women in secure services mrcpsych course - northern deanery 11 october 2011 dr r kini - consultant...
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Women in secure services
MRCPsych Course - Northern Deanery
11 October 2011
Dr R Kini - Consultant Forensic Psychiatrist
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Aim
To provide an overview of key issues relating to the assessment and management of female mentally disordered offenders in secure hospitals
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Objectives
– Secure Services– Policy Drivers– Clinical characteristics– Offence characteristics– Gender specific needs– Risk assessment and management
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SECURE SERVICES
LowHigh
Medium
WEMSS
Woman
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FEMALE SECURE PATHWAYS
WEMSSOrchard Clinic
(London)Arnold Lodge
(Leicestershire)Edenfield unit(North West)
SupportedPlacementsCommunity
PRISON
PICUNon-forensicLow Secure
NATIONAL HIGH SECURE SERVICE - RAMPTON
IndependentSector
MSU / LSU
NHSMSU / LSU
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Types of security – Least restrictive environment, safe, local– Environmental (Physical)– Relational (Quantitative, Qualitative)– Procedural (Policies, practices)– H G Kennedy (2002) “Therapeutic uses of security: mapping forensic mental health services by stratifying risk”; APT, vol. 8; pp 433-443
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POLICYDRIVERS OF CHANGE
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Policy Drivers • Butler report – 1975• Reed report – 1992• Set the principles
which underpinned development of secure psychiatric services
• 1998 audit – 94% wards mixed gender
• 1999: National Women’s project group
• 2000: DoH published Secure Futures for Women: Making a difference – women centred services should be available in hospital and community
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Policy Drivers 2• Tilt report – 2000• Review of security at high security
hospitals• Highlighted the fact that 33% no longer
required HS• TILT Funding – increase development of
RSU• NHS Plan – 2000 Aimed for 400 transfers
nationally; Accelerated Discharge Programme
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Policy Drivers 3• ADP completed by April 2005• Women’s mental health: Into the
mainstream (DoH, 2002)• Mainstreaming gender and
women’s mental health: Implementation guidance (DoH, 2003)
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Policy Drivers 4• Women at risk: The mental health
of women in contact with the judicial system (CSIP, 2006)
• Corston Report – 2007, Government response
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Baroness Corston’s Report – March 2007
A report by Baroness JeanCorston of a review of women with particular vulnerabilities in the criminal justice system
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Policy Drivers 5
• PSO 4800 – 2008• NSF: Improving
services to women offenders, MoJ / NOMS (2008)
• Standards and Criteria for women in medium secure care – RCPsych, Quality Network for Forensic Services (Tucker, S and Ince, C); 2008
• Bradley Report –2009
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Lord K Bradley’s Report – April 2009
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Lord K Bradley’s Report – April 2009
• Review of people with mental health problems or LD in the CJS
• Early intervention• All stages of the CJS• Emphasis on
diversion• NHS & CJS working
together
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Improving Health Supporting Justice
• The national delivery plan of the Health & Criminal Justice Programme board
• November 2009
• System reform to maximise opportunities for improvement
• Right treatment at the right time
• Better working practices• Innovation• No new resources
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New Horizon: “Towards a shared vision for mental health”
7 December 2009 A ten year strategy Improve the mental
well being of the population
Improve quality & accessibility of services for people with poor mental health
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Key Issues• Gender sensitivity• Over containment• Nature of treatment offered• Security, Safety – Single sex accommodation• Complex needs• Staffing composition – e.g. Female to male
staffing ratio (70% proposed)• A Bartlett; Health Inequalities & Women in
contact with the CJS
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SHSA (1995) Figures
Total Prison Low Medium High Note
1995 1085 202 539 89 255 20% of the total population requiring such care
RatiosOf F : M
1 : 2 1: 4 – 1: 7 1 : 5 Higher proportion of women in HS; higher proportion with PD; relatively less serious convictions in women in HS
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Secure Services for Women
• 2000: Out of 39 MSU (342 beds) only 14 NHS and 79 IS beds in women only services
• 2003: DoH paper – creation of enhanced MSU for women in HSS who did not need Category B high secure care
• 2008: HSS beds fell from 345 (1991) to 50 in Rampton
• 2009: 27 (18 NHS and 9 IS) MSU providing 543 (282 NHS and 261 IS) beds
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Women in secure services 1
• One in 8 of patients in medium or high secure is female
• In July 2007, 458 (12% of total) women were in either medium or high secure conditions
• Higher proportion of female restricted patients were
• Detained under psychopathic disorder sub-category (21% cf 12% men)
• 51% of women with restriction order were detained under MI cf 70% of men
• Sainsbury Centre for Mental Health, Fact-file; 2007
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Women in secure services 2
• In absolute numbers, a minority• Cf men, less than 10% on restriction orders or
sentenced prisoners• Although about 33% patients did not need HS,
the proportion of women was higher • Dr A B & Y H – APT; Dr Y Hassell & Dr A
Bartlett; 2001; Bulletin
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Women in secure services 3• Higher prevalence of mood disorders, more
severe manifestation of PTSD and bipolar disorder
• Later onset of schizophrenia• Better prognosis of schizophrenia• Amongst PD population – more diagnoses of
histrionic and dependent personality disorders. However, rate of BPD is the same in both genders overall! Paranoid and Antisocial high in men
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Women in secure services 4• In high and medium
security greater proportion under Part 2 of the Act
• Greater proportion likely to receive hospital disposal at Court
• The conviction in majority – arson
• Most victims – own children or intimate others
• Less likely violent and sexual offences
• Less likely to have pre-cons and to reoffend
• 2009 study (Sahota)– More violence than men after discharge (2 and 5 yrs); mainly arson – increased with time; lower reconviction rate
• J Sarkar & M di Lustro (2011, APT, 17, 323-31)
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Female patients in HSS • More likely than male
patients to be:• Detained under Part 2
of the Act• Be classified as having a
PD, especially borderline PD
• Have an index offence of arson
• Be admitted in the context of suicidal or
• DSH behaviour, aggression towards hospital staff or damage to property
• Higher rates of physical or sexual abuse
• Bartlett & Hassell, APT (2001), VOL.7, p. 304
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Characteristics of female patients in secure forensic services
• More likely to have a primary diagnosis of PD, especially BPD; cf men who are more likely to have a diagnosis of ASPD and Schizoid PD both in HS and in MS
• Women admitted to secure forensic psychiatry services: I. Comparison of women and men (J Coid et al; The Journal of Forensic Psychiatry; Vol 11; No. 2; September 2000; 275 – 295)
• Cluster analysis article – pp 296 – 315
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Characteristics of female patients in secure forensic services 2
• More likely than male patients to:• Be admitted as transfers from other hospitals • Have a charge or conviction of arson or
criminal damage• Have fewer criminal convictions and more
previous Ψ admissions• More likely to have diagnosis of depression,
phobia, anxiety / panic, epilepsy and IQ < 70 in MSU and Depression & other in HSH (cf Schizophrenia in men)
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Characteristics of female patients in secure forensic services 3
• Using Cluster analysis:• 7 year study of 3 HS hospitals and MSU from 3
regions (1988 – 1994)• 7 clusters: 3 PD (ASPD, BPD, Other PD); 3 MI
(Schizophrenia, Mania and Depression); 1 OBS • ASPD Cluster – Significant co-morbidity with BPD;
with criminal behaviour (arson, CD, theft); higher rates of admission to HS; pre-cons linked with major violence and Part 3 admissions
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Characteristics of female patients in secure forensic services 4
• BPD Cluster – Increased criminal behaviour (arson and minor violence), epilepsy, substance misuse, previous Ψ admissions
• Mania Cluster – Violent behaviour in other hospital settings
• Schizophrenia cluster – 34%
• Larger proportion – non UK Born, index more likely to be major violence but not significant previous violent offending, part 2 admissions,
• Depression cluster – 26% after homicide
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Characteristics of female patients in MSU 1(Sahota et al, 2010)
• Retrospective Study – 20 year follow up of all first admitted patients discharged from Arnold Lodge between 1983 and 2003
• Compared 502 men admitted with 93 women
• Women more likely to be admitted to MSU from other hospitals
• More likely to be on civil sections and without index offence
• More likely to have committed arson but less likely – violence or sex offence
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Characteristics of female patients in MSU 2(Sahota et al, 2010)
• Less likely than men to have h/o drug misuse despite being more likely to have PD (BPD)
• Odds of reconviction after discharge about half as that of men
• Higher rate of mortality, readmission• Higher rate of violent behaviours and arson
(without significantly increased conviction rates) were noted post discharge
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CBT Group Interventions• Dealing with feelings• Interpersonal effectiveness• Social problem solving• Overcoming substance use problems and
preventing relapse / P ASRO• Living with Schizophrenia• The development of a “best practice” service
for women in a medium secure psychiatric setting: Treatment components and evaluation; C Long et al; Clin Psychol Psychotherapy; 15; pp 304-319; 2008
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Interventions• Offence focussed: Life Minus Violence; Arson
treatment (e.g. Phoenix programme)• Choices, Actions, Relationships, Emotions (CARE
– Sue Kennedy)• Individual offence focussed work• Lucy Faithful foundation – Sex offender work• DBT – M Linehan – Treatment for Borderline PD• Trauma focussed CBT, EMDR (Shapiro) – NICE• Maxine Harris – Trauma Recovery &
Empowerment Model (TREM)• Rampton – Trauma and Self Injury (TASI) model
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Risk & Other Assessments
HCR – 20STARTVRSVRS – SOPCL-RCAPP
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Treatment Interventions
PD Focussed
TraumaFocussed
Psychotherapy
Offence Focussed
Medication
FamilyOriented
Ward Milieu
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Offender pathway
REMAND CONVICTION SENTENCE
•Fitness to be interviewed
•Fitness to plead•Partial defences
•s 35, 36, 48
• Dangerousness within meaning
of the CJA 2003 •s 38
•Report for disposal
•s 45, 37/41
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Dangerous and Severe Personality Disorder (DSPD)Primrose Programme
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Primrose DSPD programme
• National service
• 12 places including 1 RS
• Based at HMP Low Newton, Durham
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Service Model
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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
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Discussion
• Interface issues– Assessment by general
psychiatrist– Emergency secure bed
• Knowledge of CJS procedures– Fitness to be
interviewed
• Offender pathway– Assessment in prison
– Referral to secure unit– Gate-keeping
• Mental Health Legislation– Sections– Partial defences– Repatriation laws and
rules
• Ethical / moral dilemma
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References
• Kaye, Charles (1998) Hallmarks of a secure psychiatric service for women. Psychiatric
Bulletin. 22: pp 137-139 • Bartlett A and Hassell Y (2001) Do women need
special services? Advances in Psychiatric Treatment , vol.7, pp. 302 – 309• Hassell Y and Bartlett A (2001) The changing
climate for women patients in medium secure psychiatric units. Psychiatric Bulletin, 25: pp 340 -342
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References• Coid J et al (2000) Women admitted to secure
forensic psychiatry services: I. Comparison of women and men. The Journal of Forensic Psychiatry, Vol. 11, No. 2, September, pp 275-295
• Coid J et al (2000) Women admitted to secure forensic psychiatry services: II. Identification of categories using cluster analysis. The Journal of Forensic Psychiatry, Vol. 11, No. 2, September, pp 296-315
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References
• Kennedy, HG (2002) Therapeutic uses of security: mapping forensic mental health services by stratifying risk. Advances in Psychiatric Treatment, Vol.8, pp 433-443
• Long CG; Fulton, B; Hollin, CR (2008) The development of a ‘best practice’ service for women in a medium-secure psychiatric setting: Treatment components and evaluation. Clinical Psychology and Psychotherapy; 15, pp 304-319
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References
• Sahota, S (2010) Women admitted to Medium Secure Care: Their admission characteristics and outcome as compared with men. International Journal of Forensic Mental Health; 9: pp 110-117
• G Parry-Crooke (2009) My Life: in safe hands? Summary Report of an evaluation of women’s medium secure services; London Metropolitan University