Dr Gopi Krishnan, Clinical Director & Dr Sue Evershed, Lead Psychologist

1. From Containment to Care …. and to Treatment: High Secure Services For Patients with Personality Disorder Dr Gopi Krishnan, Clinical Director & Dr Sue Evershed, Lead Psychologist Gopi.krishnan@nottshc.nhs.uk Sue.evershed@nottshc.nhs.uk

2. HISTORICAL CONTEXTPOLITICAL/INSTITUTIONAL DYNAMICS

3. MDT working Ward based teams Clinical training Programme delivery Supervision Psychological treatment pathway Integrated programme delivery & development Sophisticated staff training pathway CURRENT STRUCTURE

4. Referring Organisations Per Year.

5. Number of Treated and Un-treated Discharges Between 1998 and 2002.

6. CHALLENGES • Development of DSPD • Continuity and flexibility - absence of care pathways * prison * msu • 50% admissions unplanned • Changes in patient characteristics

7. Based on Personality Disorder Traits. • Taken from previous reports and files, during preadmission assessments. • Any mention of traits such as: • Impulsivity • Egocentricity • Unempathic for Others • Were collated as Personality Disorder traits and added up to give a figure.

8. Based on Co-Morbidity. • The number of mental health type problems were collated. • Taken from previous reports and files, during preadmission assessments. • Any mention of problems such as: • Depression • Schizophrenia • Anxiety • Were collated as mental health type problems and added up to give a figure.

9. Based on PCL-R Scores • The PCL-R has a total score of 0 – 40. • These scores are taken from a small sample size of patients from each year, and then averaged using the median.

10. Based on an Increased Risk of Sexual / Violent Offending. • Assessment of risk of sexual recidivism. • Assessment outcome codes as: • 1 = Low • 2 = Medium • 3 = High • The HCR-20 shows the risk of violent re-offending. • The HCR-20 results show that the admissions have always been quite high – in the late 20’s early 30’s. However the range of scores are bigger in 1996 than in 2002. • 1996: lowest score = 9 and highest score = 29. • 2002 lowest score = 16 and highest = 30.

11. Based on Behavioural Presentations. Taken from previous reports and files, during preadmission assessments. Includes behaviours such as: • Self Harm / Suicide Attempts • Hostage Taking / Threats • Acts of Sexual / Physical Violence Were collated as Problematic behaviours and added up to give a figure of problematic behavioural presentations.

12. Changes in Patient Profile In Complexity • Based on diagnostic criteria. • Co-morbidity. • Behavioural presentations. In Risk • An increase in median PCL-R score. • An increase in risk of sexual offending. • An increase in risk of violent offending.

13. Implications for the Directorate • Need to address clinical complexity • Need to address risk • Emphasis on team work, supervision & training • Continued development of an integrated treatment pathway

14. Start early Criminal versatility Continuing offending patterns Antisocial & anti-authority Impulsive Poor social interaction Rewards for bad behaviour High Risk Patients

15. Personality Disorder • Poor developmental histories • Disturbed relationships and lack of support • Long-term problematic traits • Across all areas of life • Affects thinking styles, emotions, & social behaviour • Patients average 3 or more PD “types” • Different sets of traits different constellations of impairment

16. Need to Adapt Standard Treatments • Treatment “resistant” • Disrupt treatment • Drop out • Don’t apply learning • Therapy can make them worse – myths and realities • Failure can make them worse • Effects on staff

17. Treatment Adaptations • Motivational focus • Parallel individual sessions • Developing drop prevention plans and integrated coping skills • Sensitive and risky topics, e.g., SOTP • Long, frequent and paced programmes • Integrating into ward life • Linking personality issues to risk • Building positive lifestyle

18. RISK TO SELF OR OTHERS ASSESSMENT MOTIVATIONAL & THERAPY INTERFERENCE NEEDS PERSONALITY DISORDER NEEDS CRIMINOGENIC & OFFENCE RELATED NEEDS Treatment Pathway AIMS • Motivate • Reduce risk • Build effective living skills

19. INTRODUCTION TO GROUPS MEN TALKING MOTIVATIONAL INTERVIEWING SOCIAL SKILLS REASONING AND REHABILITAION Motivation & Engagement • Therapy interfering behaviours, thoughts and emotions • Beliefs in the rewards for maladaptive • behaviours • No or limited skills to explore or understand own behaviours • Reduced faith in therapy • Stigmatisation & failure • Exclusion & betrayal • Replays & reinforces • history of interpersonal • experience

20. CBT ABUSE WORK SCHEMA THERAPY DIALECTICAL BEHAVIOUR THERAPY Treatments for PD • Assessment and address specific therapy interference • Expectation and planning • for lapses • Motivational work • Dosage & pace • Therapeutic alliance • Ruptures as opportunities • Consistency in environment • PD traits as maladaptive coping strategies (Bateman, 2003; Davison, 2003; Linehan,1993; Livesley,2001; Young,1999)

21. SEX OFFENDER TREATMENT PROGRAMME ANGER MANAGEMENT VIOLENT OFFENDER PROGRAMME ARSON TREATMENT SUBSTANCE MISUSE TREATMENT Reoffending / Risk TARGET CRIMINOGENIC NEEDS • Antisocial attitudes • Problem solving, self control • & prosocial skills • Peer associations & • family issues • Substance misuse • Prosocial rewards for • adaptive behaviour • Offence cycles and relapse • prevention plans • Post discharge planning

22. Future Aspirations • In reach and out reach development work with prisons and RSU’s • Improved integration of therapy into the milieu • Named nurse development programmes • Multidisciplinary Clinical Supervision developments • Developing therapeutic programme accreditation processes • Sharing practice and research agendas through NIMHE regional development centres • Practice based research initiatives • Therapeutic adherence training in a range of interventions • Developing/implementing Good Lives Model (Ward et al, 2002)