Women in secure services

MRCPsych Course - Northern Deanery

11 October 2011

Dr R Kini - Consultant Forensic Psychiatrist

Aim

To provide an overview of key issues relating to the assessment and management of female mentally disordered offenders in secure hospitals

Objectives

– Secure Services– Policy Drivers– Clinical characteristics– Offence characteristics– Gender specific needs– Risk assessment and management

SECURE SERVICES

LowHigh

Medium

WEMSS

Woman

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

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

POLICYDRIVERS OF CHANGE

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

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

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)

Policy Drivers 4• Women at risk: The mental health

of women in contact with the judicial system (CSIP, 2006)

• Corston Report – 2007, Government response

Baroness Corston’s Report – March 2007

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

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

Lord K Bradley’s Report – April 2009

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

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

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

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

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

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

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

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

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

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)

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

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

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)

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

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

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

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

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

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

Risk & Other Assessments

HCR – 20STARTVRSVRS – SOPCL-RCAPP

Treatment Interventions

PD Focussed

TraumaFocussed

Psychotherapy

Offence Focussed

Medication

FamilyOriented

Ward Milieu

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

Dangerous and Severe Personality Disorder (DSPD)Primrose Programme

Primrose DSPD programme

• National service

• 12 places including 1 RS

• Based at HMP Low Newton, Durham

Service Model

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

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

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

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

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

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