Special Interest Seminar 2013
Welcome
Hugh Hamill
Deputy Director PBNI
Chair PPANI SMB
Anthony Harbinson
Director of Safer Communities
Department of Justice
Geraldine O’Hare
Head of Psychology PBNI
Chair PPANI SMB Education and Training Subgroup
Offenders with Mental Health
Problems
Presentation to PPANI Special Interest Seminar
18 December 2013
Geraldine O’Hare
Head of Psychology Services & Interventions
Overview
 Mental Health & the Criminal Justice System:
Prevalence
 Findings from Strategic Reports
 Towards a shared Criminal Justice & Health
Strategy
 The Vision
Mental Health & Criminal Justice
 70% of prisoners have psych osis, a personality disorder
or a substance misuse problem
 Specific concerns about women and young offenders
 Self-harm and suicide rates increased
 10% male & 30% female previous psychiatric acute
admission
 20-50% male prisoners have a learning difficulty
(Sainsbury Centre, 2011)
Prevalence
 70% of sentenced prisoners suffer from two or
more mental health problems
 64% sentenced males & 50% female prisoners
have personality disorder
 78% male prisoners on remand have personality
disorder
 20% of prisoners have four or five major mental
health disorders
 16% arrested into custody meet one or more of
the assessment criteria for mental disorder
 11% some form of physical disability
(Sainsbury Centre, 2011)
Women Offenders
 Increased three fold in last 10 years
(Corston, 2007)
 Psychosis rates 14%, compared to 0.5% general
population
(Singleton et. al)
 50% received mental health treatment before custody
30% psychiatric admissions
 Personality Disorder, particularly Borderline Personality
Disorder most prevalent
 Self-harm & suicide attempts greatly exceeds general
population
 Twice as likely as men to have received help for mental health
problems in 12 months prior to custody.
 44% have communication difficulties
Young Offenders
 Three times higher rates of mental health
problems
 10% psychosis in sentenced males
60% female remands
10% self-harmed
(Hagall, ‘02)
(Baker et al, ’03)
 84% personality disorder on remand
88% sentenced
(Lader, 2000)
 Survey by YJB (2006) (E&W) found 59% of YJA (N.I.) signs of
mental health issues
 Over 60% speech, language and communication difficulties.
Substance Misuse Problems
 73% PBNI cases assessed as having substance
misuse problems
 15% male sentenced prisoners convicted of drug
offences
 26% sentenced female prisoners (MoJ, ‘07)
 63% sentenced males
39% sentenced females classed as hazardous
drinkers prior to imprisonment
Mental Health Problems in Prisons & the
General Population
Prevalence among
prisoners (16 years +)
Prevalence among
population (16-64 years)
Psychosis
8%
0.5%
Personality Disorder
66%
5.3%
Depression, anxiety etc.
45%
13.8%
Drug dependency
45%
5.2%
Alcohol dependency
30%
11.5%
Singleton et al, 2000
Probation and Mental Illness
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Prevalence study (Brooker ‘12) of 39% mental
illness, anxiety disorder most common.
(PBNI 34%)
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60% Substance misuse
(PBNI 73%)
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48% Personality Disorder
(PBNI 60%)
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Ongoing research studies for Mental Illness and
Personality Disorder within PBNI.
Types of Mental Health Issues
Cognitive functioning
Recognition of
emotion
Hallucinations
Schizophrenia
Flat Affect/Mood
incongruence
S/L difficulties
Drug
induced
psychosis
Autism &
Aspergers
Social isolation
Delusions
Flashbacks
Paranoia
Unstable lifestyle
Guilt/Anger
Mental
Illness
and
Disorder
PTSD
Dissociation
Personality
Disorder
Dependency
Antisocial
Self harm/Suicidal ideation
Avoidant
Anxiety
Disorder
Depression
Low mood/Tearful
Safety behaviours
Bipolar
Hyper vigilance/arousal
Mania
Hopelessness and
helplessness
Prevalence of Personality Disorder within
Criminal Justice System
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70% male prisoners (47% Anti-Social PD)
42% female prisoners (41% Anti-Social PD)
Anti-Social Personality Disorder (APD) commonest
Paranoid Personality Disorder, second most common
in men
 Borderline Personality Disorder, second most common in
women
 Comorbidity most common in women
(Singleton et al, 2000)
Strategic Reports on Mental Health &
Criminal Justice
From Bradley, Bamford & Beyond …..
 Bamford (2007): Forensic Services Report
 Corston (2007): On Women Offenders & Mental Health Issues
 Bradley Report (2009): Review of Mental Health & Learning
ability within CJS in England & Wales
 CJINI: Not a Marginal Issue (2010)
 N. Ireland Personality Disorder Strategy (2010)
 Owers Report (2011)
What The Reports Found
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Some good practice, but …..
A range of deficiencies in provision across the CJS
Poor continuity of care
Poor identification at early stages
Diversion too late
Convergence between CJ & Health too late
Access to services inconsistent
Improve partnership arrangements
Improve accommodation provision
Inadequate services for personality disordered offenders
(in N. Ireland)
CJINI ‘Not a Marginal Issue’ (2010)
“Mental Health problems are prevalent and imprisonment may not be the
best response to their offending behaviour; it frequently does them no good
and risks further harming their mental health, making them more likely to
reoffend”
CJINI Recommendations
18 Recommendations for all CJ agencies, including
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Training
MDO Scheme
Sentencers access to specialist advice in interpreting reports
Flagging to Courts
Extended time for reports
Access to high secure hospital
Accommodation
Research
Personality Disorder Strategy resourced
Review of Prison Health Care
Joint Health/CJ Board be established
Independent Review of the N. Ireland
Prison Service
Final Report October 2011 Recommendation 13 which states:
“There should be a joint Healthcare & Criminal Justice Strategy covering all Health
& Social Care Trusts, with a joint Board overseeing commissioning processes within
& outside prisons, to ensure that services exist to support diversion from custody &
continuity of care”
(Owers, 2011)
Towards a Shared Mental Health Strategy for
Criminal Justice & Health in N. Ireland
 Benefits of a joint strategy - significant
 An integrated & responsive approach to mental health issues
within the CJINI
 From many models of service to an agreed joined up model
 From single practitioners, to whole team & agency approach
 From single agency challenges to joint opportunities
 From reliant on champions to strategic & planned
 Mental health & psychological wellbeing of offenders to reduce the
number of future victims & ultimately protection of the public
Joint Healthcare & Criminal
Justice Strategy
 Four Workstreams:-
1.
2.
3.
4.
Prevention & Early Identification
Offenders in the Community
Offenders in Custody
Reintegration & Rehabilitation into the
Community
 Outcomes of Strategy
Towards a Criminal Justice Mental Health
Strategy: Key Themes Identified
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Early identification
Places of safety
Diversionary options
Information sharing
Integration of Assessment, Management & Discharge with
Community Services
Personality Disorder Services
Dual diagnosis & substance misuse
Public Protection Sentences
Legislation
Joint Health Care and Criminal justice Strategy:
Key Themes Identified
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Provision for over 65’s
Provision for under 18’s
Ethnic Minorities & Foreign Nationals
Gender specific care provision
Learning disability & communication difficulties
Access to primary care services
Evaluation of effectiveness of mental health interventions
Research strategy
Resources
All-Stages Diversion within CJS
Early Intervention
Prevention
Early identification of risk factors for vulnerability, mental health
problems and offending and of supporting protective factors
Pre-arrest
 Identification of vulnerable people before they experience a crisis
 Links to local mental health and other support services
 Prevention of vulnerable people coming into contact with the
criminal justice system
 Support for families and carers
Point of Arrest
 Common sense policing’
 Options for police officers other than arrest
 Increased partnership working between the police, mental health
and other support services
 Appropriate referral to local mental health and other support
services
All-Stages Diversion within CJS
Criminal Justice Decision Making
Arrest/
Pre-Court
 Identification and assessment of mental health problems at
police stations
 Appropriate use of cautions
 Early liaison with bail support services
 Liaison with Police/PPS on charging decisions
 Appropriate referral to local mental health and other
support
services
Bail, Remand
& Sentences
 Identification and assessment of mental health problems at
the
courts
 Improved understanding and use of diversion options
 Avoidance of remand and imprisonment where appropriate
 Co-ordinated packages of care
 Assertive interventions to ensure engagement with services
All-Stages Diversion within CJS
Through Care & Recovery
Custody/
Detention
 Identification and assessment of mental health problems in
prisons
 Appropriate referral to prison mental health inreach teams
 Appropriate transfer to hospital
 Plan for resettlement & appropriate discharge plans
Community
 Resettlement and continuity of care
 Assertive interventions to ensure continuing engagement with
services
 Support to promote stabilisation and lifestyle change
 Support for families and carers
Voluntary &
Community
Groups
Provision for
Over 65s
Learning &
Communication
Difficulties
Discharge &
Resettlement
Places of
Safety
Young
People
Early
Identification
Diversion
Evaluation &
Research
Provision for
Under 18s
Health &
Criminal Justice
Strategy
Women
Information
Sharing
Personality
Substance
Misuse
Research &
Evaluation
Dual
Diagnosis
Legislation
Resources
Public
Protection
Services
Disorder
Services
Ethnic
Minorities
The Vision
REDUCE the risk of serious harm to others & serious further offending
IMPROVE mental health & psychological wellbeing, &
tackle mental health/health inequalities
DEVELOP leaders in the fields of health & criminal justice
in N. Ireland, & create a skilled and
confident workforce to deliver an
effective joined up mental health strategy
Thank You
Geraldine O’Hare
Head of Psychology Services & Interventions
Tel. No: 028 90 262400
Email: geraldine.ohare@pbni.gsi.gov.uk
Dr Richard Bunn
Consultant Psychiatrist
Belfast HSCT
Ramada Plaza
Belfast
18th December 2013
Dr Richard Bunn
Consultant in Forensic Psychiatry
Shannon Clinic, Regional Secure Unit.
Who am I really?
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]
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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 unit
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.
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<2/year NI
 Random killings have not increased in the last 30 years.
 Methods of homicide were similar to the general population, but they were
‘significantly more likely to use a sharp instrument’ (p. 106).
 Mentally ill persons who commit homicide are more likely to have a drugs
and/or alcohol dependence (p. 133).
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
 1st 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
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Threat/control override symptoms
Non-delusional suspiciousness
If delusions make people unhappy, frightened or angry.
Whether they have acted on previous delusion
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Borum et al., 1996
Violence & hallucinations
 In general, AVH not inherent risk
 Certain types increase risk
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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
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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): 325334
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
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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 ChecklistRevised (PCL-R)
 Unique interpersonal, affective, and
behavioral traits
 Not in the DSM-IV or ICD-10
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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
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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 AHP’s, users, et al
 Understand roles & responsibilities
 Risk management
 Effective communication
Promoting Quality Care
 Care Planning
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 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
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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
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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
richard.bunn@belfasttrust.hscni.net
Coffee Break
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 individual’s 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 1CD10
PERSONALITY BASED DEFICITS AND
DEFICIENCIES
CHARACTEROLOGICAL TRAITS
EPIDEMIOLOGY OF PERSONALITY
DISORDER
 - Around 14% of General Population will have a
categorical personality disorder diagnosis.
 - 0.6 – 2% general population 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.
POINTS ABOUT PERSONALITY
DISORDER
 - Common in society generally .
 - High incidence in forensic populations.
 - Acquired in significant personal adversity
 - No comprehensive legislative framework.
 - Not proven to be untreatable or fully treatable
 - Core Symptoms/ behaviours fluctuate over time.
 - Highly co-morbid - to psychosocial dysfunction,
mental illness, self-harm and suicide.
WHY WORRY ABOUT SEVERE
P.D.?
 - PUBLIC PERCEPTION OF RISK FROM MEDIA.
 - A MAJOR COMPONENT OF C.J. S.
WORKLOAD
 - 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.
Familial Dysfunctionality/Criminality/Paramilitarism.
Exposure to violent role models.
Punishment Beatings/shootings for ASPD.
Use Instrumental Violence to own ends.
Interpersonal alienation.
Abuse Drugs and Alcohol.
Non-Compliance with therapeutic Interventions.
External Attribution of Blame.
See Statutory Services as ‘oppressive agents of Social
Control’.
INEVITABLE CONSEQUENCES OF
PERSONALITY
DISORDER
 - Severe family disharmony.
 - School drop out.
 - Employment problems.
 - Extremely hazardous lifestyle.
 - Associated with Substance Misuse.
 - Associated with Criminality.
 - Associated with Mental & Physical Ill health.
 - Associated with frequent episodes of DSH.
 - High proportion commit Suicide.
 - Associated with impulsive aggressive behaviours.
PERSONALITY DISORDERED OFFENDERS
 - All ICD-10 CATEGORIES ARE REPRESENTED.
 - ASPD AND BPD MOST CLOSELY LINKED TO
VIOLENCE.
 - TEND TO HAVE LONG CRIMINAL CAREERS
 - HIGH LEVELS OF RECIDIVISM
 - TEND TO DROP OUT OF TREATMENT
PREMATURELY
 - TEND TO SHOW SOME RELIEF WITH TIME
 - 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




ABANDONMENT
TERRORISATION
CRUELTY
HUMILIATION
 - CAUSES ‘ATTACHMENT INSECURITY’
 - IMPEDES ‘SELF-REFLECTIVE FUNCTION’
 - LIMITS CAPACITY TO ARTICULATE DISTRESS
 - IMPEDES DEVELOPMENT OF EMPATHY
 - INCREASES SENSITIVITY TO THREAT
 - LEADS TO HYPERAROUSAL
DISORGANISED ATTACHMENT IN
PERSONALITY
DISORDERED
 - ASSOCIATED WITH CHILDHOOD ABUSE







- INCREASED MENTAL DISORDER
- DISSOCIATION WHEN STRESSED
- INCREASED SENSE OF THREAT
- FRANTIC ‘RE-ATTACHMENT’ EFFORTS
- ‘TOXIC’/PATHOLOGICAL ATTACHMENT
- CONTROLLING BEHAVIOURS
- 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
- ‘DISMISSIVE’ OR ‘ENMESHING’
PATHOLOGICAL
ATTACHMENTS
- 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.”
“…How dangerous is it that
this man go loose?”
HAMLET
“…Risk Assessment is not about
making an accurate prediction -
but about making informed
defensible decisions.”
(Grounds, 1995)
CHARACTERISTICS OF RISK
 - CHANGES WITH TIME.
 - CAN INCREASE OR DECREASE.
 - IS UNCERTAIN – ONLY RELATIVE
PROBABILITIES CAN BE ESTIMATED.
 - OPERATES ALONG A CONTINUUM.
 - THRESHOLDS OF RISK ARE DIFFICULT TO
ESTABLISH.
 - DIFFERENCES BETWEEN LOW – MODERATE –
HIGH OFTEN MINIMAL
GENERAL CHARACTERISTICS OF ‘AT
RISK’ PERSONALITY DISORDERED












Diagnosis frequently unclear.
Mix of ‘Treatable’ and ‘Untreatable’ Symptoms.
Neuropsychological deficits.
History of Childhood Deprivation and abuse.
Familial Dysfunctionality/Criminality.
Exposure to violent role models
Use Instrumental Violence to own ends.
Interpersonal alienation.
Abuse Drugs and Alcohol.
Non-Compliance with therapeutic Interventions.
Hostile Attribution of Blame.
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
PERSISTENT CONDUCT DISORDER –
DSM IV














- Frequent Bullying
- Starting physical fights
- Using weapons
- Physical cruelty to people and animals
- Theft with victim confrontation
- Staying out late without permission
- Truanting from school
- Vandalism
- Breaking and Entering
- Manipulative lying
- Covert Stealing
- Forced sex
- Deliberate fire setting to cause harm
- Running away from home overnight
PRESENCE OF VIOLENT
ATTITUDES
 Present from childhood.
 Fantasises about violence
 Use of instrumental violence.
 Sees violence as empowering
 Premeditates violence.
 Associates with violent peers.
 Denies/minimises seriousness.
 Not modified by legal sanction or social shame.
 - ‘MACHO PERSONALITY’
..
PERPETRATOR
ATTITUDES.
 - Belief that violence is manly.
 - Belief that danger is exciting.
 - Belief in concept of sexual entitlement.
 - Minimisation of harm experienced by
victim.
 - Association with like minded others
 - Syntoncity of ideas re: criminality.
HISTORY OF VIOLENCE
 Instigated fights from an early age.
 Fights across a range of settings.
 Threats of Harm with weapons.
 Serious injury to victims.
 Family and friends equal threats or assaults.
 Reports ‘buzz’ or sense of excitement.
 Evidence of sexual gratification.
 Urge to repeat behaviour.
 - ABNORMAL SCHEMA.
DISTORTED
THINKING
 - COMPLETE DENIAL
 - PARTIAL DENIAL
 - DENIAL OF A PROBLEM
 - MINIMISATION OF THE NATURE OF
OFFENCE
 - DENYING/MINIMISING PLANNING
 - DENYING/MINIMISING FANTASY
 - MINIMISING HARM
 - MINIMISING RESPONSIBLITY
ABNORMAL
SCEMA
 - I have to look out for myself – no one else will.
 - Ingrained thinking/assumptions.
 - Society cares nothing of me.
 - People admire strength (violence).
 - Being violent is the only way to get things done.
 “ - no one’s doing nothing for me...”
 - The weak in society are ‘mugs’.
PROBLEMS WITH SELF-AWARENESS
 - LACK OF INSIGHT
 - IMPAIRED SELF-REFLECTIVITY
 - FAILURE TO UNDERSTANDONE’S CRIME
 - FAILURE TO UNDERSTAND OFFENCE CYCLE
 - DEFICITS IN KNOWLEDGE
 - DISTORTED ATTITUDES
 - PROBLEMS WITH ANGER AND
IMPULSIVENESS
PROBLEMS WITH STRESS OR COPING







- MALADAPTIVE COPING MECHANISMS
- STRESS VULNERABILITY
- CHRONIC NEGATIVE AFFECT
- POOR SELF-REGULATION
- CHANGES IN EMPLOYMENT
- DIFFICULTIES IN INTIMATE RELATIONSHIPS
- CHANGES OF RESIDENCE.
History of problems with
relationships.
 No evidence of long-term comittment.
 Stormy, unstable or conflictual.
 Controlling, domineering, manipulative and
subugating.
 Frequent break-ups/infidelity.
 Escalating abuse and violence.
 Gratuitous/ego-boosting violence which is repeated.
History of problems with
substance misuse.
 Use starts in childhood or early adolescence.
 Heavy sustained use of multiple substances.
 Use in controlled settings – Care/prisons/hospitals,
 Involvement in drug trade.
 Associated with risky /dangerous behaviour and
criminality.
 Affects education, work, relationships
History of problems with
employment.
 Poor educational attainment.
 School drop out before exams sat.
 Long periods of unemployment.
 Frequent sackings for absenteeism, poor time
keepings, alcoholism, fights or dishonesty.
 Failure to adhere to financial comittments due to
unemployment.
History of Problems with Major
Mental
Disorder.
 Interfers with
Education, work, employment, ADL and






relationships.
Deteriorating with time.
Multiple Hospitalisations.
Poor response to medication and other therapies.
Positive symptoms.
Evidence of agitation/distress.
Evidence of illness linked to violence.
BORDERLINE
PERSONALITY DISORDER
RISK IN BORDERLINE
PERSONALITY DISORDER.
 Extreme Reactions to
 - Stress.
 - Demand.
 - Provocation.
 - Irritating situations,
 - Abandonment – real or perceived.
 - Changes of plans.
RISK IN BORDERLINE
PERSONALITY DISORDER.
 IMPULSIVITY leading to
 - Spending
Sprees.
 - Unsafe sex.
 - Hazardous driving.
 - Experimental drug use.
 - binge eating.
 - Self Harm or Suicide.
RISK IN BORDERLINE
PERSONALITY DISORDER.
 MOOD DISORDER that is –
 - Chronically Disturbed.
 - Rapidly changing.
 - Usually negative.
 - Changes last hours or minutes.
 - Associated with anger outbursts.
 - Paranoid thoughts.
 - Denigration of professionals.
PSYCHOPATHY
EMOTIONAL DEFICIENCY IN
PSYCHOPATHY
 - DECREASED ELECTRODERMAL





RESPONSIVENESS
- LESS FACIAL EXPRESSION
- ABSENCE OF AFFECTIVE STARTLE MODULATION
- LACK OF FEAR IN RESPONSE TO AVERSIVE
EVENTS
- POOR CONDITIONING
- GENERAL UNDERAROUSAL
PSYCHOPATHY PREDICTS
 - Desire to dominate.
 - Hostile Attributions
 - Absence of Empathy
 - Absence of Anxiety
 - Recklessness
 - Impulsivity
 - No concern for future
 - Antisocial attitudes.
PSYCHOPATHY AND VIOLENCE
 - LINKED TO CORE TRAITS OF:





- GRANDIOSITY
- CALLOUSNESS
- MANIPULATION
- LACK OF EMPATHY
- Lack of guilt/remorse.
 - TENDS TO BE COLD BLOODED AND
INSTRUMENTAL IN NATURE.
 - LACK OF EMOTION.
 - ABNORMAL RESPONSE TO PUNISHMENT.
UNPREMEDITATED ATTACKS IN
PSYCHOPATHIC INDIVIDUALS
 - External Locus of Control.
 - No physical evidence of pre-planning.
 - Attackers have not set out to harm.
 - Have a previous history of instability/violence.
 - Attack occurs following exposure to stress or
provocation.
 - Attack usually occurs in similar contexts.
 - Usually involves acquaintances rather than
strangers.
PREMEDITATED ATTACKS IN
PSYCHOPATHIC INDIVIDUALS.
 - Victim, setting and method of attack already




determined in attackers mind.
- May follow period of rehearsal in fantasy.
- Believes successful attack will bring rewards.
- Start attack sequence with level of self-control.
- Self-control may lessen during the attack.
CHARACTERISTICS
 - Systematic - may follow ‘script’ from T.V., Film or





Pornography.
- May have special knowledge of martial
arts/arson/poisoning.
- Self-control may degenerate into frenzy.
- Site of attack may have special significance.
- May keep post-attack ‘trophy’ or diary.
- Attacks again after certain interval.
ASSESSMENT OF RISK IN
PERSONALITY
DISORDERED
INDIVISUALS.
DEFENSIBILITY OF ASSESSMENT OF
RISK
 - All reasonable steps have been taken.
 - Reliable assessment methods have been used.
 - Information is collected and thoroughly
evaluated.
 - Decisions are recorded.
 - Staff work within Agency Policies and
Procedures.
 - Staff communicate with others to seek the
information they do not have.
CORE RISK FACTORS
 - Attitudes that support or condone violence.
 - Problems with self-awareness.
 - Problems with stress and coping.
 - Psychopathic personality disorder.
 - Major mental illness.
 - Problems with substance misuse.
 - Problems with intimate relationships.
 - Sexual deviance.
 - Diversity of offending.
 - Escalation of offending.
AIMS AND OBJECTIVES RISK
MANAGEMENT IN P.D.
 To comprehensively assess the specific
components of risk.
 To differentiate between ‘mental health’ related
issues’ of risk and those that are not.
 To express a view regarding
-Whom is at risk.
-Why they are at risk.
-Immediacy of the risk.
 To suggest risk reducing strategies.
 To monitor efficacy of risk reducing strategies.
EXAMPLES OF STRUCTURED
PROFESSIONAL JUDGEMENT
 - VIOLENCE RISK SCALE (VRS)
 - HISTORICAL-CLINICAL-RISK MANAGEMENT
GUIDE (HCR-20)
 - SEXUAL VIOLENCE RISK-20 (SVR-20)
 - STRUCTURED ASSESSMENTOF VIOLENCE RISK
IN YOUTH
 - SPOUSAL ASSAULT RISK ASSESSMENT GUIDE
HCR-20: HISTORICAL SCALE
 - H1- PREVIOUS VIOLENCE
 - H2- YOUNG AGE AT FIRST VIOLENT
INCIDENT
 - H3 - RELATIONSHIP INSTABILITY
 - H4 – EMPLOYMENT PROBLEMS
 - H5 – SUBSTANCE USE PROBLEMS
 - H6 – MAJOR MENTAL ILLNESS
 - H7 – PSYCHOPATHY
 - H8 – EARLY MALADJUSTMENT
 - H9 – PERSONALITY DISORDER
 - H10 – PRIOR SUPERVISION FAILURE.
HCR-20: CLINICAL SCALE
 - C1 – LACK OF INSIGHT
 - C2 – NEGATIVE ATTITUDES
 - C3 – ACTIVE SYMPTOMS OF MAJOR MENTAL
ILLNESS
 - C4 – IMPULSIVITY
 - C5 UNRESPONSIVE TO TREATMENT
WHAT IS RISK MANAGEMENT ?
GENERAL PRINCIPLES OF MANAGING
RISK IN PERSONALITY DISORDER









Stratify patients according to the risk they present.
Avoid Inappropriate Placements.
Ensure ‘Whole Systems Approach.’
Ensure Interagency Cooperation.
Avoid creation of artificial barriers to Service Delivery.
Ensure Continuity of Care/Responsibility.
Ensure Least Restrictive, Safe, Homely local settings.
Ensure Client Centred Approach.
Ensure good Communication and transfer of important
information.
RISK ASSESSMENT FRAMEWORK IN P.D.
 - Define the behaviour to be predicted.
 - Distinguish between the probability and the cost of the






behaviour.
- Be aware of possible sources of error.
- Take into account internal as well as external factors.
- Check all necessary information is available.
- Predict factors that will decrease as well as increase risk.
- Identify ALL key professionals or agencies from the start
involved.
- Plan key interventions jointly .
 Provide
Support/practical advice.
Risk
Management
Goals
 Facilitate monitoring and Supervision.
 Crises Intervention.
 Increase motivation.
 Improve Thinking Skills.
 Reduce distress.
 Improve problem Solving.
 Improve Social Skills.
RISK MANAGEMENT STRATEGIES
 - TREATMENT.
 - SUPERVISION.
 - MONITORING
 - VICTIM SAFETY PLANNING.
HCR-20: RISK MANAGEMENT SCALE
 - R1 - PLANS LACK FEASIBILITY
 - R2 – EXPOSURE TO DESTABILISERS
 - R3 LACK OF PERSONAL SUPPORT
 - R4 – NON-COMPLIANCE WITH REMEDIATION
ATTEMPTS
 - R5 - STRESS
MANAGING THE RISK
 - Record roles and responsibilities of each
professional/agency involved with patient.
 - Audit any adverse incidents as they arise.
 - Have predetermined plans of action.
 - Keep good quality records.
 - Assure open communications.
 - Comply with statutory requirements.
 - Adhere to organisational protocols.
 - Provide adequate trained staff.
 - Spread the risk.
THERAPEUTIC
INTERVENTIONS.
STAGES OF INTERVENTION
- SAFETY.
- CONTAINMENT.
- CONTROL AND REGULATION.
- EXPLORATION AND CHANGE.
- INTEGRATION AND SYNTHESIS

LIVESLEY, 2003
 - NOT OF
TO CURE
PERSONALITY DISORDER
AIMS
INTERVENTION
 - BUT TO –
 - AMELIORATE DISTRESSING SYMPTOMS
 - TO STABILISE IN THE ‘HERE AND NOW.’
 - TO ENCOURAGE ADAPTIVE FUNCTIONING.
 - TO INSTIL PROSOCIAL ATTITUDES.
 - TO REDUCE STIGMA/ALIENATION.
 - TO ENCOURAGE EMOTIONAL AND PRACTICAL
INVESTMENT IN SOCIETY.
Features of a Successful
Management
 Instil order as a central Plan.
feature.
 Individualised.
 Explicit Goals.
 Prioritised Goals.
 Long –term time frame.
 Consistency.
 Insistency.
 Persistency.
 Tolerance.
MULTIDIMENSIONAL TREATMENT
 - INSTIL PSYCHOLOGICAL AND
LIFESTYLE
STABILITY.
 - SOCIAL SUPPORT/MONITORING
 - ADDRESS COGNITIVE DISTORTIONS
 - ENCOURAGE EMPATHIC CONCERN
 - MANAGEMENT OF NEGATIVE EMOTIONAL
STATES
 - ANGER MANAGEMENT
 - 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 nature of future harm.
 - Severity of future harm.
 - Imminence
 - Frequency or duration
 - Likelihood
BARRIERS TO EFFECTIVE INTERAGENCY
WORKING
 - LACK OF FORMAL PROTOCOLS FOR




COOPERATION.
- INCOMPATIBLE SYSTEMS OF DATA STORAGE.
- DIFFICULTIES IN INFORMATION ACCESS AND
RETRIEVAL.
- PROFESSIONAL MISTRUST AND RIVALRIES.
- MISPLACED CONFIDENTIALITY.
IMPEDIMENTS
CHANGE
1)
 The presence of untreatedTO
Dysfunctional
Schema
(ingrained automatic patterns of thinking.)
 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.

 A perception that he/sheTO
has status
within his subIMPEDIMENTS
CHANGE
2)
cultural fringe that has to date not been afforded him
by ‘mainstream’ society.
 An inherent tendency to impulsivity and sensation
seeking behaviours.
 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.
 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.
PERSONAL QUALITIES OF P.D.
PRACTITIONERS
 - Good clinical skills/Clarity of thought.
 - Sound experience in General Psychiatry.
 - Natural curiosity regarding unusual behaviours.
 - Ability to think multi-dimensionally.
 - Tolerance for difficult patients.
 - Capacity to ‘accept’ patient’s characteristics but not
condone/collude.
 - Willingness to be flexible.
Dr Maria O’Kane
Consultant Psychiatrist
Belfast HSCT
Personality Disorder –
A Diagnosis for Inclusion
Dr Maria O’Kane
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 individual’s 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
Yes
No
Total number
Difficult parent/ caregiver 21
patient
relationship/attachment
documented
9
30
Exposure to violence
(domestic & troubles)
20 ( 5 troubles in
N.Ireland)
10
30
Involved in care system
6 ( All before age 9)
24
30
Childhood familial
sexual abuse
22 (1 unknown male)
8
30
(1 rape as adult)
Convictions History
Forensic History
2
24
28
6
30
30
Family History of mental
illness / disorder
21
7
28 (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
6 weeks
psychoeducation
group
Information
session
50% attendance
12 weeks
MBT group
Self –Activation
OPD
Assessment
95% opt in
18 months
MBT Group &
1:1
A strategic approach to comprehensive
services for PD
Commissioning
approaches
Specialist
commissioning
Collaborative
commissioning
(wider geography)
Mental Health
partnership
commissioning
Mental Health
Services
PD services
TIER 4
specialist
services
TIER 3 Intensive
day services
TIER 2 case
management &
treatment
High secure care
Secure care
Acute care
Assertive outreach
Community mental health
services
A&E liaison, crisis services
PCMH, gateway, services
TIER 1 consultation, support,
education
Wider partnership
Social care
Housing
Youth agencies
Primary care Employment
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
everybody’s business
Implementation
Recognising Complexity
Potential cost benefits
appropriate use of
Primary care
Reduced Prescribing
Community PD services
Reduced harm from drug
and alcohol abuse
(Tiers 1 to 3)
Reduced risk of offending
Reduction in A&E use
Improved Family life,
education and
employment
Improved staff retention
Recognising Complexity
Potential cost benefits
Less escalation to more
secure/intensive services
Severe and complex PD
(Tier 4)
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
(IFR’s)
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 Span
Number of Cases
1 Year
2
1-3 Years
7
3-5 Years
3
5+ Years
1
No Admission Date
1
Length of Stay (contd)
Personality Disordered
Providers
Number
Average Cost Per Day
Private Hospital
4
£472 - £548
Independent Hospital
4
£635 - £656
Independent Hospital
2
£534 - £545
Private Hospital
2
£515 - £566
Private Hospital
1
£375
NHS Hospital
1
£523
NHS High Secure Hospital
1
£970
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?
Lunch
PPANI Special Interest Seminar
Offenders with Mental Health Problems
December 18th 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

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 Asperger’s,
... and the other man was a teacher. And one day the
young guy had a book and I said, that’s 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 we’d 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 (16th 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 shouldn’t be going
on’ (SC 11, 7th 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 haven’t, because they have learned the
language of change’ (NI 8, 6th 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, 22nd 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, 24th August 2011 – forensic psychologist)

Work with the offender’s 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, 26th 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, 3rd August 2011, social services professional).
‘I don’t think we offer enough before the abuse has
actually happened.’
(RI 4, 13th 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, 23rd 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 offencefocused strategies



A ‘confessional’ v ‘a bio-psycho social
approach’
Balance between future focus and prooffending 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, 5th July 2011 – assessment
professional) BUT ...

‘If you don’t concentrate on the skills and
strengths and other things, then I think all we are
doing is reinforcing an offender’s negative views of
himself’ (SC 11, 7th 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
Summary of Audits Findings
• 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 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 offender’s 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.
Summary of Audits Recommendations
• 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
Multi Agency Panel Chaired by
Geraldine O’Hare