Joint London Probation Trust & Camden & Islington NHS personality disorder project. December 2010.

1. Joint London Probation Trust & Camden & Islington NHS personality disorder project. December 2010. Making an IMPACT: Sarah Simons – Probation Officersarah.simons@london.probation.gsi.gov.uk Stuart John Chuan – Forensic Psychologiststuart.johnchuan@candi.nhs.uk Susannah Clark - Assistant Psychologist

2. Background

3. Context Up to 78% of prison population with personality disorder(s). Historically, large shortfall in local services aimed at offenders with personality disorder living in the community. Or offender considered unsuitable for intervention (risk, compliance, understanding of diagnosis, commitment to change). Probation (offender manager) and approved premises staff, as a result, left in relative isolation to manage this complex and challenging client group. RECALL?

4. Reasons for initiating recall June 08 - June 09 High proportion of recalls initiated due to issues with residency at Probation Approved Premises – 57%. (33/58) 72% (24/33) of the PPU recalls either had a formal diagnosis of Personality Disorder or scoring above 8 on the OASys Personality Disorder Screening Tool (indicating the need for further PD assessment). Total of 175 recalls for Camden and Islington, 58 of these from Camden or Islington PPU. The table below shows the PPU sub-section) Breach of Hostel Rules * 1 3 Commission of Further Offence 6 Drug Use Gambling 5 Failure to attend Supervision 1 appointments 33 3 Data Unavailable Failure to be of Good Behaviour ** 6 Failure to disclose employment • * Including breaking curfew / leaving premises / unacceptable behaviour towards staff and/or residents • ** Not associated to hostel residency

5. The Impact model

6. Impact strategy Strengthening Pathways Developed by Kate Smith(Camden PPU Senior Probation Officer) And Dr Win Bolton (Oscar Hill Service)(Consultant Clinical Psychologist – Camden & Islington NHS Foundation Trust)

7. Fundamental Aim: “To enable and empower front line staff to work more confidently and effectively with the challenging and complex needs and presentations of offenders with personality disorder”. Model is primarily focused on enhancing staff capability through 3 main interventions: • Training: raising awareness through formal training on PD, via the delivery of the KUF (tailored specifically to meet the needs of frontline Probation staff) and more informal methods such as distribution of monthly newsletter, posters and website. • Consultation: the delivery of consultative advice using a case formulation approach to help staff understand the pd offenders they supervise, develop risk management plans and identify practical strategies for enhancing positive engagement. IMPACT fully integrated within C & I Probation, and considered part of the team. Fortnightly visits to the 2 Approved Premises in C & I for further consultative work and newly established consultancy with Islington’s IOM team. • Developing pathways: by supporting multi agency working between the criminal justice and mental health teams. The team actively seek to enhance, broker and maintain relationships between agencies.

8. Approach: Based on Individual case formulation Promoting a compassionate understanding of the individual’s primary needs that underpin surface presentation. Promoting a psychologically informed way of working with offenders. Highlighting the importance of both formal and informal case discussion, specifically the value of a reflective space. Instilling an atmosphere of empowerment, confidence and self-efficacy in staff and service user. Decreasing anxiety, pessimism & hopelessness in staff. Increasing awareness of how staff’s own reactions can help or perpetuate relational problems. Making risk management and service user needs compatible goals. Support not replace existing case working! Model needs strong management support and whilst it benefits from an integrated team approach, it also needs to retain its autonomy. Whilst both Probation Officer and psychologist retain a small caseload to provide specialist intervention and test a good practice model for offender management within this client group. This is NOT the primary focus of this project. IMPACT is very conscious about not plugging a gap in provision as this would ultimately be deskilling for workers.

9. Joint NHS & Probation team ethos Helps to overcome organisational, political and cultural barriers to effective cross-agency working Approachable and accessible service for staff in both organisations Draws on the strengths, knowledge, skills and expertise of both services. Integration of approaches around offender rehabilitation, mental health recovery, social inclusion and effective community risk management Prevents the development of bias towards one organisation Links to well established teams on both sides (eg. CMHT; Police) Keeps project up-to-date with organisational culture changes – very important given ongoing structural change Probation & NHS specialists working together to make an IMPACT.

10. Equipping staff ↑ mindful responding ↓ mindless reacting More options and better understanding = less reliance on recall as the only available risk management tool

11. Successes so far

12. PPU Recall DataSept 08 to Aug 09 vs Sept 09 to Aug 10 50% reduction

13. Comparison to other C&I teams 21% Increase

14. Comparison of teams PPU recalls: -15% Other recalls: +15%

15. Analysis of financial saving: Analysis of recall data for the PPU indicated that following recall offenders remained in custody for an average of 153 days. Howard League Study (2006) tells us: Sending one person to prison for 1 year £41,000 (cost of 153 days £17,186) 1 year Community Rehabilitation Order £3,000 (cost for 153 days £1,258) 153 days custody versus community cost estimate = £15,928

16. Cost saving Sept 09 to Aug 10 29 fewer recalls x £15,928 £461,912 Saving in 12 months 1st year project cost = £160,000 £301,912 Net saving in 12 months Nb. and NO SFOs!

17. Other potential benefits? Increase capacity of frontline (non-mental health professionals) to understand and work more effectively with PD offenders. Reduction in staff burn out: - personal, financial & organisational impact.- ongoing research question using MBI. Stability in care/management pathway. De-institutionalising, reduces social exclusion and supports recovery pathway whilst still protecting the public. Early intervention for serious offending pathway. Preventing lifers in waiting?

18. Part Four : Experience of Impact Project

19. Training needs analysisPPU and the two APs 45 min semi-structured interviews (Pre-Impact and at 1-year) “they are able to see things that I can’t see and tell me how to work specifically with that from a different perspective” I’ve found them (Impact) really useful. It’s interesting to hear like when we say some of the behaviours of Mr XXX and he kind of talks about some of the theories about why this might happen..... It’s definitely given me more of an insight into PD”. “When I was asked this before and I didn’t really understand it. I was like “well I can’t deal with those offenders cause they annoy me, they wind me up, they make me angry and I want to say something back to them.” Whereas now my experience is different cause I don’t take it personally. I can take a step back which stops me from getting so stressed out, it’s quite a big change for me”. “it gives you more confidence, it relieves stress, and I think it makes you less likely to go off sick, because you are actually dealing with the stuff here and you feel capable whereas when you’re floundering in the dark it’s really scary … he is able to see things that I can’t see and tell me how to work specifically with that from a different perspective”.

20. KUF Training FeedbackPost Training Questionnaires • “It was very useful and in a broader way than just relating to PD.” • “Very good. It is a surprise this training isn’t more widespread. Good online support too.” • “Thought the training was excellent and will be useful when I’m working with all my cases.” • “It was a supportive and reflective space. It was non-judgemental and very interesting to hear everyone’s experiences.” • “I found it much more stimulating and challenging than a normal probation training course. More interactive. The homework gives you ownership and responsibility for the learning.” • “A very empowering training. I think most practitionerswho work directly with people should attend this course.”

21. Training needs analysis Aspects of the model appreciated: Informal procedures- no referral forms- open door availability- informal conversations Combining psychology and probation- understanding of challenges of probation- PO bridges the gap Direct offender work- willingness to meet the offender- providing opinion based on first-hand experience of the offender

22. Contact details sarah.simons@london.probation.gsi.gov.uk 0207 014 9855 stuart.johnchuan@candi.nhs.uk 07810 855 661 Kate.smith@london.probation.gsi.gov.uk 0207 014 9885 www.candi.nhs.uk/impactpdproject