPPA)
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SACRO HOUSING OFFENDER CRIMINAL JUSTICE SOCIAL WORK POLICE MENTAL HEALTH
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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
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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
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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
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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
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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
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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
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Referral Referrals from CJSW and Police Assessment only
Risk Assessment Medication potential Most cases are 2:1 Supervision is provided
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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
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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
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Medication A more recent addition to the service Seen by Psychiatry
First service of its kind in Scotland Follow-up provided
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Medication Psychiatry Review notes Interview Review of Symptoms
Prescription of anti-androgens/SSRIs Follow-up
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Reports Background information PCL-R RSVP (HCR-20 if appropriate)
Marshall/Hucker Sadism scale Offence Analysis Formulation Recommendations
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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
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SOLS assessments Number of referrals Referred by 23 CJSW 14 Police 2
MAPPA 2 Court 2 NHS 3
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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
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SOLS assessments MAPPA level
Reason for referral (not mutually exclusive) Risk assessment Diagnosis and implications 11 Assessment/treatment of sexual problems 4 MAPPA level 3 4 2 13 1 0 N/A 6
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SOLS assessments Number of staff carrying out assessment Tools used
One 5 Two 18 Tools used PCL-R 10 RSVP 10 HCR SSS (Marshall/Hucker) 1
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Dr Rajan Darjee Consultant Forensic Psychiatrist
Dr Katharine Russell Chartered Clinical Psychologist The Orchard Clinic Royal Edinburgh Hospital Morningside Terrace Edinburgh EH10 5HF
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