therapy for female personality disorder offenders in custody who pose a risk of serious harm

Therapy for female personality disorder offenders in custody who pose a risk of

serious harm

The 1st National Personality Disorder Congress

Dr R Kini – Clinical Director, Primrose Programme

Dr S Cooper – Consultant Forensic Psychologist

Birmingham

19 November 2009

Aims

• Provide a brief overview of some of the

psychological programmes available to

personality disordered offenders in custody

• Present the Primrose Dangerous and Severe Personality (DSPD) programme as a service vignette

Let us reflect for a moment

Image from: Google Images http://trendsupdates.com/understanding-borderline-personality-disorder/

Let us reflect for a moment• Hopelessness• Abandonment• Anger• Fear• Being marginalised• Stigma• Feeling “bare”• Disempowerment• Frustration

Let us reflect for a moment

.....And if, we experienced

these feelings and thoughts

after a minute’sreflection......

what might it be like for

them in a lifetime?

Image from: Google Images http://www.ehow.co.uk/how_4424135_

identify-personality-disorders.html?cr=1 Copyright © 1999-2009 eHow, Inc

Self harming in female prisons

• A report compiled by the NOMS Women’s team in October 2009 revealed the scale of self harming in female prisons in E & Wales

• 24,686 incidents of DSH during 2008

• Over half of those incidents were carried

out by 6% of the prison

population• Approximately 70% of

self harm episodes are precipitated by a personal problem, often linked with past and present trauma

• 16% of women self harmed Vs 3% men (Baroness Corston)

Scale of PD in female prisons

• 50 % female prisoners have PD (Meltzer, 2008)

• In 2007, the MoJ analysed a sample of 321 PD women serving >2 years prison sentence to study the proportion of various PD

• Half the sample met the criteria for Anti-social PD

• Just over a quarter met the criteria for Borderline PD

• 15% met the criteria for Paranoid PD

• Approximately 10% met the criteria for DSPD

DSPD – Setting the context

Michael Stone Josie Russell

Images from Google Images – www.michaelstone.co.uk

Megan RussellDr Lin Russell

Personality disorder:No longer a diagnosis of exclusionPolicy implementation guidance for the development ofservices for people with personality disorder

National Institute forMental Health in England

National Service Framework

• Responsibility to provide evidence based effective services for all those with severe mental illness; including people with personality disorder who experience significant distress

Women at RiskThe mental health of women in contact with the judicial system

6 JANUARY 2006

Care Services Improvement Partnership CSIPHealth and Social Care in Criminal Justice

Baroness Corston’s Report – March 2007

A report by Baroness JeanCorston of a review of women with particular vulnerabilities in the criminal justice system

NICE Guideline for ASPD – Jan 2009

NICE Guideline for Borderline PD January 2009

Lord K Bradley’s Report – April 2009

Some of the interventions in female prisons

• A review of female prisons in 2008 carried out by the NOMS women’s team

• Alternatives to Self Harm (ASH): Psycho-educational CBT based programme; 2-3 weeks duration; HMP Holloway

• Carousel: 8 week rolling CBT based programme; Eastwood Park

• Holloway Skills Training (HOST): a rolling DBT based programme; 4 x 8 week modules; HMP Holloway

Some of the interventions in female prisons

• Safety Awareness Futures and Empowerment (SAFE): A psycho-educational, problem therapy based programme; structured group sessions; 3 days; Bronzefield & Peterbourough

• Choices Actions Relationships Emotions (CARE): S Kennedy; piloted at HMP Downview

• 22 different OBPs including ETS, CALM, and Cognitive Self Change Programme (CSCP)

• TC – SEND• Primrose DSPD

Programme, includes adapted elements of Chromis programme for DSPD men

Context & Overview

• Male – 2 high secure hospital programmes– Separate units– MHA legislation– Rampton Peaks Unit

(60 beds)– Broadmoor Paddock

(48 beds)

• Male – 2 high secure prison programmes– HMP Frankland

Westgate Unit (80 beds)– HMP Whitemoor

Fens Unit (70 beds)

• Female – – HMP & YOI Low

Newton (12 beds)

Multiple Stakeholders

M O JD O H

T E W V NHS F T

HMPS

DSPD

Service Model

Image from:The frustrating No-Man’s-Land of Borderline Personality Disorder

Harold W Koenigsberg, Larry J Siever www.dana.org/news/Cerebrum/detail.aspx?id=3372

PRIMROSE TREATMENT MODEL

16 WEEKSASSESSMENT

PHASE

Dialectical Behaviour Therapy

TRAUMATHERAPY

LIFEMINUS

VIOLENCE

WELLNESS RECOVERY ACTION PLAN (WRAP)

12 WEEKSTREATMENT

NEEDSANALYSIS

(TNA)

GENERICTREATMENT

Inclusion Criteria• Women aged 18 years or

more• A minimum of 3 years left

of sentence to serve with no current or pending appeals

• High risk of serious harm to others (e.g. violence, arson, cruelty to children)

• Severe PD linked to offending behaviour

• IQ – able to participate in psychological treatment

Referral and Assessment Criteria

Referrals can include female offenders who:

• Are in denial of their offence

• Potentially pose a risk of serious harm to others but are not disruptive

• Lack motivation to engage in psychological treatment (although not ideal)

• Are unwilling to be referred (although not ideal)

Inappropriate Referrals

• Women whose main risk is that of self-harm or suicide

• Women who cannot be managed on “normal” prison wing location

• Active major mental illness

• Individuals who have not undergone transgender reassignment and a period of readjustment

Referral Process

Primrose referral form

Referral documents

Inform prior to transfer

Letter / Report to referrer

Assessment

Written undertaking

Admission panel

Referral Documentation

•Fully completed referral form•Offence Details : PNC ID; Judges summing up; Reports - Pre and Post Sentence, Life Sentence Planning, Parole board, OASys, LIDS•Prison Security Information: Adjudications, Bullying, Hostage Taking, Fire Setting, Attempts to escape•Clinical reports: Psychology, Psychiatry, PCL-R, IPDE, HCR-20

Primrose pathway

Assessment

TreatmentNeedsAnalysis

Treatment

Time frame : Two to three years

WORK FORCE

CLINICAL OPERATIONAL ADMIN

6.7 WTE 6 WTE 2.5 WTE

Competency based roles

DBT

LMV

Trauma Therapy

CHROMIS M & E

MTC

Role Play

WRAP

Core and auxiliary treatments

Dialectical Behaviour Therapy

Life Minus

Violence

Trauma Therapy

CHROMIS Motivation &Engagement

Mobile Team

Challenge

PrimroseRole Play

Wellness & Recovery Action Plan

Workforce Development

CLINICAL SKILLS

TRAINING

PLACEMENTS&

VISITS

CHARTERSHIP&

DIPLOMAS

KNOWLEDGESKILLS

FRAMEWORK

CONTINUINGPROFESSIONALDEVELOPMENT

SECURITYSKILLS

TRAINING

INDEPENDENTCOUNSELLINGPSYCHO DYNAMIC

SUPERVISION & EDUCATION

RECOGNITION & AWARDS

SUPERVISION

Challenges & Learning Points

• Multiple stake-holders – Interface of Governance systems

• Recruiting and retaining a capable, skilled and motivated workforce

M O JD O H

T E W V NHS F T

HMPS

DSPD

Mental Health Act

Mental Health Act 2007

CHAPTER 12

Code of PracticeMental Health Act 1983

Challenges & Learning Points

• Pros & Cons of the integrated prison model• Psychological therapy – issues of voluntary engagement• Therapeutic milieu in custodial environment• Security Vs Clinical Focus – Move to hybrid approach• Elitist Vs Transferrable care models – Progression

pathways • Changing policy drivers?

AcknowledgementsOur thanks to .......

• Dr R Haigh for inviting us to speak at the conference

• Nick Benefield, Lead DoH PD Programme & Ian Goode, Operational lead DSPD Programme

for their support to the Primrose DSPD Programme

• Dr Ray Travers, former Clinical Director of Primrose DSPD Programme for his pioneering work and excellent contribution to the development of this unique service

Contact Information

• Dr R Kini 0191 3764156

Clinical Director, Primrose Programme• D Agnew 0191 3764156

Operational Lead, Primrose Programme• A Airey 01642 283374

General Manager, Forensic Directorate, TEWV NHS Foundation Trust

• Dr S Cooper 0191 3764156

Consultant Psychologist, Primrose Programme• T Noutch 0207 2170653

Ministry of Justice, Lead for Primrose Programme