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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
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OverviewOverview
• 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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HeterogeneityHeterogeneity
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No such thing as a No such thing as a stereotypical sex offenderstereotypical sex offender
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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
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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
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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
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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
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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
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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
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PERSONALITYPERSONALITY DISORDER
ANTISOCIAL PERSONALITY DISORDERPSYCHOPATHY
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PERSONALITYPERSONALITY DISORDER
ANTISOCIAL PERSONALITY DISORDERPSYCHOPATHY
SEXUAL OFFENDERSSEXUAL OFFENDERS
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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
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Stable dynamic domainsStable dynamic domains
SEXUAL PREOCCUPATI
ON / DEVIATION
ATTITUDES
SOCIO-AFFECTIVE
FUNCTIONING
SELF REGULATION
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Stable dynamic domainsStable dynamic domains
SEXUAL PREOCCUPATI
ON / DEVIATION
ATTITUDES
SOCIO-AFFECTIVE
FUNCTIONING
SELF REGULATION
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‘‘Personality disorder service’Personality disorder service’
• Personality disorder• Wider personality issues• Psychopathy• Paraphilia• Sexual dysfunction• Gender identity• Mood disorders• Developmental disorders
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Clinical inputClinical input
RISK ASSESSMENT
SUPPORTING CRIMINAL JUSTICE
AGENCIES
TREATMENT
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Clinical inputClinical input
RISK ASSESSMENT
SUPPORTING CRIMINAL JUSTICE
AGENCIES
TREATMENT
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Clinical inputClinical input
RISK ASSESSMENT
SUPPORTING CRIMINAL JUSTICE
AGENCIES
TREATMENT
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Risk AssessmentRisk Assessment
OFFENCEOFFENCE
Static factors
Stable dynamic factors
Acute dynamic factors
Triggers
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RISK ASSESSMENT
Structured Professional Judgement
Complex & unusual cases
Clinical understanding essential
RMA Guidance
Multi-agency
Integrated
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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
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Clinical inputClinical 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
Another view
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Clinical inputClinical input
RISK ASSESSMENT
SUPPORTING CRIMINAL JUSTICE AGENCIE
TREATMENT
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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
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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
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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?
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Understanding and managing Understanding and managing personality disordered offenderspersonality disordered offenders
• Risk
• Need
• Responsivity
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Forensic mental health Forensic mental health serviceservice
A ONE TRICK A ONE TRICK PONY?PONY?
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Taking responsibility for Taking responsibility for patient’s behaviourpatient’s behaviour
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Forensic mental health services working with Forensic mental health services working with criminal justice: SEARCH AND RESCUEcriminal justice: SEARCH AND RESCUE
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Section 328 definition of mental Section 328 definition of mental disorder includes personality disorderdisorder includes personality disorder
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Traditional multi-agency working Traditional multi-agency working modelmodel
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Criminal justice agenciesCriminal justice agencies
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Forensic mental health services working Forensic mental health services working with criminal justice: WORKING TOGETHERwith criminal justice: WORKING TOGETHER
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Multi-Agency Public Protection Multi-Agency Public Protection Arrangements (MAPPA)Arrangements (MAPPA)
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OFFENDER
POLICE
CRIMINAL JUSTICE
SOCIAL WORK
HOUSINGSACRO
MENTAL HEALTH
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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
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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
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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
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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
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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
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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
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ReferralReferral
• Referrals from CJSW and Police• Assessment only
• Risk Assessment• Medication potential
• Most cases are 2:1• Supervision is provided
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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
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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
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MedicationMedication
• A more recent addition to the service• Seen by Psychiatry• First service of its kind in Scotland• Follow-up provided
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MedicationMedication
• Psychiatry• Review notes• Interview• Review of Symptoms• Prescription of anti-androgens/SSRIs • Follow-up
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ReportsReports
• Background information• PCL-R• RSVP (HCR-20 if appropriate)• Marshall/Hucker Sadism scale• Offence Analysis• Formulation• Recommendations
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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
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SOLS assessmentsSOLS assessments
• Number of referrals– 23
• Referred by– CJSW 14– Police 2– MAPPA 2– Court 2– NHS 3
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 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
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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 [email protected] [email protected]
[email protected]@nhs.net