Mental Health Awareness Training for Probation Staff

2. Introduction to Personality Disorder: Session Overview Introduction Causes DSM definitions Potential issues for staff Whose problem is it anyway? How should we relate to individuals with PD? Treatment approaches

3. Introduction People with Personality Disorder often experience: Difficulties with attachments (forming and sustaining mutually beneficial relationships) Repeated invalidating message giving / experiences – being ignoring, inconsistent parenting experiences, inappropriate expectations of others and of themselves Severe abuse(s) prior to diagnosis (in some cases) Other traumatic experiences Sufferers are also likely to experience substance misuse problems, housing problems and unemployment (NIMHE, 2003: 11)

4. Causes There is evidence that Personality Disorder is ‘hardwired’, and not just dependent on environmental influences Up to 50% hereditability There is evidence of neurobiological abnormalities Lower serotonin levels is associated with impulsivity and aggression Deficits in the part the of the brain associated with emotional processing and learning (Particularly in Borderline Personality Disorder and Psychopathy) Executive deficits in Anti-Social Personality Disorder

5. DSM IV Definitions A) An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two of the following areas: Cognition (i.e., ways of perceiving and interpreting self, other people and events) Affectivity (i.e., range, intensity, and appropriateness of emotional response) Interpersonal functioning Impulse control B) The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C) The enduring pattern leads to clinically significant distress or impairment in social, occupational or other important areas of functioning. D) The pattern is stable and of a long duration and its onset can be traced back at least to adolescence or early childhood. E) The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. F) The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma)

6. DSM Categories of PD Commonly divided into “Clusters” Cluster A – ‘Odd / Eccentric’: Paranoid, Schizoid, Schizotypal; Cluster B – ‘Impulsive / Erratic’: Antisocial, Borderline, Histrionic, Narcissistic; Cluster C – ‘Anxious / Fearful’: Avoidant, Dependent, Obsessive-Compulsive; (Appendix) – Passive-Aggressive (See training pack for further information)

7. Potential Issues for Staff Violent behaviours towards self and others Boundaries Intensity of relationships Mistrustfulness Fear of abandonment

8. Whose Problem is it Anyway? NIMHE (2003) – A focus group with service users – showed that they viewed personality disorder as “A very sticky Label” – and that individuals with personality disorder were patients that Psychiatrists don’t want Furthermore: No mental disorder carries greater stigma There was an equation with ‘untreatability’ Unhelpful staff attitudes Lack of services Treatment on the margins – A&E, inappropriate admissions etc

9. How Should We Relate to Individuals With PD? Boundary setting Attitude towards PD clients Open and honest – keep your promises Calmness and personal strength Collaboration – multi-disciplinary working Consistent enforcement of rules Set small goals relating to the individual’s strengths

10. Boundaries Quality of therapeutic alliance often significant in treatment outcome. A good alliance involves disclosure of information and trust, acceptance, respect and consistency to achieve this. However… This can be the antithesis of people with PD who may: Fail appointments Demonstrate chaotic behaviours Be inappropriately intimate or seductive Attempt to control staff

11. Ground-Rules Have explicit boundaries from the beginning Set them out in as much detail as deemed necessary Clarify expectations upon workers and clients Expect challenges Do not react punitively Repeated minor infringements – ‘shrug shoulders’ Labour intensive – may have to look at co-working, additional supervision etc.

12. Treatment Approaches There are a number of possible approaches to treatment – please see your training pack for details

13. Exercise 9: Ms Patience Sordo (Part 1)

14. Post Traumatic Stress Disorder (PTSD): Session Overview What is PTSD? Features of Anxiety in PTSD Key Features of PTSD Key Features for Diagnosis/Recognition Associated Problems Risk Factors Treatment

15. What is PTSD? PTSD is usually an exaggerated stress response to a significantly negative life event such as exposure to a natural disaster/serious accident/sexual abuse/torture and can become compounded by continued exposure to the trauma.

16. Features of Anxiety in PTSD According to NICE (2005): Can occur at any age including childhood Cannot be diagnosed simply following an event such as divorce which may be described as ‘traumatic’ in everyday language. Instead, “the DSM–IV highlights that a traumatic stressor usually involves a perceived threat to life (either one’s own life or that of another person) or physical integrity, and intense fear, helplessness or horror. Other emotional responses of trauma survivors with PTSD include guilt, shame, intense anger or emotional numbing.” (NICE, 2005:5). Is more likely amongst: victims of violent and/or sexual crime members of certain professions including police and the prison service, and also emergency service personnel, and armed forces including those who are no longer in service victims of war, torture, state-sanctioned violence or terrorism, and refugees survivors of accidents and disasters women following traumatic childbirth, individuals diagnosed with a life-threatening illness (NICE, 2005: 5)

17. Key Features of PTSD Symptoms usually present within a month of the traumatic event Increased arousal – may include sleep disturbance/hyper-vigilance Avoidance of stimuli associated with the trauma Re-experiencing of the traumatic experience (flashbacks/nightmares) Can lead to depression Compounded trauma can result in the loss of ability to process information appropriately following the traumatic period e.g. reverting to thinking in a childlike way if the traumatic event occurred during childhood (stage stick) Common in problematic substance use The inability to incorporate the traumatic event into a ‘normal’ frame of reference (schema) Can lead to individuals doubting their own self schemas Can lead to individuals (negatively) re-evaluating their self schemas in light of the trauma, which may lead to problematic behaviours e.g. risk taking

18. Key Features for Diagnosis/Recognition Re-experiencing the traumatic event – nightmares/flashbacks Avoidance of stimuli associated with the trauma and/or the numbering of responses – blocking out or fading out Symptoms of increased arousal – difficulties sleeping, concentrating, exaggerated startle response, hyper-vigilance

19. Associated Problems Anxiety Depression Anger issues and suicidal thoughts Guilt (including survivor guilt) Marital problems Occupational problems Substance misuse (drugs and/or alcohol) Physiological problems

20. Risk Factors for PTSD Being female – more likely to experience a very traumatic event and/or to develop PTSD as a response Lack of social support following a traumatic event Combination of a traumatic event in someone with a family history of mental health problems

21. Treatment of PTSD Cognitive-behavioural therapy (CBT) Cognitive Analytical therapy (CAT) Eye movement desensitisation and reprocessing (EMDR)

22. Exercise 10: Ms Patience Sordo (Part 2)

23. Introduction to Learning Disability: Session Overview Definitions Prevalence in England Detection and Prevention Future Prevalence

24. Definitions Learning Disability includes the presence of: A significantly reduced ability to understand new or complex information, to learn new skills, with A reduced ability to cope independently Which started before adulthood, with lasting effects on development (Department of Health, 2001: 14) Furthermore, Valuing People states that: “This definition encompasses people with a broad range of disabilities. The presence of a low intelligence quotient, for example an IQ below 70, is not, of itself, a sufficient reason for deciding whether an individual should be provided with additional health and social care support” (Department of Health, 2001: 14) “An assessment of social functioning and communication skills should also be taken into account when determining need. Many people with learning disabilities also have physical and/or sensory impairments. The definition covers adults with autism who also have learning disabilities, but not those with a high level autistic spectrum disorder who may be of average or even above average intelligence – such as some people consider with Asperger’s Syndrome.” (Department of Health, 2001: 15) “ ‘Learning disability’ does not include all those who have a ‘learning difficulty’ which is more broadly defined in education legislation.” (Department of Health, 2001: 15)

25. World Health Organisation Definitions Impairment: A lack or loss of some physical or intellectual function. ‘Intellectual impairment’ suggests the incomplete development of mental abilities. Disability: A situation where someone cannot do certain things because of their original impairment. ‘Learning disability’ refers to someone’s reduced ability to learn as quickly or as readily as people without impairments. Handicap: A person is handicapped when, because of a disability, she/he has fewer opportunities to take part in everyday life than non-handicapped people. A person with learning disability may have difficulties in speech, self-help etc, but the real handicap may be other people’s attitudes or prejudices.

26. World Health Organisation - Classifications of Mental Handicap IQ 52-67: Mild Mental Handicap – may only be a matter of delayed development, children can be educated, adults can work in normal employment, may lead independent lives and never be classified as mentally handicapped. IQ 36-51: Moderate Mental Handicap – the person is obviously handicapped, but may learn self-help skills and work in sheltered employment IQ 20-35: Severe Mental Handicap – there may be delayed development or failure to develop physical and communication skills. May still show limited independence. Some physical handicap may be present. IQ 0-19: Profound Mental Handicap – the person requires 24-hour care for survival. Physical and sensory development may be grossly impaired with physical handicaps.

27. Prevalence in England In 2001, the Department of Health estimated that there were: 210,000 with severe learning disability in England 1.2 million with mild learning disability in England (Department of Health, 2001: 15)

28. Detection and Prevention Pre-conceptual Genetic counselling Rubella immunisation Health education e.g. smoking Family planning advice Treatment for conditions e.g. diabetes Prenatal Antenatal screening Amniocenteses Ultrasound Rubella screening Screening for syphilis Improved antenatal services Perinatal Improved obstetric care Neonatal screening Use of anti-d immunoglobin for rhesus incompatibility Postnatal Prevention of further problems Improved immunisation Minimising risk factors e.g. accidents, abuse

29. Future Prevalence Numbers of people with a Learning Disability will increase due to: Increased life expectancy Children with complex disability surviving into adulthood A rise in autistic spectrum disorders Increased prevalence in some ethnic populations

30. Depression: Session Overview Characteristics Levels Causes Treatment

31. Characteristics Depression is a very common condition and by 2020, it is predicted to be the second biggest cause of disability after coronary heart disease. Depression is characterised by: Continuous low mood – rather than ‘usual’ changes in mood – often an individual will feel particularly ‘low’ when they wake up, and may experience a lift in mood throughout the day, but then feel ‘low’ again upon waking up the following day A pessimistic attitude (which may not change in reflection of a positive change in circumstances) Feelings of hopelessness, despair and low self-esteem All of the above usually last for a minimum of two weeks before a diagnosis can be made

32. Depression is further characterised by: Anxiety and/or increased irritability Tearfulness Sleep problems (especially waking very early in the mornings) – and accompanying lack of energy Negative self-image Difficulty concentrating, forgetfulness and indecisiveness Weight loss/gain due to change in appetite Reduced activity levels Social withdrawal Feelings of loneliness even when with people Loss of interest/pleasure in activities that were previously enjoyed Loss of confidence Suicidal thoughts

33. Levels of Depression Mild depression may result in a slight impairment to social functioning – the individual will need to make an extra effort to do things, and may experience increased sadness/ reduced motivation. In moderate depression, this may progress so that symptoms actually prevent an individual from doing the things that they usually do. Finally, in severe depression, nearly all of the symptoms listed above may be present, and the individual may be unable to engage in daily activities. Severe fatigue and social withdrawal may also make it hard for the individual to engage in therapeutic work.

34. Causes Depression may be a reaction to a particular life event e.g. bereavement/unemployment/relationship failure. It may also be a side-effect of medication, or result from exposure to a number of low-level stressors rather than one major life event. It may also be part of another underlying illness such as bi-polar affective disorder or schizophrenia.

35. Treatment Anti-depressant drugs (when managing levels of risk, note that these may take up to six weeks to have their full effect, and need to be taken regularly). An individual’s risk of suicide may actually increase after they first begin taking anti-depressants as the drugs reduce some depressive symptoms enough that an individual has the energy and motivation to attempt to take their own life. In time, suicide risk should reduce as the individual’s mood, self-concept etc. improves Cognitive therapy Combination of the above Research suggests that eating a balanced diet and doing exercise may also help to combat the effects of mild depression

36. Exercise 11: Mr Jonathon Simmons

37. Eating Disorders: Session Overview Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Treatment Prognosis

38. Anorexia Nervosa Due to a pre-occupation with body weight, individuals with anorexia nervosa often restrict the amount of food that they eat (sometimes to dangerously low levels), and may also do exercise to burn off what they see as excessive calories. The condition usually develops in individuals when they are aged around 16/17 years old. Anorexia nervosa may be recognised by the presence of some/all of the following signs and symptoms: Vomiting Use of laxatives/slimming pills Wearing baggy clothes Mood swings Hyperactivity/restlessness Social withdrawal Fear of gaining weight Cutting food into small pieces Skin discoloration High level of interest in what others are eating Mistaken perception of own body weight/shape (BEAT, 2007)

39. Anorexia Nervosa (2) BEAT state that individuals with this condition may experience extreme weight loss, constipation, dizzy spells; faintness; hair loss; poor circulation; loss of periods; loss of interest in sex; loss of bone mass (which may lead to osteoporosis); and abdominal pains. In the long term it may lead to fertility problems for women. Furthermore, excessive vomiting may lead to erosion of tooth enamel, causing painful teeth. Often individuals with this condition will see weight loss as desirable and will not believe others who suggest that they need to gain weight. Up to 63% of individuals with anorexia nervosa also have depression, and around 35% of individuals with anorexia nervosa also have obsessive-compulsive disorder (National Collaborating Centre for Mental Health, 2004).

40. Bulimia Nervosa This condition is often difficult to recognise, even for individuals who are close to an individual experiencing it. It often begins when an individual is in their late teens/early twenties, and involves binge-eating large amounts of food followed by vomiting/use of laxatives/self starvation/doing lots of exercise/a combination of these to purge the food from the body. Individuals with this condition enter a cycle of bingeing and purging, which may occur anything from every few months to several times a day.

41. Bulimia Nervosa (2) The condition is characterised by the presence of some/all of the following signs and symptoms: Consuming vast amounts of food Obsession with food, which may include hoarding food/spending excessive amounts of money on food Mistaken perception of own body weight/shape Mood swings, anxiety, low self-esteem, depression, shame and guilt Frequent weight changes Feeling lonely and helpless Poor skin condition Hair loss Irregular periods Tiredness Loss of interest in sex Swollen salivary glands Tooth decay, sore throat and bad breath caused by frequent vomiting Reluctance to socialise Self-harm (BEAT, 2007) The prevalence of personality disorder in people with bulimia nervosa is estimated at between 21% and 77% (National Collaborating Centre for Mental Health, 2004).

42. Binge Eating Disorder (BED) This condition is similar to Bulimia Nervosa described above, but sufferers over-eat, but do not purge, and are therefore more likely to become over-weight. This condition is characterised by individuals: Eating more quickly than usual Eating large amounts of food when they are not physically hungry Eating until uncomfortably full Feeling guilt after overeating Avoiding social situations Eating alone due to embarrassment over the amount of food that they are consuming (National Collaborating Centre for Mental Health, 2004: 21). Although this disorder often develops when an individual is in their late teens/early twenties, individuals often do not present to health services until 10-20 years later.

43. Treatment Individuals who are displaying symptoms of any of the above should be strongly encouraged to see their GP as they may be in need of professional help from a counsellor/psychologist/specialist eating disorder service. Individuals with bulimia/anorexia may benefit from CBT/other psychotherapies. In some cases, medication may also be offered to patients – for example high doses of anti-depressants can be used to reduce the urge to binge-eat, and medication may be prescribed in cases where an eating disorder is comorbid with another disorder such as obsessive-compulsive disorder. Self-help programmes are also available for individuals with bulimia nervosa Staff could also encourage their clients to stick to regular mealtimes (even if they only eat a little at each meal, it is important that they eat regularly), and to keep a diary of what they are eating each day and how they are feeling (which they could take to the GP with them)

44. Prognosis The National Collaborating Centre for Mental Health state that with effective treatment, the prognosis for individuals with bulimia can be expected to be as follows: 50% of individuals being treated are asymptomatic 2-10 years after assessment 20% of individuals being treated continue with the full form of bulimia nervosa 30% of individuals being treated either have persistent but sub-diagnostic bulimia, or go into remission and then relapse (2004: 20) For those with anorexia nervosa, studies estimate that: 43% of individuals recover completely 36% of individuals improve 20% of individuals develop a chronic eating disorder 5% of individuals die (National Collaboration Centre for Mental Health, 2004: 16)

45. Session 6. Mental Health and Probation Practice Aims: To explore issues regarding mental health in the assessment and management of need and risk To increase staff confidence in working with offenders with mental health problems and referring them to local specialist mental health services Objectives: To provide information and discuss the assessment and management of mental health needs within risk assessment systems, e.g. OASys (See Workbook)

46. Exercise 12: Mr Andy Thomas

47. Session 7: A Brief Overview of the Care Programme Approach (CPA) in Mental Health Session Aim(s): To increase participants understanding of CPA To increase participants understanding of the key people involved in CPA in mental health To increase participants understanding of the core values which govern the provision of CPA Session Objective(s): To provide an historical analysis of the development of CPA To provide details on how CPA is provided and the relationships necessary for effective care planning To set a context for ‘Recovery’ orientated CPA in mental health services

48. Background to the CPA Systematic assessment of health and social needs A ‘Care Plan’ identifying health and social care required from providers Appointment of a key worker (Care Co-ordinator) as close contact to service user and co-ordinator and monitor of care Regular review of care plan

49. Two Tiers of CPA Standard: for those whose needs can be met by one agency or professional or who may need only low key support from more than one agency or professional, who are more able to self manage their mental health problem, who pose little danger to self or others, and who are more likely to maintain contact with services. Enhanced: likely to have multiple care needs which require inter-agency co-ordination, to require more frequent and intensive interventions, to be at risk of harming themselves or others, and to be more likely to disengage with services

51. The Care Co-ordinator Role Care co-ordination involves negotiation, the sharing of responsibility, and the recognition of authority. Best practice includes maximising the impact of the respective talents and experiences of team members as determined by the needs of each service user. In this respect the care co-ordinator orchestrates the process. The degree to which the care co-ordinator is directly involved in the delivery of care will vary but the responsibility of overseeing the care package is consistent. Care co-ordination also involves a partnership relationship with service users and informal carers based on the involvement and shared understanding of respective roles and responsibilities of all parties in assessment, care planning, interventions and the review of care.

52. The Values and Principles Underpinning the Care Programme Approach Diverse opinion Promotes social inclusion Service user as a person Power can be shared Abilities and strengths, sharing information Tension between managing risk and promoting safety and positive risk taking Supporting them in their individual diverse roles Care Co-ordinator needs to manage diverse opinions with awareness and sensitivity

53. Exercise 13: Shared and Different Values in Multi-Disciplinary/Multi-Agency Working

54. Next Steps