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Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 Forensic Network A Forensic.

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Presentation on theme: "Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 Forensic Network A Forensic."— Presentation transcript:

1 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network A Forensic Perspective The Risks of Excluding Offenders with Personality Disorder

2 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Conference Aims To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk. To consider the aetiology of PD as a route to both engagement and management, in particular the issue of disadvantage. To discuss current progress and future plans for services for people with PD who offend To present a model of assessment and management based on shared risk and to examine this in community, hospital and prison settings.

3 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Conference Aims: Outline To engage staff from all fields of mental health in the assessment and management of people with personality disorder who offend or present a significant risk. -Prevalence- Current service & practice -Recidivism- Current issues To discuss current progress and future plans for services for people with PD who offend

4 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Background: Prevalence of ASPD General population2-3% 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

5 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network 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

6 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Recidivism Rates Prison State Hospital Recidivism RateViolent Recidivism Duration 60%- 2 years 31% (20%)19% (12%) 11 (2)

7 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network 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

8 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network 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.

9 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network 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.

10 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network 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

11 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Forensic Network Report on Services for People with Personality Disorder 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

12 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Summary 2005 No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety

13 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Mental Welfare Commission: Mr G Impact of diagnosis of personality disorder: “Untreatable”, “get out clause for services” -Speciality services not offered or withdrawn -No use of structured psychological treatments, despite good evidence supporting their use -Little help given to alter behaviour – capable of choosing -Historical information distorted to support diagnosis

14 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Mental Welfare Commission: Mr G SGMHD & SPS to review specialist mental health input to prisons SPDN to produce guidance on appropriate interventions for people with a diagnosis of personality disorder Education on fronto-temporal dementia

15 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Summary 2005 No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety

16 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network

17 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Fatal Accident Inquiry Death in Custody Evidence Expertise

18 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network LegislationMH(C&T)(S)A 2003 Definition of Mental DisorderMental disorder means any mental illness, personality disorder or learning disability however caused or manifested Exclusions - relevant when the exclusion category listed is the only factor. Sexual orientation Sexual deviancy Transsexualism Transvestism Alcohol or drug dependence or use Behaviour that causes, or is likely to cause, harassment, alarm or distress to any other person Acting as no prudent person would act.

19 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Criteria for Detention Mental disorder Significantly impaired ability to make decisions about treatment[Not for MDOs] Significant risk to health, safety or welfare; or safety of others Available treatments likely to prevent mental disorder from worsening or alleviate symptoms or effects Necessity Underlying principles

20 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Summary 2005 No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety

21 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Multi-Agency Public Protection Arrangements MAPPA Management of Offenders etc. (Scotland) Act 2005 Health service: Duty to co-operate for all offenders Responsible authority for restricted patients

22 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network MAPPA – Types of Offenders Registered Sex Offenders – April 2007 Restricted patients – 30 April 2008 Violent Offenders – 2009 or 2010? ‘Category 3’– others with a conviction posing a risk of serious harm

23 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network MAPPA Levels Level 1 – no specific review meeting Level 2 – regular review meetings considering a number of cases Level 3 – dedicated Multi-Agency Public Protection Panel (MAPPP) considers an individual case Level based on complexity of multi-agency risk management, not risk assessment.

24 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Summary 2005 No longer a diagnosis of exclusion Training Sharing of Risk Prison based pilots Inpatient initiatives Community pilots Patient engagement Staff engagement Improved patient care Improved public safety

25 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Problem Behaviour Clinic Stalking Threatening Fire Setting Violent Offending Persistent Complaining Morbid Jealousy Problem Gambling

26 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network

27 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Perpertrator

28 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network PREVALENCE OF STALKING IN SCOTLAND “Persistent and unwanted attention” : 17% women ] : 7% men] lifetime : 5% women] : 2% men] in last year “Stalked” : 10% women] : 4% men] lifetime 2002 Non harassment orders 37 PROTECTION FROM HARASSMENT ACT 1997 Interdicts1,511

29 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network MENTAL DISORDER AND STALKERS Symptomatic Pathologies of love - schizophrenia, dementia Pure Pathologies of love - erotomanic delusional disorder Continuum morbid infatuation  Delusions of love Personality Disorder Substance Abuse

30 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network CLASSIFICATION OF STALKERS Rejected - pursues ex-intimates for reconciliation, revenge or both Intimacy seekers - seeking love from someone they love Incompetent - inappropriate intrusion, seeking a date or sexual encounter Resentful - pursue victims as revenge for actual or perceived injury Predatory - for sexual offending

31 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Stalking Stalking is as prevalent in Scotland as in the rest of the Western World Legislation exists in response to this issue Research has focussed on legal matters There is little clinical input in this area Treatment: CJSW/Prisons +/- Mental Health input

32 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network Progress 2008 Scottish Government Tripartite Group Pilot projects within CJSW Services and SPS for joint health, social services and criminal justice assessment and management of “problem clients”. Shared risk – MAPPA Joint working with SPD Network Forensic Network MAPPA and Sex Offender lead

33 Personality Disorder: A Risky Business? Forensic Network & SPDN 13 th June 2008 L.D.G.Thomson@ed.ac.ukL.D.G.Thomson@ed.ac.uk Forensic Network

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