03. FPRS PD presentation 24-6-05

Personality Disorder and Offenders in Scotland: a time to change our practice? : 

Personality Disorder and Offenders in Scotland: a time to change our practice? Report of the Working Group on Services for People with Personality Disorder Forensic Mental Health Services Managed Care Network

Working Group Members : 

Working Group Members Dr Fiona Biggam Forensic Clinical Psychologist Dr Derek Chiswick Consultant Forensic Psychiatrist Dr Raj Darjee Lecturer in Forensic Psychiatry Prof. Kate Davidson Consultant Clinical Psychologist Caroline Doyle Lead Nurse, DSPD Unit, HMP Frankland Dr Edward Duncan Clinical Specialist Occupational Therapist Prof. Don Grubin Professor of Forensic Psychiatry Prof. Roisin Hall Chief Executive, Risk Management Authority Formerly Director of Psychological Services, SPS Annie McGeeney Social Worker Diane Perera Registered Mental Nurse, HMP Perth Dr Maureen Sturrock Psychiatric Adviser, The Scottish Executive

Terms of Reference : 

Terms of Reference To consider the assessment and management of individuals with personality disorders who present a real risk of physical or psychological harm to others and who come into contact with criminal justice system or are likely to come into contact with the criminal justice system. = Forensic Personality Disorder To describe services currently available to Scotland for this group. To describe treatment strategies currently used in Scotland with this group. To make recommendations regarding the development of services and strategies, including staff training, for this group.

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Background: Prevalence of ASPD : 

Background: Prevalence of ASPD General population 2-3% Prison population 80% State Hospital - primary diagnosis 5.4% - secondary diagnosis 27-42% - psychopathy : PCL-R 30+ 0% : PCL-R 25+ 15% ISD 5.1% of discharges in 2000 primary or secondary dx

Background: Current Practice : 

Background: Current Practice Do not admit individuals with a primary diagnosis of personality disorder to forensic psychiatric units. Community forensic mental health services - rudimentary. Most forensic psychiatrists - a small cohort of outpatients with a primary diagnosis of personality disorder. Offender + Primary Personality Disorder ? Prison / Y.O.I.

Background: SPS : 

Background: SPS Identify problem behaviours and needs 3 principal structures: Sentence Management Risk Management groups Mental Health teams. CBT interventions - focus on violent behaviour and sexual offending behaviour

Background: Serious, Violent & Sexual Offenders : 

Background: Serious, Violent & Sexual Offenders Maclean Committee 2001 Risk Management Authority Risk Assessment Order Order for Lifelong Restriction Emphasis on offence and risk, rather than on a diagnosis such as psychopathy or severe personality disorder.

Background: England and Wales : 

Background: England and Wales Rejection of personality disorder as a diagnosis of exclusion Multiagency Public Protection Arrangements Significant investment by the Department of Health and the Home Office: pilot services for people with personality disorder in general psychiatric and forensic services including pilot community forensic personality disorder services and five inpatient forensic personality disorder units. Dangerous and Severe Personality Disorder - 4 DSPD units: HMP Grendon - therapeutic community

Survey of Services for People with Forensic Personality Disorder in Scotland : 

Survey of Services for People with Forensic Personality Disorder in Scotland 7 implicitly exclude people with a primary PD Dx from admission 7 assess people with a primary diagnosis of PD 8 use multidisciplinary and 10 comprehensive methods of assessment 4 use structured clinical tools for the assessment of PD 6 services did not accept people with a primary diagnosis of PD for specific intervention, treatment or management, 4 services did not accept people with a secondary dx No reliable figures

Survey of Services for People with Forensic Personality Disorder in Scotland : 

Survey of Services for People with Forensic Personality Disorder in Scotland Access to services appropriate to people with PD: Drug and alcohol services 10 Cognitive behavioural therapy 9 Individual psychotherapy 6 Dialectical behaviour therapy 2 Specialist interventions 4 Training requirements were identified in particular for developing case formulations and employing evidence based interventions.

Recommendations: General : 

Recommendations: General Personality Disorder should not be a diagnosis of exclusion from Forensic Mental Health Services Services for people with personality disorder should be provided given the frequency with which they are found in the criminal justice and mental health systems in Scotland. Data collection systems should be improved to provide accurate information on forensic personality disorder for service planning.

Recommendations: Assessment : 

Recommendations: Assessment All forensic mental health consultations Case formulation Personality Disorder Clinical assessment based on ICD-10 or DSM-IV criteria International Personality Disorder Examination Psychopathy Checklist-Revised or Screening Version Mental Illness - Clinical ICD-10 Risk of Violence - Historical Clinical Risk 20 Risk of Sexual Offending - Risk of Sexual Violence Protocol Risk Matrix 2000

Recommendations: Management : 

Recommendations: Management Some evidence Accreditation criteria Problem behaviour focus

Recommendations: Community : 

Recommendations: Community Risk sharing - MAPPA style - Risk Management Authority Criminal Justice Social Workers – pilot

Recommendations: Inpatient Services : 

Recommendations: Inpatient Services No change to current clinical practice Comorbidity – services State Hospital – no more new cases - interim compulsion order - hospital direction - automatic review of prisoners before expiry of sentence - similar options for Northern Ireland

Recommendations: Inpatient Services : 

Recommendations: Inpatient Services Service for State Hospital patients Specialist team for resettlement Scottish Criminal Cases Review Commission

Recommendations: Prison : 

Recommendations: Prison Pilot prison and mental health team - detailed assessments of problematic prisoners - to develop management plans in conjunction with the prison’s Risk Management Group

Recommendations: Training : 

Recommendations: Training Training and supervision are essential - A change of culture - The development of a competency framework for practice - The development and use of robust risk management procedures Specific training programmes should be created for the pilots recommended and at the State Hospital. The training programmes should subsequently be rolled out to all forensic mental health settings in Scotland.

Summary : 

Summary Staff engagement Sharing of Risk Public safety