the role of mental health services in the management of personality disordered offenders in the...

The Role of Mental Health The Role of Mental Health Services in the Services in the Management of Management of

Personality Disordered Personality Disordered Offenders in the Offenders in the

CommunityCommunityDr Rajan Darjee

Consultant Forensic Psychiatrist

Dr Katharine Russell

Chartered Clinical Psychologist

OverviewOverview

• Why we’re doing what we’re doing?• How we’re doing it?• What we’ve been doing?

"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)

HeterogeneityHeterogeneity

No such thing as a No such thing as a stereotypical sex offenderstereotypical sex offender

Mental disorder in sex offendersMental disorder in sex offendersFazel Fazel et al. et al. (2007)(2007)

0 5 10 15 20 25 30 35

Schizophrenia

Bipolar disorder

Other psychosis

Depression

Anxiety

Alcohol/drug related disorders

Personality disorder

Learning disability

Adjusted Odds Ratio

Mental disorder in sex offendersMental disorder in sex offendersAlden Alden et al. et al. (2007)(2007)

comorbid personality disorder comorbid personality disorder v v comorbid substance misuse comorbid substance misuse v v no no comorbiditycomorbidity

0 2 4 6 8 10

Schizophrenia

Organic

Affective

Other psychosis

Any psychosis

Odds Ratio

Mental disorder in ‘paedophilic Mental disorder in ‘paedophilic sex offenders’sex offenders’

Raymond Raymond et al. et al. (1999)(1999)

0 10 20 30 40 50 60 70 80

Mood

Anxiety

Alcohol/drug relateddisorders

Other Paraphilias

Sexual Dysfunction

Personality disorder

Percentage

Mental disorder in elderly sex Mental disorder in elderly sex offendersoffendersFazel Fazel et al. et al. (2002)(2002)

0 5 10 15 20 25 30 35

Psychosis

Depression

Personality disorder

Dementia

Percentage

Mental disorder in referrals to Mental disorder in referrals to specialist residential treatment specialist residential treatment

Dunsieth Dunsieth et al. et al. (2004)(2004)

0 20 40 60 80 100

Mood

Anxiety

Alcohol/drug relateddisorders

Paraphilias

Personality disorder

Percentage

Mental disorder in sexual Mental disorder in sexual murderersmurderers

Stone (2001),Stone (2001), Firestone et al (1998), Firestone et al (1998), Proulx & Sauvetre (2007)Proulx & Sauvetre (2007)

0 20 40 60 80 100

Psychosis

Mood disorder

Anxiety

Paraphilia

Alcohol/drug related

Personality disorder

Percentage

PERSONALITYPERSONALITY DISORDER

ANTISOCIAL PERSONALITY DISORDERPSYCHOPATHY

PERSONALITYPERSONALITY DISORDER

ANTISOCIAL PERSONALITY DISORDERPSYCHOPATHY

SEXUAL OFFENDERSSEXUAL OFFENDERS

Personality disorder in sex Personality disorder in sex offendersoffenders

• 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

Stable dynamic domainsStable dynamic domains

SEXUAL PREOCCUPATI

ON / DEVIATION

ATTITUDES

SOCIO-AFFECTIVE

FUNCTIONING

SELF REGULATION

Stable dynamic domainsStable dynamic domains

SEXUAL PREOCCUPATI

ON / DEVIATION

ATTITUDES

SOCIO-AFFECTIVE

FUNCTIONING

SELF REGULATION

‘‘Personality disorder service’Personality disorder service’

• Personality disorder• Wider personality issues• Psychopathy• Paraphilia• Sexual dysfunction• Gender identity• Mood disorders• Developmental disorders

Clinical inputClinical input

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE

AGENCIES

TREATMENT

Clinical inputClinical input

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE

AGENCIES

TREATMENT

Clinical inputClinical input

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE

AGENCIES

TREATMENT

Risk AssessmentRisk Assessment

OFFENCEOFFENCE

Static factors

Stable dynamic factors

Acute dynamic factors

Triggers

RISK ASSESSMENT

Structured Professional Judgement

Complex & unusual cases

Clinical understanding essential

RMA Guidance

Multi-agency

Integrated

Tiered approach to risk Tiered approach to risk assessment and assessment and

managementmanagement

Needs assessment

Risk screening & monitoring

Specialist assessment

and risk

management

Assessment & supervision of

stable & dynamic risk

Clinical inputClinical input

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE

AGENCIES

TREATMENT

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

Another view

Clinical inputClinical input

RISK ASSESSMENT

SUPPORTING CRIMINAL JUSTICE AGENCIE

TREATMENT

TREATMENT

Supporting use of criminal justice treatment

Attention to the context and relationships

Specialist psychological treatment of offending behaviour

Specific therapies for personality disorder

Tailored sex offender programme

Pharmacological treatment

TreatmentTreatmentPsychological treatment of sex offendersPsychological 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

TreatmentTreatmentPharmacological treatment of sex offendersPharmacological 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?

Understanding and managing Understanding and managing personality disordered offenderspersonality disordered offenders

• Risk

• Need

• Responsivity

Forensic mental health Forensic mental health serviceservice

A ONE TRICK A ONE TRICK PONY?PONY?

Taking responsibility for Taking responsibility for patient’s behaviourpatient’s behaviour

Forensic mental health services working with Forensic mental health services working with criminal justice: SEARCH AND RESCUEcriminal justice: SEARCH AND RESCUE

Section 328 definition of mental Section 328 definition of mental disorder includes personality disorderdisorder includes personality disorder

Traditional multi-agency working Traditional multi-agency working modelmodel

Criminal justice agenciesCriminal justice agencies

Forensic mental health services working Forensic mental health services working with criminal justice: WORKING TOGETHERwith criminal justice: WORKING TOGETHER

Multi-Agency Public Protection Multi-Agency Public Protection Arrangements (MAPPA)Arrangements (MAPPA)

OFFENDER

POLICE

CRIMINAL JUSTICE

SOCIAL WORK

HOUSINGSACRO

MENTAL HEALTH

Forget the nonsenseForget 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 hospitalXX

How we’re doing itHow 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

How we’re doing itHow 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

How we’re doing itHow 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

Sex Offender Liaison Service Sex Offender Liaison Service (SOLS)(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

Sex Offender Liaison Service Sex Offender Liaison Service (SOLS)(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

ReferralReferral

• Referrals from CJSW and Police• Assessment only

• Risk Assessment• Medication potential

• Most cases are 2:1• Supervision is provided

ReferralsReferrals

• 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

Risk AssessmentRisk 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

MedicationMedication

• A more recent addition to the service• Seen by Psychiatry• First service of its kind in Scotland• Follow-up provided

MedicationMedication

• Psychiatry• Review notes• Interview• Review of Symptoms• Prescription of anti-androgens/SSRIs • Follow-up

ReportsReports

• Background information• PCL-R• RSVP (HCR-20 if appropriate)• Marshall/Hucker Sadism scale• Offence Analysis• Formulation• Recommendations

Follow-upFollow-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

SOLS assessmentsSOLS assessments

• Number of referrals– 23

• Referred by– CJSW 14– Police 2– MAPPA 2– Court 2– NHS 3

SOLS assessmentsSOLS assessments

• Offence (most serious sexual offence)– 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

SOLS assessmentsSOLS assessments

• Reason for referral (not mutually exclusive)– Risk assessment 12– Diagnosis and implications 11– Assessment/treatment of sexual problems 4

• MAPPA level– 3 4– 2 13– 1 0– N/A 6

SOLS assessmentsSOLS assessments

• Number of staff carrying out assessment– One 5– Two 18

• Tools used– PCL-R 10– RSVP 10– HCR-20 3– SSS (Marshall/Hucker) 1

SOLS assessmentsSOLS 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

SOLS assessmentsSOLS assessments

• Paraphilia (n=23)– Definite 7– Possible 2– None 14

• Specific paraphilias– Paedophilia 9– Non-sadistic rape fantasies 1– Fetishism 1– Exhibitionism 1

Mr ZMr 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

Mr Z #2Mr 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

Mr Z #3Mr 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

Mr Z #4Mr 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

Mr Z #5Mr 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

Mr Z #6Mr 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

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

Future developmentsFuture developmentsFUNDING• NHS Lothian• Scottish GovernmentLOCALLY (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 pilotNATIONALLY (Forensic Network)• Developing role of forensic mental health in MAPPA• Teaching and training – PD, sex offending, risk• Developing assessment and treatment of sex offenders

Dr Rajan DarjeeDr Rajan Darjee Consultant Forensic PsychiatristConsultant Forensic Psychiatrist

Dr Katharine RussellDr Katharine Russell Chartered Clinical Chartered Clinical PsychologistPsychologist

The Orchard ClinicThe Orchard ClinicRoyal Edinburgh HospitalRoyal Edinburgh HospitalMorningside Terrace Morningside Terrace Edinburgh EH10 5HFEdinburgh EH10 5HF0131 537 58660131 537 5866rajan.darjee@nhs.net rajan.darjee@nhs.net

katharine.russell@nhs.netkatharine.russell@nhs.net