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The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community

The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community. Dr Rajan Darjee Consultant Forensic Psychiatrist Dr Katharine Russell Chartered Clinical Psychologist. Overview. Why we’re doing what we’re doing? How we’re doing it?

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The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community

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  1. The Role of Mental Health Services in the Management of Personality Disordered Offenders in the Community Dr Rajan Darjee Consultant Forensic Psychiatrist Dr Katharine Russell Chartered Clinical Psychologist

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

  3. "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)

  4. Heterogeneity

  5. No such thing as a stereotypical sex offender

  6. Mental disorder in sex offendersFazel et al. (2007)

  7. Mental disorder in sex offendersAlden et al. (2007)comorbid personality disorder v comorbid substance misuse v no comorbidity

  8. Mental disorder in ‘paedophilic sex offenders’Raymond et al. (1999)

  9. Mental disorder in elderly sex offendersFazel et al. (2002)

  10. Mental disorder in referrals to specialist residential treatment Dunsieth et al. (2004)

  11. Mental disorder in sexual murderersStone (2001), Firestone et al (1998), Proulx & Sauvetre (2007)

  12. PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

  13. SEXUAL OFFENDERS PERSONALITY DISORDER PERSONALITY ANTISOCIAL PERSONALITY DISORDER PSYCHOPATHY

  14. Personality disorder in sex offenders • 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

  15. Stable dynamic domains SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION

  16. Stable dynamic domains SEXUAL PREOCCUPATION / DEVIATION ATTITUDES SOCIO-AFFECTIVE FUNCTIONING SELF REGULATION

  17. ‘Personality disorder service’ • Personality disorder • Wider personality issues • Psychopathy • Paraphilia • Sexual dysfunction • Gender identity • Mood disorders • Developmental disorders

  18. Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

  19. Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

  20. Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

  21. Risk Assessment Staticfactors Stable dynamic factors Acute dynamic factors Triggers OFFENCE

  22. RISK ASSESSMENT Structured Professional Judgement Multi-agency Integrated Complex & unusual cases RMA Guidance Clinical understanding essential

  23. Tiered approach to risk assessment and management Specialist assessment and risk management Assessment & supervision of stable & dynamic risk Risk screening & monitoring Needs assessment

  24. Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIES TREATMENT

  25. Part of the MAPPA team Available for advice Clinical understanding of offending Clinical perspective on management Linking offenders in with services SUPPORTING CRIMINAL JUSTICE AGENCIES Another view

  26. Clinical input RISK ASSESSMENT SUPPORTING CRIMINAL JUSTICE AGENCIE TREATMENT

  27. Pharmacological treatment Tailored sex offender programme Specific therapies for personality disorder Specialist psychological treatment of offending behaviour Attention to the context and relationships TREATMENT Supporting use of criminal justice treatment

  28. TreatmentPsychological 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

  29. TreatmentPharmacological 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?

  30. Understanding and managing personality disordered offenders • Risk • Need • Responsivity

  31. Forensic mental health service A ONE TRICK PONY?

  32. Taking responsibility for patient’s behaviour

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

  34. Section 328 definition of mental disorder includes personality disorder

  35. Traditional multi-agency working model

  36. Criminal justice agencies

  37. Forensic mental health services working with criminal justice: WORKING TOGETHER

  38. Multi-Agency Public Protection Arrangements (MAPPA)

  39. SACRO HOUSING OFFENDER CRIMINAL JUSTICE SOCIAL WORK POLICE MENTAL HEALTH

  40. X Forget 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 hospital

  41. How 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

  42. How 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

  43. How 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

  44. Sex Offender Liaison Service (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

  45. Sex Offender Liaison Service (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

  46. Referral • Referrals from CJSW and Police • Assessment only • Risk Assessment • Medication potential • Most cases are 2:1 • Supervision is provided

  47. Referrals • 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

  48. Risk 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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