Women in secure services

1. Women in secure services MRCPsych Course - Northern Deanery 11 October 2011 Dr R Kini - Consultant Forensic Psychiatrist

2. Aim To provide an overview of key issues relating to the assessment and management of female mentally disordered offenders in secure hospitals

3. Objectives Secure Services Policy Drivers Clinical characteristics Offence characteristics Gender specific needs Risk assessment and management

4. SECURE SERVICES High Low Woman WEMSS Medium

5. FEMALE SECURE PATHWAYS NATIONAL HIGH SECURE SERVICE - RAMPTON Supported Placements Community NHS MSU / LSU WEMSS Orchard Clinic (London) Arnold Lodge (Leicestershire) Edenfield unit (North West) PRISON Independent Sector MSU / LSU PICU Non-forensic Low Secure

6. Types of security Least restrictive environment, safe, local Environmental (Physical) Relational (Quantitative, Qualitative) Procedural (Policies, practices) H G Kennedy (2002) “Therapeutic uses of security: mapping forensic mental health services by stratifying risk”; APT, vol. 8; pp 433-443

7. POLICYDRIVERS OF CHANGE

8. Policy Drivers Butler report – 1975 Reed report – 1992 Set the principles which underpinned development of secure psychiatric services 1998 audit – 94% wards mixed gender 1999: National Women’s project group 2000: DoH published Secure Futures for Women: Making a difference – women centred services should be available in hospital and community

9. Policy Drivers 2 Tilt report – 2000 Review of security at high security hospitals Highlighted the fact that 33% no longer required HS TILT Funding – increase development of RSU NHS Plan – 2000 Aimed for 400 transfers nationally; Accelerated Discharge Programme

10. Policy Drivers 3 ADP completed by April 2005 Women’s mental health: Into the mainstream (DoH, 2002) Mainstreaming gender and women’s mental health: Implementation guidance (DoH, 2003)

11. Policy Drivers 4 Women at risk: The mental health of women in contact with the judicial system (CSIP, 2006) Corston Report – 2007, Government response

12. Baroness Corston’s Report – March 2007 A report by Baroness Jean Corston of a review of women with particular vulnerabilities in the criminal justice system

13. PSO 4800 – 2008 NSF: Improving services to women offenders, MoJ / NOMS (2008) Standards and Criteria for women in medium secure care – RCPsych, Quality Network for Forensic Services (Tucker, S and Ince, C); 2008 Bradley Report –2009 Policy Drivers 5

14. Lord K Bradley’s Report – April 2009

15. Lord K Bradley’s Report – April 2009 • Review of people with mental health problems or LD in the CJS • Early intervention • All stages of the CJS • Emphasis on diversion • NHS & CJS working together

16. Improving Health Supporting Justice • The national delivery plan of the Health & Criminal Justice Programme board • November 2009 • System reform to maximise opportunities for improvement • Right treatment at the right time • Better working practices • Innovation • No new resources

17. 7 December 2009 A ten year strategy Improve the mental well being of the population Improve quality & accessibility of services for people with poor mental health New Horizon: “Towards a shared vision for mental health”

18. Key Issues • Gender sensitivity • Over containment • Nature of treatment offered • Security, Safety – Single sex accommodation • Complex needs • Staffing composition – e.g. Female to male staffing ratio (70% proposed) • A Bartlett; Health Inequalities & Women in contact with the CJS

19. SHSA (1995) Figures

20. Secure Services for Women 2000: Out of 39 MSU (342 beds) only 14 NHS and 79 IS beds in women only services 2003: DoH paper – creation of enhanced MSU for women in HSS who did not need Category B high secure care 2008: HSS beds fell from 345 (1991) to 50 in Rampton 2009: 27 (18 NHS and 9 IS) MSU providing 543 (282 NHS and 261 IS) beds

21. Women in secure services 1 • One in 8 of patients in medium or high secure is female • In July 2007, 458 (12% of total) women were in either medium or high secure conditions • Higher proportion of female restricted patients were • Detained under psychopathic disorder sub-category (21% cf 12% men) • 51% of women with restriction order were detained under MI cf 70% of men • Sainsbury Centre for Mental Health, Fact-file; 2007

22. Women in secure services 2 • In absolute numbers, a minority • Cf men, less than 10% on restriction orders or sentenced prisoners • Although about 33% patients did not need HS, the proportion of women was higher • Dr A B & Y H – APT; Dr Y Hassell & Dr A Bartlett; 2001; Bulletin

23. Women in secure services 3 • Higher prevalence of mood disorders, more severe manifestation of PTSD and bipolar disorder • Later onset of schizophrenia • Better prognosis of schizophrenia • Amongst PD population – more diagnoses of histrionic and dependent personality disorders. However, rate of BPD is the same in both genders overall! Paranoid and Antisocial high in men

24. Women in secure services 4 In high and medium security greater proportion under Part 2 of the Act Greater proportion likely to receive hospital disposal at Court The conviction in majority – arson Most victims – own children or intimate others Less likely violent and sexual offences Less likely to have pre-cons and to reoffend 2009 study (Sahota)– More violence than men after discharge (2 and 5 yrs); mainly arson – increased with time; lower reconviction rate J Sarkar & M di Lustro (2011, APT, 17, 323-31)

25. Female patients in HSS • More likely than male patients to be: • Detained under Part 2 of the Act • Be classified as having a PD, especially borderline PD • Have an index offence of arson • Be admitted in the context of suicidal or • DSH behaviour, aggression towards hospital staff or damage to property • Higher rates of physical or sexual abuse • Bartlett & Hassell, APT (2001), VOL.7, p. 304

26. Characteristics of female patients in secure forensic services • More likely to have a primary diagnosis of PD, especially BPD; cf men who are more likely to have a diagnosis of ASPD and Schizoid PD both in HS and in MS • Women admitted to secure forensic psychiatry services: I. Comparison of women and men (J Coid et al; The Journal of Forensic Psychiatry; Vol 11; No. 2; September 2000; 275 – 295) • Cluster analysis article – pp 296 – 315

27. Characteristics of female patients in secure forensic services 2 • More likely than male patients to: • Be admitted as transfers from other hospitals • Have a charge or conviction of arson or criminal damage • Have fewer criminal convictions and more previous Ψ admissions • More likely to have diagnosis of depression, phobia, anxiety / panic, epilepsy and IQ < 70 in MSU and Depression & other in HSH (cf Schizophrenia in men)

28. Characteristics of female patients in secure forensic services 3 • Using Cluster analysis: • 7 year study of 3 HS hospitals and MSU from 3 regions (1988 – 1994) • 7 clusters: 3 PD (ASPD, BPD, Other PD); 3 MI (Schizophrenia, Mania and Depression); 1 OBS • ASPD Cluster – Significant co-morbidity with BPD; with criminal behaviour (arson, CD, theft); higher rates of admission to HS; pre-cons linked with major violence and Part 3 admissions

29. Characteristics of female patients in secure forensic services 4 • BPD Cluster – Increased criminal behaviour (arson and minor violence), epilepsy, substance misuse, previous Ψ admissions • Mania Cluster – Violent behaviour in other hospital settings • Schizophrenia cluster – 34% • Larger proportion – non UK Born, index more likely to be major violence but not significant previous violent offending, part 2 admissions, • Depression cluster – 26% after homicide

30. Characteristics of female patients in MSU 1(Sahota et al, 2010) • Retrospective Study – 20 year follow up of all first admitted patients discharged from Arnold Lodge between 1983 and 2003 • Compared 502 men admitted with 93 women • Women more likely to be admitted to MSU from other hospitals • More likely to be on civil sections and without index offence • More likely to have committed arson but less likely – violence or sex offence

31. Characteristics of female patients in MSU 2(Sahota et al, 2010) Less likely than men to have h/o drug misuse despite being more likely to have PD (BPD) Odds of reconviction after discharge about half as that of men Higher rate of mortality, readmission Higher rate of violent behaviours and arson (without significantly increased conviction rates) were noted post discharge

32. CBT Group Interventions Dealing with feelings Interpersonal effectiveness Social problem solving Overcoming substance use problems and preventing relapse / P ASRO Living with Schizophrenia The development of a “best practice” service for women in a medium secure psychiatric setting: Treatment components and evaluation; C Long et al; Clin Psychol Psychotherapy; 15; pp 304-319; 2008

33. Interventions Offence focussed: Life Minus Violence; Arson treatment (e.g. Phoenix programme) Choices, Actions, Relationships, Emotions (CARE – Sue Kennedy) Individual offence focussed work Lucy Faithful foundation – Sex offender work DBT – M Linehan – Treatment for Borderline PD Trauma focussed CBT, EMDR (Shapiro) – NICE Maxine Harris – Trauma Recovery & Empowerment Model (TREM) Rampton – Trauma and Self Injury (TASI) model

34. Risk & Other Assessments HCR – 20 START VRS VRS – SO PCL-R CAPP

35. Treatment Interventions Medication Offence Focussed Family Oriented Ward Milieu PD Focussed Psychotherapy Trauma Focussed

36. Offender pathway REMAND CONVICTION SENTENCE • Fitness to be interviewed • Fitness to plead • Partial defences • s 35, 36, 48 • Dangerousness within meaning of the CJA 2003 • s 38 • Report for disposal • s 45, 37/41

37. Dangerous and Severe Personality Disorder (DSPD) Primrose Programme

38. Primrose DSPD programme • National service • 12 places including 1 RS • Based at HMP Low Newton, Durham

39. Service Model

40. Inclusion Criteria Women aged 18 years or more A minimum of 3 years left of sentence to serve with no current or pending appeals High risk of serious harm to others (e.g. violence, arson, cruelty to children) Severe PD linked to offending behaviour IQ – able to participate in psychological treatment

41. Case Vignette 1

42. Synopsis • 32 year old foreign national • Professional • No previous offending • Significant psycho-social stressors (e.g. Marital difficulties, financial hardships, bullying / racial harassment, poor social support • Significant stresses of parenting, stigma of mental illness • History of depression and post natal depression • Killed 11 months old baby and attempted suicide

43. Discussion • Interface issues • Assessment by general psychiatrist • Emergency secure bed • Knowledge of CJS procedures • Fitness to be interviewed • Offender pathway • Assessment in prison • Referral to secure unit • Gate-keeping • Mental Health Legislation • Sections • Partial defences • Repatriation laws and rules • Ethical / moral dilemma

44. References • Kaye, Charles (1998) Hallmarks of a secure psychiatric service for women. Psychiatric Bulletin. 22: pp 137-139 • Bartlett A and Hassell Y (2001) Do women need special services? Advances in Psychiatric Treatment , vol.7, pp. 302 – 309 • Hassell Y and Bartlett A (2001) The changing climate for women patients in medium secure psychiatric units. Psychiatric Bulletin, 25: pp 340 -342

45. References Coid J et al (2000) Women admitted to secure forensic psychiatry services: I. Comparison of women and men. The Journal of Forensic Psychiatry, Vol. 11, No. 2, September, pp 275-295 Coid J et al (2000) Women admitted to secure forensic psychiatry services: II. Identification of categories using cluster analysis. The Journal of Forensic Psychiatry, Vol. 11, No. 2, September, pp 296-315

46. References Kennedy, HG (2002) Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Advances in Psychiatric Treatment, Vol.8, pp 433-443 Long CG; Fulton, B; Hollin, CR (2008) The development of a ‘best practice’ service for women in a medium-secure psychiatric setting: Treatment components and evaluation. Clinical Psychology and Psychotherapy; 15, pp 304-319

47. References Sahota, S (2010) Women admitted to Medium Secure Care: Their admission characteristics and outcome as compared with men. International Journal of Forensic Mental Health; 9: pp 110-117 G Parry-Crooke (2009) My Life: in safe hands? Summary Report of an evaluation of women’s medium secure services; London Metropolitan University