special interest seminar 2013. welcome hugh hamill deputy director pbni chair ppani smb

Special Interest Seminar 2013

Welcome Hugh Hamill Deputy Director PBNI Chair PPANI SMB

Anthony Harbinson Director of Safer Communities Department of Justice

Geraldine OHare Head of Psychology PBNI Chair PPANI SMB Education and Training Subgroup

Dr Richard Bunn Consultant Psychiatrist Belfast HSCT

Ramada Plaza Belfast 18 th December 2013

Dr Richard Bunn Consultant in Forensic Psychiatry Shannon Clinic, Regional Secure Unit.

Who am I really?

Public Protection

Violence and Mentally Disordered Offenders Mentally ill offenders are more violent than the general population. They commit more homicides. Medication is irrelevant. Severe personality disorder is not associated with violent offending.

Violence and Mentally Disordered Offenders Mentally ill offenders are not more violent than the general population. They do not commit more homicides. Breakdown in medication regimes can be a trigger factor. [Boyd Committee] Boyd Committee: A Preliminary Report on Homicide - A Report of the Steering Committee of the Confidential Inquiry into Homicide and Suicide of Mentally Ill Persons. London: Boyd Committee. Severe personality disorder has been associated with violent offending, and requires specific assessment.

Most violence is committed by people WITHOUT mental illness

mental health, violence and homicide

Schizophrenic who killed Jonathan Zito set to be moved from high-security prison By Daily Mail Reporter Christopher Clunis, who stabbed Jonathan Zito through the eye, is being moved to a medium-security unitDaily Mail Reporter Christopher Clunis, a schizophrenic,was jailed indefinitely after stabbing Jonathan Zito, 27, through the eye at a packed Finsbury Park tube station in December 1992. The case caused outrage when it was revealed that Clunis, now 45, who had a history of violent behaviour, had been released under the controversial 'care in the community' programme just weeks before the killing. Eight days before the attack, Clunis, who had stopped taking his medication, was found wandering the streets with a screwdriver and breadknife, threatening children. Sources at Rampton high security hospital, in Nottinghamshire, have said there are plans to move 18st Clunis to a medium-secure unit in Northamptonshire. One source told the Evening Standard: 'Clunis will be transferred on a trial-leave basis for six months with a view to him staying put if all goes to plan. 'It is hugely significant and the beginning of a stage-by-stage process designed to prepare patients for eventual release back into the community. 'It shows experts feel Clunis is responding to treatment and he could have his freedom sooner than anyone ever expected.' Clunis was diagnosed as a paranoid schizophrenic in 1986. An inquiry after Mr Zito's death found a 'catalogue of failure and missed opportunity' by professionals who should have been monitoring him.

The National Confidential Inquiry 9% of all homicides in England and Wales are committed by mentally ill persons. The rate is approximately 50 per year or one a week.

The National Confidential Inquiry Mentally ill persons who commit homicide are more likely to have a history of previous violence. 25% of mentally ill persons who committed homicide were non-compliant with medication in the month preceding the event. 1 in 20 homicides are committed by persons with schizophrenia. In the week prior to the homicide 29% of patients were seen by services; and only 9% were thought to be of short-term moderate or high risk of violent behaviour.

Mental Health

Question 1. Mental Illness is rare. False As many as 1 in 6 adults are affected at any one time and up to 1 in 4 consultations with a GP concern mental health issues. (Source - Sainsbury Centre for Mental Health) Question 2. People with mental illness are more likely to kill strangers than people who do not suffer from mental illness. False Those suffering from mental illness are less likely to kill than the General population. (Source - National Confidential Inquiry into Homicide and Suicide) Question 3. The rate of homicide committed by people suffering from mental illness is increasing. False There is evidence of an absolute decline. (Source - Mental Health and Serious Harm to Others, NHS National Programme on Forensic Mental Health Research and Development) Question 4. The rate of serious violence committed by those suffering from mental illness is increasing. True & False. The rate is rising but not as much as in the general population. (Source - Mental Health and Serious Harm to Others, NHS National Programme on Forensic Mental Health Research and Development) Question 5. Young people are likely to understand the discrimination associated with mental health problems. True. A survey in 2001 found that 80% of young people believe that having a mental health problem will lead to discrimination. 65% also identified young people as major perpetrators of discrimination. (Source - Dept. of Health Press Release 11.3.2001)

Mental illness can lead directly to or create a vulnerability to crime. People with mental illness, whether or not they have committed a serious offence, may be more likely... to be compromised or damaged by the criminal justice system. For example, they may be: More vulnerable to arrest. More vulnerable to injustice within the criminal justice system. At more risk of other harm by the system, for example adverse effects of custodial care and/or other institutions, e.g. an elevated suicide rate among prisoners. Susceptible people without mental illness on entry to the criminal justice system may develop it. People with mental illness may be more vulnerable to becoming a victim of crime through: Direct victimisation. Becoming victims of press and/or public fear and hostility whether having offended or not, and, where they have, at a disproportionate level compared to offenders without mental illness.

Outline: Classification of Mental Disorders

Violence & Schizophrenia 1 st episode schizophrenia 52/253 violent in 1992 study 36 violent in preceding year 16 > 1 year after admission Humphreys, et al (1992) Dangerous behavior preceding first admissions for schizophrenia Br J Schiz 161:501-505 Violence & Mental Illness Violence was greater only with acute symptoms Schizophrenia lower rates of violence than depression or Bipolar Disorder Substance Abuse > than Mental Illness Monahan, 1997 Actuarial support for the clinical assessment of violence risk. International Review of psychiatry 176:312-319.

Violence & Paranoia Paranoid psychotic patients Violence well-planned and in-line with beliefs Relatives or friends are usual targets Paranoid in community more dangerous than institutionalized given weapons access Krakowski et al., (1986) Psychopathology and Violence: a review of the literature. Compr Psych 27 (2): 131-148

Violence & Delusions Delusions conflicting data Factors to consider Threat/control override symptoms Non-delusional suspiciousness If delusions make people unhappy, frightened or angry. Whether they have acted on previous delusion Borum et al., 1996

Violence & hallucinations In general, AVH not inherent risk Certain types increase risk Hallucinations that generate negative emotions If pts. have not developed coping strategies Command Hallucinations 7 studies that showed no relationship MacArthur study (2001) showed general hallucinations were not associated but there was a relationship between command hallucinations to commit violence

Violence & Mania High percentage of assaultive or threatening behavior Serious violence is rare Violence with restraints Violence with limit setting Tardiff (1980) Assault, suicide, and mental illness. Arch Gen Psych 37 (2): 164-169

Violence & Depression Depression May strike out in despair Depressed mothers who kill their children Most common diagnosis in murder-suicide Extension of suicide In couples, associated with feelings of jealousness and possessiveness Resnick (1969) Child murder by parents: a psychiatric review of filicide. Am J Psych 126 (3): 325- 334 Rosenbaum (1990) The role of depression in couples involved in murder-suicide and homicide. Am J Psych 147 (8): 1036-1039

Violence & Brain Injury Brain Injury Aggressive features: Trivial triggering stimuli Impulsivity No clear aim or goals Explosive outbursts Concern and remorse following episode Geriatric senile organic psychotic disease More assaultive than ANY other diagnosis Kalunian (1990) Violence by geriatric patients who need psychiatric hospitalization. J Clin Psych 51 (8): 340-343

Violence & Personality Personality Disorders Borderline somewhat associated Antisocial personal disorder most common Violence is cold and calculated Motivated by revenge Occurs during periods of heavy drinking Combined with low IQ very ominous combination

Violence & personality Personality Traits Impulsivity Inability to tolerate criticism Repetitive antisocial behavior Reckless driving A sense of entitlement and superficiality Typical Violence paroxysmal, episodic Borum (1996)

Violence & Psychopathy Originally described by Cleckley (1941) in The Mask of Sanity Operationalized by Hare (1980, 1991, 2003): The Psychopathy Checklist- Revised (PCL-R) Unique interpersonal, affective, and behavioral traits Not in the DSM-IV or ICD-10 The most important factor in the risk of predatory violence.

Violence &: PTSD Domestic Violence Intellectual disability ADHD Substances - 50-80% involved in violent crimes are under the influence of alcohol at the time of the offense.

Violence & Substances 50-80% involved in violent crimes are under the influence of alcohol at the time of the offense. ".. people with a mental disorder are at least as likely to use substances as anyone else and people with anti-social personality disorder are significantly more likely than average to drink too much. The combination of an anti-social personality disorder and use of alcohol is strongly associated with a high risk of harm to other people." De Montfort University (2007) Substance Use, Mental Health and Crime. BA (Hons.) Community and Criminal Justice Module Guide. Leicester, De Montfort University, p. 96.

Mental Health Services available for Offenders Voluntary Sector Community Mental Health Teams (CMHTs) Community Forensic Mental Health Teams (CFMHT) Psychiatric Hospital Regional Secure Units People with mental health problems who are caught up in the criminal justice system may be admitted into a regional secure unit. They may be: Admitted from the courts under an order of the Mental Health Order, Transferred from an ordinary hospital because it is thought they need to be in a more secure setting, Transferred from prison under the Mental Health Order, or Transferred from a special hospital because they no longer need to be under maximum security. Special Hospitals People with a major mental disorder, who are detainable under mental health law and who are considered to pose a risk to others, may be admitted to a high security special hospital. Ashworth, Broadmoor, Carstairs and Rampton. Hospital orders and the transfer of prisoners to hospital for mental health treatment. It is important for those dealing with offenders being compulsorily detained in these and similar circumstances to understand the legal position.

Offenders and Mental Health The numbers of offenders with mental health both in the community and in prison are disproportionate to the numbers of people in the general population. This is particularly true in relation to female and young offenders. Prisoners have significantly higher rates of mental health problems than the general public (see table below from ).

Briefing No 39: Mental health care and the criminal justice system Sainsbury Centre for Mental Health gives these figures: Up to 90% of prisoners have some form of mental health problem (Singleton et al. 1998). 10% of male and 30% of female prisoners have previously experienced a psychiatric acute admission to hospital (DOH 2007). Most prisoners with mental health problems have common conditions, such as depression or anxiety. A smaller number have more severe conditions such as psychosis. Some Black communities are overrepresented in secure mental health forensic hospitals (Rutherford & Duggan 2007). A study of 500 women prisoners found that "women in custody are five times more likely to have a mental health concern than women in the general population" (University of Oxford, cited in Prison Reform Trust 2008). Young people in custody have an even greater prevalence of poor mental health, with 95% of 16 to 20 year olds having at least one mental health problem and 80% having more than one (Lader et al. 2000). The Office for National Statistics (ONS) study showed 78% of male remand prisoners with personality disorder, 64% of male sentenced prisoners and 50% of female prisoners. Anti-social personality disorder had the highest prevalence of any category of personality disorder. (Bradley review). A disproportionate 28% of Mental health treatment requirements made in 2006 were made in relation to non-white ethnic groups. (Seymour & Rutherford Sainsbury centre for mental health 2008). A third of women subject to community supervision by the Probation Service said they had a mental disorder. During the same period the figure for men was one in five (Mair and May 1997, quoted in Seymour & Rutherford). By 2006 research In London demonstrated that 48 per cent of offenders in touch with the London probation Service were experiencing mental health concerns and that as many as a third of offenders in the community also had a personality disorder (Solomon and Rutherford 2007 quoted in Seymour & Rutherford).

Promoting Quality Care Improve Safety Promote consistency Support services & Interfaces Regional Learning Promote good practice Principles Work with service users and carers Team working Risk Management Communication Recovery & Positive Risk taking Collaborative working AHPs, users, et al Understand roles & responsibilities Risk management Effective communication

Promoting Quality Care Care Planning Contingency & Crises plan Level of risk Frequency of review Comprehensive Risk Assessment Key worker responsibilities Care coordination responsibilities Recording of information Manage transfer & transitions - NCISH Discharge planning RQIA AUDIT

Why do we do it? Tarasoff v. The regents of the University of California, 1976.

Considering Mental Health

For further sources on mental disorder and violent crime: Blumenthal, S. and Lavender, T. (2001) Violence and mental disorder: A critical aid to the assessment and management of risk. Jessica Kingsley Publishers, published for the Zito Trust. Bonta, J., Law, M. and Hanson, K. (1998) The prediction of criminal and violent recidivism among mentally disordered offenders. Psychological Bulletin, Vol. 123, pp. 123-142. Coid, J. et al. (2007) Predicting and understanding risk of re-offending: the Prisoner Cohort Study. Home Office Research Summary 6/07, Ministry of Justice, London. Doyle, M. and Dolan, M. (2006) Predicting community violence from patients discharged from mental health services. British Journal of Psychiatry, Vol. 189, pp. 520-526. Monahan, J. (1992) Mental disorder and violent behaviour. American Psychologist, Vol. 47, pp. 511-521. Monahan, J. et al. (2001) Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence. Oxford University Press. Prins, H. (2005) Mental disorder and violent crime: a problematic relationship. Probation Journal, Vol. 52 (4), pp. 333-357. Snowden, R. J., Gray, N., Taylor, J. and MacCulloch, M. J. (2007) Actuarial prediction of violent recidivism in mentally disordered offenders. Psychological Medicine, Vol. 37, pp. 1539-1549. Taylor, P. and Gunn, J. (1999) Homicides by People with Mental Illness: Myth and Reality. British Journal of Psychiatry, Vol. 174, pp. 9-14.

For guidance see: Ministry of Justice - Mentally disordered offenders. Ministry of Justice - Mentally disordered offenders, guidance. Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services. (Dept of Health 2007) Avoidable deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness (2006). The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness is a national research project carried out at the University of Manchester since 1996 with periodic updates. The inquiry collects detailed clinical information on all suicides and homicides that occur under mental health services in England, Wales, Scotland and Northern Ireland. Morgan S. (2000) Clinical Risk Management: A Clinical Tool and Practitioners Manual. The Sainsbury Centre for Mental Health. Giving up the culture of blame: risk assessment and risk management in psychiatric practice. Prepared for the Royal College of Psychiatrists, by Dr John F. Morgan (2007). The Mental Health Policy Implementation Guide. Dual Diagnosis Good Practice Guide. (Dept of Health, 2002) advises that the possible association between substance misuse and increased risk of aggressive or anti-social behaviour forms an integral part of the risk assessment, and should be explicitly documented. MAPPA Guidance 2009, version 3, sections mental health paragraphs 24.9-24.9.7.

Additional Materials: Fernando, S. (1991) Mental Health, Race and Culture. Basingstoke: Macmillan. Madden, A. (2009) Treating Violence a guide to risk management in mental health. Oxford: Oxford University Press. (Anthony Madden is a practicing psychiatrist with a very pro-active view on risk assessment in mental health). Prins, H. (2005) Offenders, Deviants or Patients? London, Routledge. Prison Inspectorate (2007) The mental health of prisoners: A thematic review of the care and support of prisoners with mental health needs. These websites are useful sources of more information: Department of Health Royal College of Psychiatrists. Mind (National Association for Mental Health). Personality Disorder Website.

Dr Richard Bunn 02895 046323 [email protected]

Coffee Break

PERSONALITY DISORDER AND MANAGEMENT OF RISK Dr. Ian Bownes.

WHAT IS PERSONALITY DISORDER? - a personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress and/or impairment. - a personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress and/or impairment.

SPECTRUM OF DISORDER DANGEROUS SEVERE PERSONALITY DISORDER CATEGORICAL DISORDER OF PERSONALITY AS CATEGORISED BY 1CD- 10 PERSONALITY BASED DEFICITS AND DEFICIENCIES CHARACTEROLOGICAL TRAITS ODD/ECCENTRIC/NON-CONFORMING

EPIDEMIOLOGY OF PERSONALITY DISORDER - Around 14% of General Population will have a categorical personality disorder diagnosis. - Around 14% of General Population will have a categorical personality disorder diagnosis. - 0.6 2% general population will have ASPD - 0.6 2% general population will have ASPD - But 50 70 % of CJS Clientele will have ASPD - But 50 70 % of CJS Clientele will have ASPD - Combination of ASPD and Emotionally Unstable Personality Traits most associated with harm to self and others. - Combination of ASPD and Emotionally Unstable Personality Traits most associated with harm to self and others.

POINTS ABOUT PERSONALITY DISORDER - Common in society generally. - Common in society generally. - High incidence in forensic populations. - High incidence in forensic populations. - Acquired in significant personal adversity - Acquired in significant personal adversity - No comprehensive legislative framework. - No comprehensive legislative framework. - Not proven to be untreatable or fully treatable - Not proven to be untreatable or fully treatable - Core Symptoms/ behaviours fluctuate over time. - Core Symptoms/ behaviours fluctuate over time. - Highly co-morbid - to psychosocial dysfunction, mental illness, self-harm and suicide. - Highly co-morbid - to psychosocial dysfunction, mental illness, self-harm and suicide.

WHY WORRY ABOUT SEVERE P.D.? - PUBLIC PERCEPTION OF RISK FROM MEDIA. - PUBLIC PERCEPTION OF RISK FROM MEDIA. - A MAJOR COMPONENT OF C.J. S. WORKLOAD - A MAJOR COMPONENT OF C.J. S. WORKLOAD - ASSOCIATED WITH PERSONAL DISTRESS. - ASSOCIATED WITH PERSONAL DISTRESS. - MAJOR FINANCIAL BURDEN TO TRUSTS - A&E SELF HARM. - POPULATE PSYCHIATRIC ADMISSION WARDS DUE TO PSYCHIATRIC COMORBIDITIES. - NEED TREATMENT FOR SUBSTANCE MISUSE. - REQUIRE SOCIAL SERVICES INTERVENTION.

CHARACTERISTICS OF PERSONALITY DISORDERED History of Childhood Deprivation and abuse. History of Childhood Deprivation and abuse. Familial Dysfunctionality/Criminality/Paramilitarism. Familial Dysfunctionality/Criminality/Paramilitarism. Exposure to violent role models. Exposure to violent role models. Punishment Beatings/shootings for ASPD. Punishment Beatings/shootings for ASPD. Use Instrumental Violence to own ends. Use Instrumental Violence to own ends. Interpersonal alienation. Interpersonal alienation. Abuse Drugs and Alcohol. Abuse Drugs and Alcohol. Non-Compliance with therapeutic Interventions. Non-Compliance with therapeutic Interventions. External Attribution of Blame. External Attribution of Blame. See Statutory Services as oppressive agents of Social Control. See Statutory Services as oppressive agents of Social Control.

INEVITABLE CONSEQUENCES OF PERSONALITY DISORDER - Severe family disharmony. - Severe family disharmony. - School drop out. - School drop out. - Employment problems. - Employment problems. - Extremely hazardous lifestyle. - Extremely hazardous lifestyle. - Associated with Substance Misuse. - Associated with Substance Misuse. - Associated with Criminality. - Associated with Criminality. - Associated with Mental & Physical Ill health. - Associated with Mental & Physical Ill health. - Associated with frequent episodes of DSH. - Associated with frequent episodes of DSH. - High proportion commit Suicide. - High proportion commit Suicide. - Associated with impulsive aggressive behaviours. - Associated with impulsive aggressive behaviours.

PERSONALITY DISORDERED OFFENDERS - All ICD-10 CATEGORIES ARE REPRESENTED. - All ICD-10 CATEGORIES ARE REPRESENTED. - ASPD AND BPD MOST CLOSELY LINKED TO VIOLENCE. - ASPD AND BPD MOST CLOSELY LINKED TO VIOLENCE. - TEND TO HAVE LONG CRIMINAL CAREERS - TEND TO HAVE LONG CRIMINAL CAREERS - HIGH LEVELS OF RECIDIVISM - HIGH LEVELS OF RECIDIVISM - TEND TO DROP OUT OF TREATMENT PREMATURELY - TEND TO DROP OUT OF TREATMENT PREMATURELY - TEND TO SHOW SOME RELIEF WITH TIME - TEND TO SHOW SOME RELIEF WITH TIME - NEED 4-8 YEARS OF TREATMENTTO MAKE DIFFERENCE - NEED 4-8 YEARS OF TREATMENTTO MAKE DIFFERENCE

PSYCHOPATHOLOGY IN PERSONALITY DISORDERED. PSYCHOPATHY - MANIPULATIVE INSTRUMENTAL VIOLENCE MOOD SWINGS IMPULSIVE BEHAVIOUR ACTING OUT OPPOSITIONAL & DEFIANT BEHAVIOUR ANXIETY STATES POOR SLEEP WORRIES ABOUT FAMILY/PERSONAL SECURITY STAYING IN CELL

ORIGINS OF RISK IN THE PERSONALITY DISORDERED

TRAUMATIC CHILDHOOD EXPERIENCES - UP TO 80% OF PERSONALITY DISORDERED - UP TO 80% OF PERSONALITY DISORDERED ABANDONMENT ABANDONMENT TERRORISATION TERRORISATION CRUELTY CRUELTY HUMILIATION HUMILIATION - CAUSES ATTACHMENT INSECURITY - CAUSES ATTACHMENT INSECURITY - IMPEDES SELF-REFLECTIVE FUNCTION - IMPEDES SELF-REFLECTIVE FUNCTION - LIMITS CAPACITY TO ARTICULATE DISTRESS - LIMITS CAPACITY TO ARTICULATE DISTRESS - IMPEDES DEVELOPMENT OF EMPATHY - IMPEDES DEVELOPMENT OF EMPATHY - INCREASES SENSITIVITY TO THREAT - INCREASES SENSITIVITY TO THREAT - LEADS TO HYPERAROUSAL - LEADS TO HYPERAROUSAL

DISORGANISED ATTACHMENT IN PERSONALITY DISORDERED - ASSOCIATED WITH CHILDHOOD ABUSE - ASSOCIATED WITH CHILDHOOD ABUSE - INCREASED MENTAL DISORDER - INCREASED MENTAL DISORDER - DISSOCIATION WHEN STRESSED - DISSOCIATION WHEN STRESSED - INCREASED SENSE OF THREAT - INCREASED SENSE OF THREAT - FRANTIC RE-ATTACHMENT EFFORTS - FRANTIC RE-ATTACHMENT EFFORTS - TOXIC/PATHOLOGICAL ATTACHMENT - TOXIC/PATHOLOGICAL ATTACHMENT - CONTROLLING BEHAVIOURS - CONTROLLING BEHAVIOURS - RE-ENACTMENT OF TRAUMA - RE-ENACTMENT OF TRAUMA

ATTACHMENT AND THE PERSONALITY DISORDERD - WEAKENING OF ATTACHEMENT LEADS TO: - DISCHARGE OF EMOTION - ABANDONMENT FEARS - ANNIHILATION FEAR - RESENTMENT - SENSE OF BETRAYAL - SENSE OF LOSS - VIOLENCE

PATHOLOGICAL ATTACHMENTS - DISMISSIVE OR ENMESHING - COMPENSATORY FOR RECENT LOSS - EMOTIONALLY CHARGED/CONTRADICTORY - FEELINGS OF LOVE OR HATE - FEELINGS OF BEING CONTROLLED - FEELINGS OF BEING EXPLOITED - FEELINGS OF BEING UNDER THREAT - DEVOID OF FEELINGS OF TENDERNESS - NEW ATTACHMENTS MIRROR OLD ONES - RISK OF VIOLENCE MAY INCREASE

RISK AND PERSONALITY DISORDER

WHAT IS RISK? risk is simply the probability or likelihood of a particular event occurring. risk is simply the probability or likelihood of a particular event occurring.

How dangerous is it that this man go loose? How dangerous is it that this man go loose? HAMLET HAMLET

Risk Assessment is not about making an accurate prediction - but about making informed defensible decisions. Risk Assessment is not about making an accurate prediction - but about making informed defensible decisions. (Grounds, 1995)

CHARACTERISTICS OF RISK - CHANGES WITH TIME. - CHANGES WITH TIME. - CAN INCREASE OR DECREASE. - CAN INCREASE OR DECREASE. - IS UNCERTAIN ONLY RELATIVE PROBABILITIES CAN BE ESTIMATED. - IS UNCERTAIN ONLY RELATIVE PROBABILITIES CAN BE ESTIMATED. - OPERATES ALONG A CONTINUUM. - OPERATES ALONG A CONTINUUM. - THRESHOLDS OF RISK ARE DIFFICULT TO ESTABLISH. - THRESHOLDS OF RISK ARE DIFFICULT TO ESTABLISH. - DIFFERENCES BETWEEN LOW MODERATE HIGH OFTEN MINIMAL - DIFFERENCES BETWEEN LOW MODERATE HIGH OFTEN MINIMAL

GENERAL CHARACTERISTICS OF AT RISK PERSONALITY DISORDERED Diagnosis frequently unclear. Diagnosis frequently unclear. Mix of Treatable and Untreatable Symptoms. Mix of Treatable and Untreatable Symptoms. Neuropsychological deficits. Neuropsychological deficits. History of Childhood Deprivation and abuse. History of Childhood Deprivation and abuse. Familial Dysfunctionality/Criminality. Familial Dysfunctionality/Criminality. Exposure to violent role models Exposure to violent role models Use Instrumental Violence to own ends. Use Instrumental Violence to own ends. Interpersonal alienation. Interpersonal alienation. Abuse Drugs and Alcohol. Abuse Drugs and Alcohol. Non-Compliance with therapeutic Interventions. Non-Compliance with therapeutic Interventions. Hostile Attribution of Blame. Hostile Attribution of Blame. See Statutory Services as oppressive agents of Social Control. See Statutory Services as oppressive agents of Social Control.

Settings where At Risk Personality Disordered clients are Located. HIGH SECURITY MEDIUM SECURITY PSYCHIATRIC INTENSIVE CARE LOW SECURE SERVICES COMMUNITY HOSTELS SOCIAL SERVICES PROBATION SERVICES FORENSIC OUTPATIENTS CLINICS

P.D. RISK MANAGEMENT INTERFACES. CRIMINAL JUSTICE SYSTEM PRISONS POLICE COURTS PROBATION SERVICE COMMUNITY SERVICES SOCIAL SERVICES PRIMARY CARE VOLUNTARY CARE HOSTELS COMMUNITY PSYCHIATRY THE PERSONALITY DISORDERED CLIENT HOSPITAL SERVICES HIGHER SECURE SERVICES P.I.C.U. PSYCHIATRY PSYCHOLOGY OCCUPATIONAL THERAPY

AREAS OF DEFICIT AND DEFICIENCY IN THE PERSONALITY DISORDERED THAT CAN LEAD TO RISK.

ANTISOCIAL PERSONALITY DISORDER ANTISOCIAL PERSONALITY DISORDER

PERSISTENT CONDUCT DISORDER DSM IV - Frequent Bullying - Frequent Bullying - Starting physical fights - Starting physical fights - Using weapons - Using weapons - Physical cruelty to people and animals - Physical cruelty to people and animals - Theft with victim confrontation - Theft with victim confrontation - Staying out late without permission - Staying out late without permission - Truanting from school - Truanting from school - Vandalism - Vandalism - Breaking and Entering - Breaking and Entering - Manipulative lying - Manipulative lying - Covert Stealing - Covert Stealing - Forced sex - Forced sex - Deliberate fire setting to cause harm - Deliberate fire setting to cause harm - Running away from home overnight - Running away from home overnight

PRESENCE OF VIOLENT ATTITUDES PRESENCE OF VIOLENT ATTITUDES Present from childhood. Present from childhood. Fantasises about violence Fantasises about violence Use of instrumental violence. Use of instrumental violence. Sees violence as empowering Sees violence as empowering Premeditates violence. Premeditates violence. Associates with violent peers. Associates with violent peers. Denies/minimises seriousness. Denies/minimises seriousness. Not modified by legal sanction or social shame. Not modified by legal sanction or social shame.

PERPETRATOR ATTITUDES. - MACHO PERSONALITY.. - MACHO PERSONALITY.. - Belief that violence is manly. - Belief that violence is manly. - Belief that danger is exciting. - Belief that danger is exciting. - Belief in concept of sexual entitlement. - Belief in concept of sexual entitlement. - Minimisation of harm experienced by victim. - Minimisation of harm experienced by victim. - Association with like minded others - Association with like minded others - Syntoncity of ideas re: criminality. - Syntoncity of ideas re: criminality.

HISTORY OF VIOLENCE Instigated fights from an early age. Instigated fights from an early age. Fights across a range of settings. Fights across a range of settings. Threats of Harm with weapons. Threats of Harm with weapons. Serious injury to victims. Serious injury to victims. Family and friends equal threats or assaults. Family and friends equal threats or assaults. Reports buzz or sense of excitement. Reports buzz or sense of excitement. Evidence of sexual gratification. Evidence of sexual gratification. Urge to repeat behaviour. Urge to repeat behaviour.

DISTORTED THINKING - ABNORMAL SCHEMA. - ABNORMAL SCHEMA. - COMPLETE DENIAL - COMPLETE DENIAL - PARTIAL DENIAL - PARTIAL DENIAL - DENIAL OF A PROBLEM - DENIAL OF A PROBLEM - MINIMISATION OF THE NATURE OF OFFENCE - MINIMISATION OF THE NATURE OF OFFENCE - DENYING/MINIMISING PLANNING - DENYING/MINIMISING PLANNING - DENYING/MINIMISING FANTASY - DENYING/MINIMISING FANTASY - MINIMISING HARM - MINIMISING HARM - MINIMISING RESPONSIBLITY - MINIMISING RESPONSIBLITY

ABNORMAL SCEMA - Ingrained thinking/assumptions. - Ingrained thinking/assumptions. - I have to look out for myself no one else will. - I have to look out for myself no one else will. - Society cares nothing of me. - Society cares nothing of me. - People admire strength (violence). - People admire strength (violence). - Being violent is the only way to get things done. - Being violent is the only way to get things done. - no ones doing nothing for me... - no ones doing nothing for me... - The weak in society are mugs. - The weak in society are mugs.

PROBLEMS WITH SELF- AWARENESS - LACK OF INSIGHT - LACK OF INSIGHT - IMPAIRED SELF-REFLECTIVITY - IMPAIRED SELF-REFLECTIVITY - FAILURE TO UNDERSTANDONES CRIME - FAILURE TO UNDERSTANDONES CRIME - FAILURE TO UNDERSTAND OFFENCE CYCLE - FAILURE TO UNDERSTAND OFFENCE CYCLE - DEFICITS IN KNOWLEDGE - DEFICITS IN KNOWLEDGE - DISTORTED ATTITUDES - DISTORTED ATTITUDES - PROBLEMS WITH ANGER AND IMPULSIVENESS - PROBLEMS WITH ANGER AND IMPULSIVENESS

PROBLEMS WITH STRESS OR COPING - MALADAPTIVE COPING MECHANISMS - MALADAPTIVE COPING MECHANISMS - STRESS VULNERABILITY - STRESS VULNERABILITY - CHRONIC NEGATIVE AFFECT - CHRONIC NEGATIVE AFFECT - POOR SELF-REGULATION - POOR SELF-REGULATION - CHANGES IN EMPLOYMENT - CHANGES IN EMPLOYMENT - DIFFICULTIES IN INTIMATE RELATIONSHIPS - DIFFICULTIES IN INTIMATE RELATIONSHIPS - CHANGES OF RESIDENCE. - CHANGES OF RESIDENCE.

History of problems with relationships. No evidence of long-term comittment. No evidence of long-term comittment. Stormy, unstable or conflictual. Stormy, unstable or conflictual. Controlling, domineering, manipulative and subugating. Controlling, domineering, manipulative and subugating. Frequent break-ups/infidelity. Frequent break-ups/infidelity. Escalating abuse and violence. Escalating abuse and violence. Gratuitous/ego-boosting violence which is repeated. Gratuitous/ego-boosting violence which is repeated.

History of problems with substance misuse. Use starts in childhood or early adolescence. Use starts in childhood or early adolescence. Heavy sustained use of multiple substances. Heavy sustained use of multiple substances. Use in controlled settings Care/prisons/hospitals, Use in controlled settings Care/prisons/hospitals, Involvement in drug trade. Involvement in drug trade. Associated with risky /dangerous behaviour and criminality. Associated with risky /dangerous behaviour and criminality. Affects education, work, relationships Affects education, work, relationships

History of problems with employment. Poor educational attainment. Poor educational attainment. School drop out before exams sat. School drop out before exams sat. Long periods of unemployment. Long periods of unemployment. Frequent sackings for absenteeism, poor time keepings, alcoholism, fights or dishonesty. Frequent sackings for absenteeism, poor time keepings, alcoholism, fights or dishonesty. Failure to adhere to financial comittments due to unemployment. Failure to adhere to financial comittments due to unemployment.

History of Problems with Major Mental Disorder. Interfers with Education, work, employment, ADL and relationships. Interfers with Education, work, employment, ADL and relationships. Deteriorating with time. Deteriorating with time. Multiple Hospitalisations. Multiple Hospitalisations. Poor response to medication and other therapies. Poor response to medication and other therapies. Positive symptoms. Positive symptoms. Evidence of agitation/distress. Evidence of agitation/distress. Evidence of illness linked to violence. Evidence of illness linked to violence.

BORDERLINE PERSONALITY DISORDER BORDERLINE PERSONALITY DISORDER

RISK IN BORDERLINE PERSONALITY DISORDER. Extreme Reactions to Extreme Reactions to - Stress. - Stress. - Demand. - Demand. - Provocation. - Provocation. - Irritating situations, - Irritating situations, - Abandonment real or perceived. - Abandonment real or perceived. - Changes of plans. - Changes of plans.

RISK IN BORDERLINE PERSONALITY DISORDER. IMPULSIVITY leading to IMPULSIVITY leading to - Spending Sprees. - Spending Sprees. - Unsafe sex. - Unsafe sex. - Hazardous driving. - Hazardous driving. - Experimental drug use. - Experimental drug use. - binge eating. - binge eating. - Self Harm or Suicide. - Self Harm or Suicide.

RISK IN BORDERLINE PERSONALITY DISORDER. MOOD DISORDER that is MOOD DISORDER that is - Chronically Disturbed. - Chronically Disturbed. - Rapidly changing. - Rapidly changing. - Usually negative. - Usually negative. - Changes last hours or minutes. - Changes last hours or minutes. - Associated with anger outbursts. - Associated with anger outbursts. - Paranoid thoughts. - Paranoid thoughts. - Denigration of professionals. - Denigration of professionals.

PSYCHOPATHY PSYCHOPATHY

EMOTIONAL DEFICIENCY IN PSYCHOPATHY - DECREASED ELECTRODERMAL RESPONSIVENESS - DECREASED ELECTRODERMAL RESPONSIVENESS - LESS FACIAL EXPRESSION - LESS FACIAL EXPRESSION - ABSENCE OF AFFECTIVE STARTLE MODULATION - ABSENCE OF AFFECTIVE STARTLE MODULATION - LACK OF FEAR IN RESPONSE TO AVERSIVE EVENTS - LACK OF FEAR IN RESPONSE TO AVERSIVE EVENTS - POOR CONDITIONING - POOR CONDITIONING - GENERAL UNDERAROUSAL - GENERAL UNDERAROUSAL

PSYCHOPATHY PREDICTS PSYCHOPATHY PREDICTS - Desire to dominate. - Desire to dominate. - Hostile Attributions - Hostile Attributions - Absence of Empathy - Absence of Empathy - Absence of Anxiety - Absence of Anxiety - Recklessness - Recklessness - Impulsivity - Impulsivity - No concern for future - No concern for future - Antisocial attitudes. - Antisocial attitudes.

PSYCHOPATHY AND VIOLENCE - LINKED TO CORE TRAITS OF: - LINKED TO CORE TRAITS OF: - GRANDIOSITY - GRANDIOSITY - CALLOUSNESS - CALLOUSNESS - MANIPULATION - MANIPULATION - LACK OF EMPATHY - LACK OF EMPATHY - Lack of guilt/remorse. - Lack of guilt/remorse. - TENDS TO BE COLD BLOODED AND INSTRUMENTAL IN NATURE. - TENDS TO BE COLD BLOODED AND INSTRUMENTAL IN NATURE. - LACK OF EMOTION. - LACK OF EMOTION. - ABNORMAL RESPONSE TO PUNISHMENT. - ABNORMAL RESPONSE TO PUNISHMENT.

UNPREMEDITATED ATTACKS IN PSYCHOPATHIC INDIVIDUALS - External Locus of Control. - External Locus of Control. - No physical evidence of pre-planning. - No physical evidence of pre-planning. - Attackers have not set out to harm. - Attackers have not set out to harm. - Have a previous history of instability/violence. - Have a previous history of instability/violence. - Attack occurs following exposure to stress or provocation. - Attack occurs following exposure to stress or provocation. - Attack usually occurs in similar contexts. - Attack usually occurs in similar contexts. - Usually involves acquaintances rather than strangers. - Usually involves acquaintances rather than strangers.

PREMEDITATED ATTACKS IN PSYCHOPATHIC INDIVIDUALS. - Victim, setting and method of attack already determined in attackers mind. - Victim, setting and method of attack already determined in attackers mind. - May follow period of rehearsal in fantasy. - May follow period of rehearsal in fantasy. - Believes successful attack will bring rewards. - Believes successful attack will bring rewards. - Start attack sequence with level of self- control. - Start attack sequence with level of self- control. - Self-control may lessen during the attack. - Self-control may lessen during the attack.

CHARACTERISTICS - Systematic - may follow script from T.V., Film or Pornography. - Systematic - may follow script from T.V., Film or Pornography. - May have special knowledge of martial arts/arson/poisoning. - May have special knowledge of martial arts/arson/poisoning. - Self-control may degenerate into frenzy. - Self-control may degenerate into frenzy. - Site of attack may have special significance. - Site of attack may have special significance. - May keep post-attack trophy or diary. - May keep post-attack trophy or diary. - Attacks again after certain interval. - Attacks again after certain interval.

ASSESSMENT OF RISK IN PERSONALITY DISORDERED INDIVISUALS. ASSESSMENT OF RISK IN PERSONALITY DISORDERED INDIVISUALS.

DEFENSIBILITY OF ASSESSMENT OF RISK - All reasonable steps have been taken. - All reasonable steps have been taken. - Reliable assessment methods have been used. - Reliable assessment methods have been used. - Information is collected and thoroughly evaluated. - Information is collected and thoroughly evaluated. - Decisions are recorded. - Decisions are recorded. - Staff work within Agency Policies and Procedures. - Staff work within Agency Policies and Procedures. - Staff communicate with others to seek the information they do not have. - Staff communicate with others to seek the information they do not have.

CORE RISK FACTORS - Attitudes that support or condone violence. - Attitudes that support or condone violence. - Problems with self-awareness. - Problems with self-awareness. - Problems with stress and coping. - Problems with stress and coping. - Psychopathic personality disorder. - Psychopathic personality disorder. - Major mental illness. - Major mental illness. - Problems with substance misuse. - Problems with substance misuse. - Problems with intimate relationships. - Problems with intimate relationships. - Sexual deviance. - Sexual deviance. - Diversity of offending. - Diversity of offending. - Escalation of offending. - Escalation of offending.

AIMS AND OBJECTIVES RISK MANAGEMENT IN P.D. To comprehensively assess the specific components of risk. To comprehensively assess the specific components of risk. To differentiate between mental health related issues of risk and those that are not. To differentiate between mental health related issues of risk and those that are not. To express a view regarding To express a view regarding -Whom is at risk. -Whom is at risk. -Why they are at risk. -Why they are at risk. -Immediacy of the risk. -Immediacy of the risk. To suggest risk reducing strategies. To suggest risk reducing strategies. To monitor efficacy of risk reducing strategies. To monitor efficacy of risk reducing strategies.

EXAMPLES OF STRUCTURED PROFESSIONAL JUDGEMENT - VIOLENCE RISK SCALE (VRS) - VIOLENCE RISK SCALE (VRS) - HISTORICAL-CLINICAL-RISK MANAGEMENT GUIDE (HCR-20) - HISTORICAL-CLINICAL-RISK MANAGEMENT GUIDE (HCR-20) - SEXUAL VIOLENCE RISK-20 (SVR-20) - SEXUAL VIOLENCE RISK-20 (SVR-20) - STRUCTURED ASSESSMENTOF VIOLENCE RISK IN YOUTH - STRUCTURED ASSESSMENTOF VIOLENCE RISK IN YOUTH - SPOUSAL ASSAULT RISK ASSESSMENT GUIDE - SPOUSAL ASSAULT RISK ASSESSMENT GUIDE

HCR-20: HISTORICAL SCALE - H1- PREVIOUS VIOLENCE - H1- PREVIOUS VIOLENCE - H2- YOUNG AGE AT FIRST VIOLENT INCIDENT - H2- YOUNG AGE AT FIRST VIOLENT INCIDENT - H3 - RELATIONSHIP INSTABILITY - H3 - RELATIONSHIP INSTABILITY - H4 EMPLOYMENT PROBLEMS - H4 EMPLOYMENT PROBLEMS - H5 SUBSTANCE USE PROBLEMS - H5 SUBSTANCE USE PROBLEMS - H6 MAJOR MENTAL ILLNESS - H6 MAJOR MENTAL ILLNESS - H7 PSYCHOPATHY - H7 PSYCHOPATHY - H8 EARLY MALADJUSTMENT - H8 EARLY MALADJUSTMENT - H9 PERSONALITY DISORDER - H9 PERSONALITY DISORDER - H10 PRIOR SUPERVISION FAILURE. - H10 PRIOR SUPERVISION FAILURE.

HCR-20: CLINICAL SCALE - C1 LACK OF INSIGHT - C1 LACK OF INSIGHT - C2 NEGATIVE ATTITUDES - C2 NEGATIVE ATTITUDES - C3 ACTIVE SYMPTOMS OF MAJOR MENTAL ILLNESS - C3 ACTIVE SYMPTOMS OF MAJOR MENTAL ILLNESS - C4 IMPULSIVITY - C4 IMPULSIVITY - C5 UNRESPONSIVE TO TREATMENT - C5 UNRESPONSIVE TO TREATMENT

WHAT IS RISK MANAGEMENT ?

GENERAL PRINCIPLES OF MANAGING RISK IN PERSONALITY DISORDER Stratify patients according to the risk they present. Stratify patients according to the risk they present. Avoid Inappropriate Placements. Avoid Inappropriate Placements. Ensure Whole Systems Approach. Ensure Whole Systems Approach. Ensure Interagency Cooperation. Ensure Interagency Cooperation. Avoid creation of artificial barriers to Service Delivery. Avoid creation of artificial barriers to Service Delivery. Ensure Continuity of Care/Responsibility. Ensure Continuity of Care/Responsibility. Ensure Least Restrictive, Safe, Homely local settings. Ensure Least Restrictive, Safe, Homely local settings. Ensure Client Centred Approach. Ensure Client Centred Approach. Ensure good Communication and transfer of important information. Ensure good Communication and transfer of important information.

RISK ASSESSMENT FRAMEWORK IN P.D. - Define the behaviour to be predicted. - Define the behaviour to be predicted. - Distinguish between the probability and the cost of the behaviour. - Distinguish between the probability and the cost of the behaviour. - Be aware of possible sources of error. - Be aware of possible sources of error. - Take into account internal as well as external factors. - Take into account internal as well as external factors. - Check all necessary information is available. - Check all necessary information is available. - Predict factors that will decrease as well as increase risk. - Predict factors that will decrease as well as increase risk. - Identify ALL key professionals or agencies from the start involved. - Identify ALL key professionals or agencies from the start involved. - Plan key interventions jointly. - Plan key interventions jointly.

Risk Management Goals Provide Support/practical advice. Provide Support/practical advice. Facilitate monitoring and Supervision. Facilitate monitoring and Supervision. Crises Intervention. Crises Intervention. Increase motivation. Increase motivation. Improve Thinking Skills. Improve Thinking Skills. Reduce distress. Reduce distress. Improve problem Solving. Improve problem Solving. Improve Social Skills. Improve Social Skills.

RISK MANAGEMENT STRATEGIES - TREATMENT. - TREATMENT. - SUPERVISION. - SUPERVISION. - MONITORING - MONITORING - VICTIM SAFETY PLANNING. - VICTIM SAFETY PLANNING.

HCR-20: RISK MANAGEMENT SCALE - R1 - PLANS LACK FEASIBILITY - R1 - PLANS LACK FEASIBILITY - R2 EXPOSURE TO DESTABILISERS - R2 EXPOSURE TO DESTABILISERS - R3 LACK OF PERSONAL SUPPORT - R3 LACK OF PERSONAL SUPPORT - R4 NON-COMPLIANCE WITH REMEDIATION ATTEMPTS - R4 NON-COMPLIANCE WITH REMEDIATION ATTEMPTS - R5 - STRESS - R5 - STRESS

MANAGING THE RISK - Record roles and responsibilities of each professional/agency involved with patient. - Record roles and responsibilities of each professional/agency involved with patient. - Audit any adverse incidents as they arise. - Audit any adverse incidents as they arise. - Have predetermined plans of action. - Have predetermined plans of action. - Keep good quality records. - Keep good quality records. - Assure open communications. - Assure open communications. - Comply with statutory requirements. - Comply with statutory requirements. - Adhere to organisational protocols. - Adhere to organisational protocols. - Provide adequate trained staff. - Provide adequate trained staff. - Spread the risk. - Spread the risk.

THERAPEUTIC INTERVENTIONS.

STAGES OF INTERVENTION - SAFETY. - SAFETY. - CONTAINMENT. - CONTAINMENT. - CONTROL AND REGULATION. - CONTROL AND REGULATION. - EXPLORATION AND CHANGE. - EXPLORATION AND CHANGE. - INTEGRATION AND SYNTHESIS - INTEGRATION AND SYNTHESIS LIVESLEY, 2003 LIVESLEY, 2003

AIMS OF INTERVENTION - NOT TO CURE PERSONALITY DISORDER - NOT TO CURE PERSONALITY DISORDER - BUT TO - BUT TO - AMELIORATE DISTRESSING SYMPTOMS - AMELIORATE DISTRESSING SYMPTOMS - TO STABILISE IN THE HERE AND NOW. - TO STABILISE IN THE HERE AND NOW. - TO ENCOURAGE ADAPTIVE FUNCTIONING. - TO ENCOURAGE ADAPTIVE FUNCTIONING. - TO INSTIL PROSOCIAL ATTITUDES. - TO INSTIL PROSOCIAL ATTITUDES. - TO REDUCE STIGMA/ALIENATION. - TO REDUCE STIGMA/ALIENATION. - TO ENCOURAGE EMOTIONAL AND PRACTICAL INVESTMENT IN SOCIETY. - TO ENCOURAGE EMOTIONAL AND PRACTICAL INVESTMENT IN SOCIETY.

Features of a Successful Management Plan. Instil order as a central feature. Instil order as a central feature. Individualised. Individualised. Explicit Goals. Explicit Goals. Prioritised Goals. Prioritised Goals. Long term time frame. Long term time frame. Consistency. Consistency. Insistency. Insistency. Persistency. Persistency. Tolerance. Tolerance.

MULTIDIMENSIONAL TREATMENT - INSTIL PSYCHOLOGICAL AND LIFESTYLE STABILITY. - INSTIL PSYCHOLOGICAL AND LIFESTYLE STABILITY. - SOCIAL SUPPORT/MONITORING - SOCIAL SUPPORT/MONITORING - ADDRESS COGNITIVE DISTORTIONS - ADDRESS COGNITIVE DISTORTIONS - ENCOURAGE EMPATHIC CONCERN - ENCOURAGE EMPATHIC CONCERN - MANAGEMENT OF NEGATIVE EMOTIONAL STATES - MANAGEMENT OF NEGATIVE EMOTIONAL STATES - ANGER MANAGEMENT - ANGER MANAGEMENT - SOCIAL SKILLS TRAINING/COPING STRATEGIES - SOCIAL SKILLS TRAINING/COPING STRATEGIES

HIERARCHY OF THERAPEUTIC INTERVENTIONS SPECIALISED FORENSIC PSYCHOTHERAPY COGNITIVE BEHAVIOUR THERAPY ENHANCED THINKING SKILLS MENTALISATION THERAPY OFFENCE FOCUSSED WORK PROBLEM SOLVING SKILLS SOCIAL SKILLS TRAINING ANGER MANAGEMENT ANXIETY MANAGEMENT ANTI-SOCIAL SCHEMA WORK STRUCTURED DAY

RISK SCENARIO PLANNING - Consider more than one scenario. - Consider more than one scenario. - Consider nature of future harm. - Consider nature of future harm. - Severity of future harm. - Severity of future harm. - Imminence - Imminence - Frequency or duration - Frequency or duration - Likelihood - Likelihood

BARRIERS TO EFFECTIVE INTERAGENCY WORKING - LACK OF FORMAL PROTOCOLS FOR COOPERATION. - LACK OF FORMAL PROTOCOLS FOR COOPERATION. - INCOMPATIBLE SYSTEMS OF DATA STORAGE. - INCOMPATIBLE SYSTEMS OF DATA STORAGE. - DIFFICULTIES IN INFORMATION ACCESS AND RETRIEVAL. - DIFFICULTIES IN INFORMATION ACCESS AND RETRIEVAL. - PROFESSIONAL MISTRUST AND RIVALRIES. - PROFESSIONAL MISTRUST AND RIVALRIES. - MISPLACED CONFIDENTIALITY. - MISPLACED CONFIDENTIALITY.

IMPEDIMENTS TO CHANGE 1) The presence of untreated Dysfunctional Schema (ingrained automatic patterns of thinking.) The presence of untreated Dysfunctional Schema (ingrained automatic patterns of thinking.) Alienation from and absence of a need to invest emotionally in society coupled with Alienation from and absence of a need to invest emotionally in society coupled with Unquestioning and non-judgemental practical and emotional support from his/her dysfunctional substance abusing peer grouping. Unquestioning and non-judgemental practical and emotional support from his/her dysfunctional substance abusing peer grouping.

IMPEDIMENTS TO CHANGE 2) A perception that he/she has status within his sub-cultural fringe that has to date not been afforded him by mainstream society. A perception that he/she has status within his sub-cultural fringe that has to date not been afforded him by mainstream society. An inherent tendency to impulsivity and sensation seeking behaviours. An inherent tendency to impulsivity and sensation seeking behaviours. Failure of normal society to provide individual with challenging and exciting legal activities. Failure of normal society to provide individual with challenging and exciting legal activities.

IMPEDIMENTS TO CHANGE 3) Absence of a wholesome, non- criminogenic and supportive social network that he could readily identify with. Absence of a wholesome, non- criminogenic and supportive social network that he could readily identify with. Poor academic attainment and failure to build up a skills base. Poor academic attainment and failure to build up a skills base. Fear of ridicule, fear of failure and fear of the unfamiliar if he was to leave his to date well tried and tested comfort zone of a dysfunctional peer grouping. Fear of ridicule, fear of failure and fear of the unfamiliar if he was to leave his to date well tried and tested comfort zone of a dysfunctional peer grouping.

PERSONAL QUALITIES OF P.D. PRACTITIONERS - Good clinical skills/Clarity of thought. - Good clinical skills/Clarity of thought. - Sound experience in General Psychiatry. - Sound experience in General Psychiatry. - Natural curiosity regarding unusual behaviours. - Natural curiosity regarding unusual behaviours. - Ability to think multi-dimensionally. - Ability to think multi-dimensionally. - Tolerance for difficult patients. - Tolerance for difficult patients. - Capacity to accept patients characteristics but not condone/collude. - Capacity to accept patients characteristics but not condone/collude. - Willingness to be flexible. - Willingness to be flexible.

Dr Maria OKane Consultant Psychiatrist Belfast HSCT

Personality Disorder A Diagnosis for Inclusion Dr Maria OKane Consultant Psychiatrist / Clinical Lead BHSCT PD Service

Background Population of NI 1.8 million, Belfast 420k GHQ (DHSSPSNI, 2001) prevalence of mental illness 20% higher than England and Scotland No validated epidemiological stats for Personality Disorder in NI Suicide rates in deprived areas of the city x2 average UK, Self harmx4 (Protect Life Strategy review 2012- PD levels not identified ) Benzodiazepine and Antidepressant usage x2 average UK POMH-PD Audit 2012 95% on medications Unemployment rate 30% higher than remainder of UK 30 years of civil unrest ( 1968-1998) continued paramilitary violence Personality Disorder Strategy adopted Winter 2010 1.5 million regionally

Context to PD Services in N. Ireland Legal Context & Mental Health Legislation in N. Ireland Bamford Review of Mental Health & Learning Disability (N. Ireland) (2007) Forensic & Adult Mental Health Reports Public Protection Arrangements N. Ireland (PPANI) Health & Criminal Justice Provision

Overview Personality Disorder Strategy N. Ireland Recommendations New Developments to date Partnership Working . is it working? Personality Disorder Treatments & Interventions Future plans for Personality Disorder Services in N. Ireland

Why is PD important? 5 13% general population 20 50% substance misuse attenders 50 78% of prisoners 47 77% of people who commit suicide 50% of children with conduct disorder and many care leavers

What is it ? GENERAL DIAGNOSTIC CRITERIA FOR A PERSONALITY DISORDER DEFINITION ICD 10 / DSMIV/V An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture. This pattern is manifested in two (or more) of the following areas. Cognition (I.e. ways of perceiving and interpreting, self, other people and events) Affectivity (I.e. the range, intensity, lability and appropriateness of emotional response) Interpersonal functioning Impulse control The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. The pattern is stable and of long duration and its onset can be traced back to at least to adolescence or early adulthood. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. The enduring pattern is not due to the direct physiological effects of a substance or general medical condition

Clusters A/Paranoid Personality Disorder 4% of pop A /Schizoid Personality Disorder < 1% A/ Schizotypal Personality Disorder 2% B/Anti-social Personality Disorder 1.5% pop B/Emotionally Unstable Personality Disorder 2% pop B/Histrionic Personality Disorder 2% pop B/Narcissitic Personality Disorder C/Anxious / Avoidant Personality Disorder C/Dependent Personality Disorder

Recorded Common Historical Themes YesNoTotal number Difficult parent/ caregiver patient relationship/attachment documented 21930 Exposure to violence (domestic & troubles) 20 ( 5 troubles in N.Ireland) 1030 Involved in care system6 ( All before age 9)2430 Childhood familial sexual abuse 22 (1 unknown male)8 (1 rape as adult) 30 Convictions History Forensic History 2 24 28 6 30 Family History of mental illness / disorder 21728 (2 adopted)

The Team Staff Composition 0.5 Consultant Psychiatrist 1 Band 7 Team Leader 2 Band 7 Nurse Therapists 1 Junior Doctor CT3 2 Band 6 Social Workers 1 Band 3 Job-share Carer Advocate 1 Band 3 Advocate ( vacant) 1Band 3 Mental Health Support Worker Administrative support The Service Integrated Health and Social Care Model MBT Keywork once engaged Progression and review through treatment programme Twice weekly and individual staff supervision

The Belfast Self Harm and PD Service Referral 10 per week Information session 50% attendance Assessment 95% opt in 6 weeks psychoeducatio n group 12 weeks MBT group 18 months MBT Group & 1:1 Self Activation OPD

A strategic approach to comprehensive services for PD Commissioning approaches Specialist commissioning Collaborative commissioning (wider geography ) Mental Health partnership commissioning Wider partnership Primary care Employment Housing Social care TIER 1 consultation, support, education PCMH, gateway, services A&E liaison, crisis services Community mental health services Assertive outreach Acute care Secure care High secure care Mental Health Services PD services Youth agencies TIER 4 specialist services TIER 3 Intensive day services TIER 2 case management & treatment

Personality Disorder Strategy N.I. A Diagnosis for Inclusion Core Principles Service Model User & Carer Involvement Training Provision in N. Ireland for PD Services

Strategy Recommendations 17 Recommendations Commissioning of PD Services/Multi-Agency Lead Trust Tiered Approach Criminal Justice PD Unit Prison Based Services PD Network across Health/Criminal Justice Integrated Care Pathways

N.I. Personality Disorder Strategy Recommendations Recommendations 1 - 5: Commissioning services Recommendations 6 - 8: Specialist Units & Criminal Justice Services Recommendations 9 - 12:PD Network & Pathways of Care & Training Recommendations 13 - 17:Research & Evaluation

Background NICE Guidelines Bradley Review Knowledge and Understanding Framework Recognising Complexity Personality Disorder is everybodys business Implementation

Recognising Complexity Potential cost benefits Community PD services (Tiers 1 to 3) appropriate use of Primary care Reduced Prescribing Reduced harm from drug and alcohol abuse Reduced risk of offending Reduction in A&E use Improved Family life, education and employment Improved staff retention

Recognising Complexity Potential cost benefits Severe and complex PD (Tier 4) Less escalation to more secure/intensive services Reduced risk to self or others Managing the challenge to services

Recognising Complexity Potential cost benefits Severe PD, high risk of harm to others (Tier 5) Less escalation to prison, segregation, secure or forensic placements Strengthened community management More rational use of high cost placements

Recognising Complexity Commissioning guidance for PD services Aims to support commissioners to work collaboratively to address need and improve outcomes for people with PD

Recognising Complexity Commissioning for complexity Recognising overlapping client groups with: learning disability substance misuse offending behaviour think PD Encouraging effective pathways think cooperation, co-production As part of other required duties and needs assessments think PD Equalities matter think PD

Cases Transferred Out Of N. Ireland for Treatment Analysis of Independent Funding Requests (IFRs) for Personality Disorder at November 12 = 15 cases Total cost = 2.76million per annum 6 had forensic needs identified All had secure needs: 5 low 1 low to medium 8 medium 1 high 11 detained & 4 voluntary patients

Length of Stay Time SpanNumber of Cases 1 Year 2 1-3 Years7 3-5 Years3 5+ Years1 No Admission Date1

Length of Stay (contd) Personality Disordered Providers NumberAverage Cost Per Day Private Hospital4472 - 548 Independent Hospital4635 - 656 Independent Hospital2534 - 545 Private Hospital2515 - 566 Private Hospital1375 NHS Hospital1523 NHS High Secure Hospital1970

Progress To Date Commissioning of PD Services Development of PD Teams within Trust areas Lead Trust (Belfast Health & Social Care Trust) Service Delivery Model/Carers & Users Prison based service Care Pathway Multi-Agency Training Implementation Group

Partnership Working .. is it working? Who is responsible? Pathways across services Criminal Justice & Health Interface Integrated Model Challenges & Opportunities

Future Plans for Personality Disorder Services in N. Ireland Strategic approach Collaborative working/shared vision Effective partnerships Joint training Effective practice/outcomes Evaluation & Research Leaders in this area of work

Challenges at the Interface Diagnosis/ Misdiagnosis/ Overdiagnosis of PD Drugs- Illicit/ prescribed Alcohol Misuse Lack of awareness of Community options/ Tier 1-2/ Pathway Collusion / Expectation / Entitlement/ Impulsivity/ Threats 3 week window

QUESTIONS?

PPANI Special Interest Seminar Offenders with Mental Health Problems December 18 th 2013

Primary Research: England and Wales (Birmingham); Scotland (Edinburgh); Northern Ireland (Belfast)and the Republic of Ireland (Dublin) 51 semi-structured interviews with Statutory agencies inc police, prisons, probation, HSS Voluntary sector agencies Independents inc forensic and clinical psychologists

To examine official, public and academic discourses on grooming To deconstruct the term grooming and examine its role in the onset of sexual offending against children, and how in turn it may be prevented

Access Compliance Secrecy But also about normalisation & huge impact on victims

Who? Child Grooming; Familial; Societal; peer-to-peer ; self-grooming Where? Intra-familial and extra-familial grooming How? On-line grooming; face-to-face, street grooming, institutional grooming

Difficulties of defining/identifying grooming Limited to known risk - conviction/serious concern about future harm Complement with a PHA - early intervention at primary & secondary levels of prevention

Similarities & differences Easier to police on-line grooming due to digital chain of evidence, but problems with advancing technology Each poses their own sets of challenges for preventing, targeting and criminalising grooming & abuse

Differences between first time & subsequent offending Offending as a combination of offender motivation, victim vulnerability, and opportunity Psychological & environmental factors preferential, opportunist, situational offending Variations with age or gender of perpetrator The victim-offender continuum

Complexities of onset environment/others Apt to describe deliberate/conscious course of conduct Short hand reference but less appropriate with intra-familial abuse Less appropriate for SOs with learning difficulties/MDOs/poor social skills Complexity means a multi-layered approach to prevention/intervention/ protection

Children/young people grooming others Interactions between offenders in group treatment settings

older adult offenders grooming younger offenders Implications for treatment settings Dynamics of group work settings Individual offender progress Effectiveness/outcomes of treatment Training for professionals

There was an older guy in the group and his orientation was young males.... I was really taken aback. This [young] guy, he suffers from Aspergers,... and the other man was a teacher. And one day the young guy had a book and I said, thats a very interesting book and he said, yeah, the other guy gave it to me.... he asked me for my number a couple of weeks ago and phoned me, and said he had it, so once I had read it wed meet for coffee and chat about it. So I could see it, you know, in exactly the same format he used to get young guys into his house... So it was like it was happening actually in front of us. RI 3 (16 th May 2011) (Treatment Professional).

Grooming within child care institutions by those in position of trust Grooming of assessment, treatment and management professionals

Interactions between offenders and professionals Professional Grooming a sense of being tested... [or] being pulled into some sort of relationship dynamic that really shouldnt be going on (SC 11, 7 th September 2011 assessment/treatment professional) an occupational hazard Impact on assessment/ treatment/ management Prisons and prison staff The therapeutic alliance Police/social services and suspect offenders

The experience of the offender? Greater occurrence of professional grooming among offenders who had gone through treatment I tend to find that I am groomed more by those people who have been through the programmes than those who havent, because they have learned the language of change (NI 8, 6 th July 2011- police). they would be very conscious of what responses they need to give.... So I think any institutionalised delivery of programmes, they are going to know how to tick the box (NI 5, 22 nd June 2011 voluntary sector).

Impact on assessment/management? impression management/transference How ascertain whether change is genuine rather than false or manipulative? Tension between human and emotional/professional and detached side of work with sex offenders Play professionals off against each other = the watering down of evidence/losing sight of the risk that someone poses Importance of going back to the offence & balancing victim and offender perspectives:

one of the most difficult things in forensic work is trying to stay in the middle all the time... not over identifying with victims; not over indentifying with offenders. It is not being drawn into... completely seeing the side that the offender wants you to see, but also seeing the other side (SC 9, 24 th August 2011 forensic psychologist)

Work with the offenders family/partner Ultimately, when all the agencies pull away, those are the individuals that will be responsible for standing over whether that adult or young person is applying the learning in their day to day life. (NI 12, 26 th July 2011, treatment professional).

Work with First-time offenders there is a whole gap in service provision about engaging perpetrators who are outside of the court criminal system (NI 14, 3 rd August 2011, social services professional). I dont think we offer enough before the abuse has actually happened. (RI 4, 13 th June 2011, social services professional).

Training of professionals around the dynamics of abuse e.g. education & health sector on new and emerging forms of grooming e.g. law enforcement agencies on sexual exploitation and impact on victim e.g. judiciary on pre-abuse/pro-offence behaviours

Extremely complex and nuanced nature of sexual offending against children Multi-layered approach - Interventions with potential victims, as well as offenders and families how do we couple monitoring, management and the building in of protective factors? (RI 8, 23 rd June 2011 Probation)

Balance victim and offender focus - address victim vulnerability and offender opportunity Blended protection (Kemshall) protective and reintegrative strategies Proactive management of risk, plus strengths- and needs- Offender-focused as well as offence- focused strategies

A confessional v a bio-psycho social approach Balance between future focus and pro- offending behaviour Correlation between grooming and recidivism (e.g. Scalora and Garbin, 2003)

we need to have a very sensitised and nuanced view of grooming and we need to spend our time looking at the seemingly insignificant decisions made by offenders (RI 11, 5 th July 2011 assessment professional) BUT... If you dont concentrate on the skills and strengths and other things, then I think all we are doing is reinforcing an offenders negative views of himself (SC 11, 7 th September 2011 assessment & treatment professional)

Marcella Leonard PPANI Coordinator

Summary of PPANI Audits 2013

Audit team consists of: PSNI Managers Public Protection Team / PPANI Links PBNI Manager PPT / LAPPP Chair NIPS Governor Trust Principal Officer PPANI Lay Advisors PPANI Co-ordinator

Audit Team meets 4 times a year and reviews 100% Category 3 LAPPP papers 5% Category 2 5% Those reduced to Category 1 Specific theme in each audit: SA07 Integration, DV, Prison LAPPP Risk Management Plans Report provided to Chair of Policy and Practice Subgroup Report provided to quarterly PPANI SMB meeting

Introduction of new LAPPP Forms which have evidenced improved quality of information and structure from LAPPP meeting Record of multiagency discussion provides more accurate reflection of the depth of discussion at the LAPPP meeting Challenge posed by domestic violence cases due to lack of assessment tool and where there is no legal mandate to enforce cooperation with PPANI Risk Management Plan Audit team acknowledges continued improvement in the quality of the LAPPP papers Summary of Audits Findings

Summary of Audit Findings Audit which focused on quality of the Risk Management Plans identified the risks identified were not correlated with the risk management plan. Risk Management Plans were too generic and lacked specific risk posed by individual offender Risk Management Plans not including the findings of the Sa07 Lack of clarity and context to some statements in LAPPP papers could lead to misunderstanding

Summary of Audit Findings Lack of clarity between the PSNI DRM role and the visiting officer role could lead to confusion re accountability for RMP When agency / professional involvement with offender ceases explanation should be provided to LAPPP Lack of reports from external agencies /professionals providing assessments or treatment to PPANI offenders Challenges for DRMs where no statutory orders are in place Significant improvement in quality of information for prison LAPPPs

Summary of Audits Recommendations DRMs to provide analysis of SA07 assessments DRMs to provide analysis of their intervention with offender since previous LAPPP DRMs to provide outline as to how offenders specific risks are being addressed including within any treatment programmes Where LAPPP makes decision to reduce offender to Category 1, a summary of risk posed and areas to be addressed must be provided

Summary of Audits Recommendations DRMs must ensure sharing of information with all relevant agencies and personnel Guidance to be developed for DRMs to assist in risk management of domestic violence cases Impact on the links with victims when they do not register with victim information schemes, all relevant agencies to improve the uptake of victims accessing the scheme All relevant agencies / professionals involved in the management and treatment of PPANI offenders must provide written report at least 2 days before LAPPP to DRM and if possible attend the LAPPP

Summary of Audits Recommendations All resources, interventions and treatments must be evidenced in the DRM report Any dissent in the LAPPP meeting regarding category of risk should be recorded in the LAPPP papers Child and Vulnerable Adult protection concerns should be added to the LAPPP agenda Risks identified need to be evidenced in specific Risk Management Plans

Summary of Audits Recommendations DRMs must identify what is the risk posed by associates not naming the individuals LAPPP Chairs need to be mindful of Data Protection issues when referencing others in LAPPP papers Guidance for agencies regarding the sharing of soft intelligence within the LAPPP with other agencies Consideration should be given to inclusion of offences which are left on the books in the risks posed by the offender.

When DRM refers to any agency assessments context must be given to the scoring analysis within the DRM report for explanation for other agency representatives. NIPS LAPPP papers should provide EDR on the front of LAPPP papers. All Audit findings and recommendations are overseen by Policy and Practice subgroup on behalf of PPANI SMB Summary of Audits Recommendations

Multi Agency Panel Chaired by Geraldine OHare

special interest seminar 2013. welcome hugh hamill deputy director pbni chair ppani smb

Documents