Transcript Dangerous and Severe Personality Disorder Unit

Dangerous and Severe
Personality Disorder Unit
DSPD in practice :
The Westgate Unit
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The History
• The Government Consultation Paper Managing Dangerous People
with Severe Personality Disorder, Proposals for Policy Development
(1999)
• The 2001 election manifesto published stating that “to deal with the
most dangerous offenders of all – those with a dangerous severe
personality disorder – we will pass new legislation and create over
300 more high-secure prison and hospital places”
• Programme delivery – the DSPD programme was created to
“develop, pilot and deliver new services specifically for people who
present a high risk of committing serious sexual and/or violent
offences as a result of severe personality disorder”
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Who is involved?
This is a collaborative programme involving:
• Department of Health
• National Health Service
• The Ministry of Justice
• Her Majesty’s Prison Service
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What are its aims?
The target outcomes of the programme are:
• Improved public protection
• Provision of new treatment services improving mental health
outcomes and reducing risk
• Better understanding of what works in the treatment and
management of those who meet the DSPD criteria
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Who is the programme for?
An individual will be suitable for admission for treatment to a DSPD
pilot unit if assessment indicates:
• They are more likely than not to commit an offence that might be
expected to lead to serious physical or psychological harm from
which the victim would find it difficult or impossible to recover
• A severe disorder of personality
• Their offending is linked to personality disorder
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What are the programme objectives?
To enhance public protection and improve mental health
outcomes by better understanding:
• How to identify, assess and treat those who are dangerous and
severely personality disordered
• The nature and challenges of treatments and service delivery
involving multi-disciplined teams working across agencies
• The extent to which treatment might reduce (or manage better) the
risks of re-offending and how best to move on those offenders who
have benefited from the programme, as well as those who have not
• To strengthen the clinical, service delivery and policy evidence base
in this area, informing the options for future services, and the costs
and benefits
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What have we achieved?
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Designed and built or newly modified 9 units
Established guidance and commissioning arrangements
Led strategic planning for severe personality disorder
Commissioned services and training initiatives
Identified financial resources
Developed monitoring and improvement arrangements
Designed a research programme and systems for disseminating
learning
• Established multi-disciplinary methods of working
• Undertaken a Stocktake Review
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What have we leant to date?
• Too soon to come to a view about effectiveness
• Service delivery is complex and difficult
• Developing a competent and confident workforce is key – more so
than the buildings
• The patient group is too heterogeneous and difficult to manage
solely in one setting
• The conditions and risks are almost certainly life-long – we might
hope to reduce risks so that some can be managed in less intrusive
ways
• Risk reduction needs to be tested in different environments – hence
the need for managed pathways
• Those released into the community will continue to need supervision
and aftercare
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Westgate Unit
• Purpose built unit – opened in May 2004 (£14m build cost)
• Based within the walls of Frankland High Security Prison
• 80 beds (soon to be 86)
• Assessment and Treatment processes supported by a
complementary regime including education, gym and horticulture
• Primary Care facilities on site – skills mix within nursing team
• WAMMS - Timetabled ‘options’ regime, 4 sessions per day
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Staffing
• Staff members (N = 175)
126 Operational staff
21 Psychologists
9 Administrative staff
7 Westgate Therapists
3 Researchers
3 Progression
3 Horticulturalists
2 Cleaners
1 Substance Misuse Worker
• Also have education staff and provide some finance for staff
contained within main establishment’s budget (eg DST, RESPECT,
Chaplain and OSGs)
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DSPD Referral Process
• Standardised referral form that requests information from variety of
sources
• MDT referral panel at each site
• DSPD Roadshows
• To date Westgate Unit have processed over 500 referrals
• Referring staff and prisoner informed in writing
• Joint referral panels with Rampton Hospital
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Westgate Unit Ethos
Conditions of Success
Participate constructively at all times
Keep an open channel of communication
Be respectful at all times
Strategy of Choices
Working with prisoners to explore all options and their
consequences in a given situation to encourage them to take
responsibility for their own choices/decisions
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Assessment Process
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The assessment process at Westgate Unit consists of two stages :
1)
DSPD Criteria Assessment
2)
Westgate Individual Treatment Needs Analysis and
Progression (WITNAP)
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MDT approach to all elements of assessment
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Triangulated approach also adopted
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NB : DSPD is not a clinical diagnosis, though the disorders used
to determine a prisoner’s suitability for DSPD services are
clinically-based
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DSPD Criteria Assessment
• DSPD services are considered suitable if the following criteria are
met:
Dangerousness:
The individual is more likely than not to commit an offence that might be
expected to lead to serious physical or psychological harm from which the
victim would find it difficult or impossible to recover
Severe Personality Disorder:
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A PCL-R score at the 95.8 percentile or above (or the PCL-SV
equivalent) compared to a British norm group; or
PCL-R score falling between the 85.2 and 94.4 percentile (or the PCLSV equivalent) plus at least one DSM-IV personality disorder diagnosis
other than anti-social personality disorder; or
Two or more DSM-IV personality disorder diagnoses
The offending is linked to personality disorder.
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Common Data Set
• Risk Tools:
– HCR-20
– VRS
– RM2000
– Static 99
• Personality Tools:
– PCL-R
– IPDE
• Mental Health Tool:
– SCID 1
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Criteria Assessment Process
• MDT Approach
Including : chartered forensic psychologist, trainee psychologists, psychological assistants,
psychiatrist, discipline officers, general/psychiatric nurses. Can also include: gym,
education,horticulture, chaplaincy staff
• 4 week assessment period
• Collateral searching / Prisoner interviews / Scoring of assessment
tools and Report writing
• MDT case conference
• Feedback to prisoner
• Exclusion criteria – mental health? IQ? Denial? Motivation?
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WITNAP
• Westgate Individual Treatment Needs Analysis and Progression
• Successful offender treatment interventions found to consider
principles of RISK and TREATMENT NEED, alongside
RESPONSIVITY
• Pre-treatment WITNAP process establishes a comprehensive
treatment plan based on all 3 principles
• WITNAP process also involves assessing progress following
completion of Westgate treatment interventions
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WITNAP Aims
• Explore relevance of treatment need areas to offending behaviour
and personality disorder
• Identify individualised treatment need areas
• Highlight appropriate treatment modules
 Assist preparations for future group work through an experiential
learning sub-module called WITNAP – Parallel Therapy
• Employ a collaborative approach
• Develop insight
• Develop responsivity plan
• Enable progress made by prisoners following treatment to be
evaluated in light of pre-treatment level of functioning
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WITNAP Treatment Domains
• Treatment need areas identified in WITNAP are directly linked to
Westgate Clinical Framework domains:
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Self Management
Social and Interpersonal Competencies
Thinking Processes, Attitudes and Beliefs
Offending and Offence Interests
Progression
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WITNAP Process
• 10 week process
• Group and individual work
• MDT
• Interviews, psychological testing, offence analysis, parallel therapy,
collaborative feedback to gain a better understanding of level of
insight, knowledge, coping strategies and ability to generalise skills
• Motivation and Engagement component of Chromis ©
• MDT case conference
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Assessment and WITNAP diagram
DBRS
Review
DSPD Criteria Assessment
Wk1 – Intro & IPDE Interview
Wk2 – Combined Interview & Scoring
Wk3 – Report Writing
Case
Review:
Suitable?
No
Criteria Assessments Scored by Assessment Team:
HCR-20, VRS, PCL-R, IPDE, RM2000, Static-99, SCID1
Complete Criteria Report
Wk4 – Report Writing
Wk5 – Full Disclosure
Referral to
Appropriate
Service
Yes
Wing
History
Review
WITNAPPT
Session
Obs
WITNAP
Wk 4 – Intro, Consent, “How I see my needs”
Wk 5 – Psychological Testing
Wk 6 – Offence Analysis
Wk 7 – Personality Disorder Feedback
Wk 8 – Collaborative Interviews on need
(including psychometric feedback)
Wk 9 – Collaborative Interviews on need
(including psychometric feedback)
Wk 10 – Progression, Debriefing, “HISMN”
Wk 11 – Report Writing
Case
Review:
Suitable?
No
Psychological Tests Analysed by Research Dept: PRD,
ADS, DAST, SPSI, BIS, SSS, NAS-PI, LOC, PTQ, RQ, PICTS,
YSQ, SIV, IIP, STAXI, BECKS, SOTP BATTERY, MSI, SARN
Complete WITNAP
Wk12 – Report Writing
Wk13 – Full Disclosure
Referral to
Appropriate
Service
Yes
Complete WITNAP
Wk 12 – Report Writing
Wk 13 – Full Disclosure
Treatment at
Westgate
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Establishing the Functional Link
• Trait-based approach that explores “links” rather than single link
• Trait level propensities can be explicitly linked with risky behaviours
• Individuals have a range of traits that make up their personality
disorders
• Therefore, likely to a range of functional links between traits that
make up their personality disorders and their risk
• Understanding and managing influence of PD traits on individual’s
responsivity is of equal importance to clinical considerations about
functional links between PD and risk
• Some PD traits may not be linked to risk but may function as
obstacles to their engagement with treatment designed to address
risk
• Functional links developed collaboratively with individual
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DSPD Prisoners
Common misconceptions
• Media and cinematic stereotyping: Hannibal Lecter, Norman Bates,
Patrick Bateman, etc.
• Prisoners with personality disorders are ‘mad’, ‘unstable’, ‘violent’
and ‘untreatable’
The reality:
• Age?
• Offence type?
• Sentence length?
• Mad?
• Personality Disordered?
• Psychopathic?
• Violent?
• Treatable?
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Westgate Unit’s Clinical Framework
• Risk reduction is primary focus of treatment at Westgate
• Integrated approach to treatment – drawing on CBT, DBT and
psychodynamic approaches (“One size does not fit all”)
• CHROMIS – currently the only site delivering CHROMIS ©
• Aim - To teach prisoners the skills to make choices in their lives that
still allow them to reach the goals that are important to them, but
without causing harm or problems for others (i.e. injury, distress) or
for themselves (i.e. custody)
• Aim - To help prisoners to self-manage the problems associated with
their personality disorders, rather than to try to ‘cure’ them
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The Clinical Framework continued
• Domain based approach
* Psycho Education
* Self Management
* Social and Interpersonal
* Thinking Processes, Attitudes and Beliefs
* Offending and Offence Interests
* Progression
• It is estimated that it will take prisoners up to 5 years to complete
their individualised treatment within the Westgate Unit model.
• Individual sessions (2:1 working policy)
• Group sessions (max 5 prisoners)
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Psycho Education Domain
• This domain of treatment aims to develop the offender’s
understanding of the fundamental concepts within DSPD and how
they relate to him as an individual.
• A number of modules are offered within this domain:
Boundary Setting
Risk Assessment Awareness
Personality Disorder Awareness
Introduction to Treatment
• Trauma Psycho Ed for those who require it
• Also delivered to staff as part of the induction programme and
ongoing CPD
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Self Management Domain
• This domain focuses upon self-management skills: specifically in
relation to a prisoner’s ability to plan, problem-solve, regulate
impulses and regulate emotions so as to better achieve long term
goals.
• A number of modules are offered within this domain
Iceberg (substance misuse)
Emotion Modulation
Creative Thinking ©
Handling Conflict ©
Problem Solving ©
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Social and Interpersonal Competencies Domain
• This domain is concerned with how an individual relates to others,
how he thinks and feels about himself and others and the impact of
these on his social skills
• Two modules are offered within this domain:
Social and Interpersonal Competencies
Relationship and Intimacy skills
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Thinking Processes, Attitudes and Beliefs Domain
• This domain focuses on the attitudes and beliefs driving the internal
(thoughts and feelings) and external (actions) behaviour of the
individual
• Work concentrating on developing the understanding of cognitive
distortions, automatic thoughts, core beliefs and schemas held by
individual prisoners, is completed throughout the Westgate Clinical
Framework
• In addition, Westgate Unit has a number of trained cognitive
therapists who are able to provide specialised treatments within this
area (including social phobia, depression, OCD)
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Offending and Offence Interests Domain
• Currently in development
• Will
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include modules to address
Violent Offending – CSCP ©
Arson
Sexual Offending – PPG, HSF
Domestic Violence
• Important to note that all our treatment addresses risk factors
associated with offending - It is expected that these modules will
build on the work and skills developed during the previous domains
in order to develop understanding of the relevance of treatment
need areas within the specific context of offending behaviours
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Parallel Therapy
• Activity-based intervention to complement formal, classroom-based
treatment
• Delivered in different complementary regime settings (e.g., gym,
horticulture, education)
• Delivered by Parallel Therapists, Formal Therapists and
Complementary Regime Professionals
• Delivered to a staff-prisoner group, which is directed by prisoner
participants
• Makes the prisoner progress during treatment observable: subject to
behavioural monitoring
• Provides activities that promote therapeutic alliance
• Designed to reinforce treatment objectives of specific Formal
Therapy (FT) sessions through experiential learning activities
• An opportunity to take ‘processes’ from a classroom environment
and practice them in environments that are closer to ‘real life’
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Clinical Practices continued
• DBT
• Trauma
• Self Managing Self Harm
• GLAD – Westgate’s alternative to the IEP scheme
• LINKS
• Substance Misuse Team
• Stress Busters
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Generalisation
• Behavioural Monitoring
• Coaching / Mentors
• Parallel Therapy
• Review mechanisms include CPA, sentence planning and WITNAP
reviews
• Measurement of awareness of need, knowledge of skill and ability to
apply skill
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Progression Reviews
• Post module reviews including objective setting
• Yearly WITNAP reviews which aim to :
– Update progress in each need area found to be relevant in pretreatment WITNAP process
– Identify new targets to address areas of treatment and
responsivity need and risk reduction
• Includes re-administration of HCR-20 and VRS (changes calculated
on basis of changes in WITNAP factors)
• All reviews are multi disciplinary with significant others also being
invited
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Progression
• Proactive and very skilled progression team at Westgate Unit
• Keen to ensure the establishment of suitable step down/ step across
/ progression sites both within and outside of the Prison Service
• Prisoners can be given lateral transfers to special hospitals under
section where applicable (i.e. if their determinate sentence ends and
they’re still deemed high risk)
• Prisoners may alternatively progress to lower security prisons,
hospitals, or release under ‘MAPPA’
• Development of a progression domain – employment, social
networks, long term goal planning etc
• Relapse prevention work will be ongoing following the prisoner’s
departure from Westgate as will continued monitoring
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Development Centre
• Co-developed with the Chromis Team
• Offered to all staff seeking to be involved within clinical practice at
Westgate Unit
• Four competencies assessed via four different exercises :
* Problem Solving
* Team Playing and Networking
* Communicating Clearly
* Analytical skills
• Skills development plan and recommended roles
• To date over 150 staff have completed the Development Centre
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Clinical Integrity and Staff Support
• Audit
• Clinical Governance
• 2:1 working policy / Maximum of five prisoners per treatment group
• Carefirst / Health reviews
• 4x daily briefings
• Continued staff development, support and supervision
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Research at Westgate Unit
• The Unit is headed by Dr Mark Freestone, who is also an Honorary
Senior Research Fellow at the University of Durham and a co-chair
of the Personality Disorder Institute.
• The Research Centre maintains strong links to established research
environments at the Universities of Durham and Newcastle as well
as the new Personality Disorder Institute established in
Nottinghamshire Healthcare NHS Trust.
• Some of the current research projects ongoing or recently
established within the Centre include:
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Clinical effectiveness of new treatments for psychopathy (Mark Freestone/OBPU)
Validation Study of the Violence Risk Scale (collaboration with Oxford University and Broadmoor Hospital)
Development of a ‘parallel therapy’ in a complementary regime (Jason Morris)
DSPD Ward climate and therapeutic effectiveness (Karen Twiselton in collaboration with Rampton Hospital)
The Collection of a DSPD Minimum Data Set (Imperial College/Westgate Unit)
Inclusion for DSPD: Evaluation and Assessment (Oxford University)
Ethnographic Investigation of the DSPD Pilot Sites (Mark Freestone)
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The Future
• Does it work?
• Joint working
• Review of referral procedures (DSPD spaces are a limited resource)
• Research
• Roll out further treatment modules
• Progression
• Accreditation
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Contact Details
• John Buckle – DSPD Programmes Unit
[email protected]
• Kim Gibson – Assessment Lead, Westgate Unit
[email protected]
• Emma Clark – Treatment Lead, Westgate Unit
[email protected]
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