1. From Containment to Care …. and to Treatment: High Secure Services For Patients with Personality Disorder Dr Gopi Krishnan, Clinical Director & Dr Sue Evershed, Lead Psychologist Gopi.krishnan@nottshc.nhs.ukGopi.krishnan@nottshc.nhs.uk Sue.evershed@nottshc.nhs.uk

2. HISTORICAL CONTEXT POLITICAL/INSTITUTIONAL DYNAMICS HUMBLE BEGINNINGS 1994 1 WARDSHSA EXPANSION 1996 3 WARDSDEMAND 20006 WARDS + ASHWORTH CATCHMENT AREA PD/LD/MI INTEGRATION 2002 ONWARDS 7 WARDSTRANSFER OF ASHWORTH PATIENTS

3. CURRENT STRUCTURE MDT working Ward based teams Clinical training Programme delivery Supervision Psychological treatment pathway Integrated programme delivery & development Sophisticated staff training pathway Assessment 8 Treatment Main Building 14 Treatment Villa 16 Treatment Main Building 12 Treatment Villa 16 Treatment Main Building 14 Treatment Villa 16

4. Referring Organisations Per Year.

5. Number of Treated and Un-treated Discharges Between 1998 and 2002.

6. CHALLENGES Development of DSPD Continuity and flexibility - absence of care pathways * prison * msu 50% admissions unplanned Changes in patient characteristics

7. Based on Personality Disorder Traits. Taken from previous reports and files, during preadmission assessments. Any mention of traits such as: Impulsivity Egocentricity Unempathic for Others Were collated as Personality Disorder traits and added up to give a figure.

8. Based on Co-Morbidity. The number of mental health type problems were collated. Taken from previous reports and files, during preadmission assessments. Any mention of problems such as: Depression Schizophrenia Anxiety Were collated as mental health type problems and added up to give a figure.

9. Based on PCL-R Scores The PCL-R has a total score of 0 – 40. These scores are taken from a small sample size of patients from each year, and then averaged using the median.

10. Based on an Increased Risk of Sexual / Violent Offending. Assessment of risk of sexual recidivism. Assessment outcome codes as: 1 = Low 2 = Medium 3 = High The HCR-20 shows the risk of violent re-offending. The HCR-20 results show that the admissions have always been quite high – in the late 20’s early 30’s. However the range of scores are bigger in 1996 than in 2002. 1996: lowest score = 9 and highest score = 29. 2002 lowest score = 16 and highest = 30.

11. Based on Behavioural Presentations. Taken from previous reports and files, during preadmission assessments. Includes behaviours such as: –Self Harm / Suicide Attempts –Hostage Taking / Threats –Acts of Sexual / Physical Violence Were collated as Problematic behaviours and added up to give a figure of problematic behavioural presentations.

12. Changes in Patient Profile In Complexity Based on diagnostic criteria. Co-morbidity. Behavioural presentations. In Risk An increase in median PCL-R score. An increase in risk of sexual offending. An increase in risk of violent offending.

13. Implications for the Directorate Need to address clinical complexity Need to address risk Need to address risk Emphasis on team work, supervision & training Emphasis on team work, supervision & training Continued development of an integrated treatment pathway Continued development of an integrated treatment pathway

14. High Risk Patients Start early Criminal versatility Continuing offending patterns Antisocial & anti-authority Impulsive Poor social interaction Rewards for bad behaviour

15. Personality Disorder Poor developmental histories Disturbed relationships and lack of support Long-term problematic traits Across all areas of life Affects thinking styles, emotions, & social behaviour Patients average 3 or more PD “types” Different sets of traits different constellations of impairment

16. Need to Adapt Standard Treatments  Treatment “resistant”  Disrupt treatment  Drop out  Don’t apply learning  Therapy can make them worse – myths and realities  Failure can make them worse  Effects on staff

17. Treatment Adaptations  Motivational focus  Parallel individual sessions  Developing drop prevention plans and integrated coping skills  Sensitive and risky topics, e.g., SOTP  Long, frequent and paced programmes  Integrating into ward life  Linking personality issues to risk  Building positive lifestyle

18. Treatment Pathway AIMS Motivate Reduce risk Build effective living skills

19. Motivation & Engagement  Therapy interfering behaviours, thoughts and emotions  Beliefs in the rewards for maladaptive behaviours  No or limited skills to explore or understand own behaviours  Reduced faith in therapy  Stigmatisation & failure  Exclusion & betrayal  Replays & reinforces history of interpersonal experience

20. Treatments for PD  Assessment and address specific therapy interference  Expectation and planning for lapses  Motivational work  Dosage & pace  Therapeutic alliance  Ruptures as opportunities  Consistency in environment  PD traits as maladaptive coping strategies (Bateman, 2003; Davison, 2003; Linehan,1993; Livesley,2001; Young,1999)

21. Reoffending / Risk TARGET CRIMINOGENIC NEEDS  Antisocial attitudes  Problem solving, self control & prosocial skills  Peer associations & family issues  Substance misuse  Prosocial rewards for adaptive behaviour  Offence cycles and relapse prevention plans  Post discharge planning

22. Future Aspirations In reach and out reach development work with prisons and RSU’s Improved integration of therapy into the milieu Named nurse development programmes Multidisciplinary Clinical Supervision developments Developing therapeutic programme accreditation processes Sharing practice and research agendas through NIMHE regional development centres Practice based research initiatives Therapeutic adherence training in a range of interventions Developing/implementing Good Lives Model (Ward et al, 2002)