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Treatment of Personality Disorder in Forensic Settings
Programme
25th May 2012, Stirling Management Centre
08:30
Registration
09:30
Welcome & Introduction
09:40
Morning Keynote
“Desistence and innovation with high
personality disordered offenders in a
averse world”
Andreana Adamson
Jackie Craissati
risk
risk
10:40
Session A
11:40
Coffee
12:00
Session B
13:00
Lunch
14:00
Afternoon Keynote
“You Can Lead a Horse to Water … The
Treatment Approach to ‘Dangerous and Severe
Personality Disorder’ in a Medium Secure
Setting?”
Celia Taylor
15:00
Plenary session
“The PD Offender Pathway - From Strategy to
Implementation”
Nick Benefield
15:45
Coffee
16:00
Session C
17:00
Close
Session details
Morning Keynote - Jackie Craissati; Desistence and innovation with high risk personality
disordered offenders in a risk averse world
Session A (10:40 – 11:40)
A1
Using Offence Paralleling Behaviour to Assess
Risk and Enhance Treatment in a Forensic
Service for Prisoners with a Personality Disorder.
Des McVey & Rick Everson
HMP Whitemoors
Introducing ‘A Prison Officers Guide to Working
with Personality Disordered Offenders’
Marc Kozlowski, HMP Shotts
Psychopathic Personality Disorder in Women
Offenders:
assessment,
presentation
and
Implications for Clinical Practice
Mette
Valley
What it id like to be a patient in forensic services
and how to improve services for future patients:
a user perspective.
A
user
facilitated
Cawthorne,
Network
A3
The NHS Lothian Sex Offenders Liaison Service –
a successful model for providing clinical input to
help criminal justice agencies manage high risk
personality disordered offenders.
Dr Katharine Russell, Dr
Rajan Darjee & Emily Baron,
The Sex Offender Liaison
Service
A4
Personality disorder in forensic setting
Paul Carter, Cheswold Park
Hospital
A5
Voices from behind the fence
Tony
Gammidge
maker)
A2
Kreis,
NHS
Forth
presentation
by
Patricia
The Forensic
(film
Session B (12:00 – 13:00)
B1
Introducing a multi-dimensional model of care
within a low secure female forensic ward.
Michael Steel, The Ayr Clinic
Tethering Hale’s Kite? Working with personality
disorder and complex co-morbidity in a medium
security
Dr
Dan
Beales,
Edenfield Centre
B2
Utility of DSM & ICD personality traits versus
criminogenic needs
Dr
Ewan
Independent
B3
Mentalization Based Treatment
Patricia Cawthorne & Jon
Patrick, The State Hospital
B4
Multiagency training leading
treatment & engagement
B5
A Psychological skills set for PD service workers
to
improved
The
Lundie,
Dr Dawn Carson, Donna
Maguire, Christine Breslin,
Carole Montgomery, Ailsa
Hospital
Dr
Gwen
Adshead,
Broadmoor Hospital.
Afternoon keynote – Celia Taylor; “You Can Lead a Horse to Water … The Treatment
Approach to ‘Dangerous and Severe Personality Disorder’ in a Medium Secure Setting?”
Session C (16:00 – 17:00)
C1
A Balancing Act: using protective factors to
address risks on community leave with
personality disordered offenders.
Corrine Spearing – Millfields
Unit
The rehabilitation phase from the perspective of
the separation/individuation process
Dr Jan van der Leeuw
(Netherlands)
C2
3 key strategies to enhancing therapeutic
outcome for people with personality disorder
Des McVey, Dr Naomi
Murphy & Rick Everson –
HMP Whitemoors
C3
CAT & multidisciplinary working to address
personality disorder.
Dr Mark Ramm, The Orchard
Clinic
C4
Mentalization based treatment for anti-social
personality disorder
Dr Jessica Yakely – Portman
Clinic
C5
The use of proportional scoring in personality
disorder
Hugh McGregor –
Lanarkshire Council
South
Title of workshop
Using Offence Paralleling behaviour to assess risk and enhance
treatment in a forensic service for prisoners with personality
disorder
Name(s) of
presenters
Des McVey, Adam Lees
DETAILS OF PROPOSAL
Within the prison system and indeed within healthcare secure services it can be argued that
too much emphasis is placed upon maintaining the safety of staff working within the services,
at the cost of addressing the dangerousness and distress of the prisoner/ patients. The
concept of the “model prisoner” is a classic example as it implies that the prisoner should
leave his antisocial behaviour at the gate and pick it up on his return to the community.
Patients who present as settled and attend therapy are often considered as the ones who are
making progress whilst those who act out are considered in less favourable terms. It
therefore could be argued that these services merely protect the public whilst the
patient/prisoner is detained as the salient issues triggering their offending are managed by
the “system”.
“Offence Paralleling behaviour” is a nascent concept and works within the context of a rich
clinical formulation. It can be used in forensic services to place more emphasis upon
“treatment” and less reliance on “management”. It can allow teams to better understand the
driving dynamics around the individuals offending and to spot episodes when the
prisoner/patient is indeed acting out their offending process. This can allow for richer risk
assessment and addressing treatment at the core of the problem.
This presentation will aim to describe the theory of offence paralleling, and discuss how it
has been operationalized in a maximum secure unit for prisoners with personality disorder. It
will use rich clinical examples to highlight when this process has proved beneficial in
treatment and management of risk.
Title of workshop
A prison officer’s guide to working with personality disordered
offenders
Name(s) of
presenters
Marc Kozlowski, HMP Shotts
DETAILS OF PROPOSAL
We are all aware that offenders with personality disorder evoke powerful and varied
emotional responses in the staff working with them. Hence we professionals seek to criticise
them, distance ourselves from them, or jump right in and rescue them. This results in the
tell-tale split team, the rotating prison-hospital door and the rotating mainstream-protectionsegregation door.
Sometimes almost forgotten as extras in this one-act play endlessly repeating itself in the
lives of personality disordered offenders, are the people who actually deal on a daily basis
with the snot, tears, aggression and tantrums. If I am a prison officer then I have no
academic or practical expertise in personality disorder. What I do have is somebody in my
face kicking-off yet again and setting colleague against colleague around me. Tell me what to
do. Tell me what not to do. Tell me how I can look after myself because, you know what, I
am feeling exhausted and battered from working with this person.
A new training package for prison officers is being piloted at HMP Shotts. The training lasts
an hour. It includes no jargon. It aims to deliver what prison officers need to know to work
effectively with this client group. It aims to provide simple tools for containing problematic
behaviour. It aims to provide simple tips to help staff to keep themselves healthy. It does not
look under the bonnet of personality disorder, but rather provides a basic driving lesson. And
guess what, prison officers are finding it genuinely useful!
Title of workshop
Psychopathic
personality
disorder
in
women
offenders:
assessment, presentation and implications for clinical practice
Name(s) of
presenters
Mette K. F. Kreis
DETAILS OF PROPOSAL
The construct of psychopathy in women has received more focus in the literature in the past
two decades. Yet, empirical investigation of this severe personality disorder in women
continues to be scarce, and knowledge about the nature and manifestation of psychopathic
traits in females is limited. This lack of research with women is partly due to the limitation of
many psychopathy measures to adequately capture the construct in females. Furthermore,
the lack of clinical case studies of psychopathic women also limits a clear conceptualisation of
the construct.
This paper reports on a study that explored the expression of psychopathic traits in a sample
of 20 women offenders from a high secure female prison in England, including women from a
Dangerous and Severe Personality Disorder (DSPD) programme, and from a forensic
psychiatric hospital in Canada. The study employed the newly developed Comprehensive
Assessment of Psychopathic Personality - Institutional Rating Scale (CAPP-IRS; Cooke, Hart,
Logan, & Michie, 2004) and the Psychopathy Checklist Screening Version (PCL:SV; Hart,
Cox, & Hare, 1995). The study was the first to utilize the CAPP-IRS with women as part of
the measure’s ongoing construct validation.
The expression of psychopathy traits in women is discussed using case examples. The results
suggest that there are key gender differences in the typical expression of psychopathic traits,
and that the CAPP-IRS is more sensitive than the PCL:SV to both within and between gender
differences in psychopathy. The implications of this for clinical practice are discussed.
Title of workshop
The NHS Lothian Sex Offender Liaison Service - a successful model
for providing clinical input to help criminal justice agencies manage
high risk personality disordered offenders
Name(s) of
presenters
Dr Katharine Russell, Consultant Forensic Clinical Psychologist
Dr Rajan Darjee, Consultant Forensic Psychiatrist
Emily Baron, Honorary Psychology Assistant
DETAILS OF PROPOSAL
30 - 60% of sexual offenders have personality disorders, almost all offenders who cause
serious harm or offend repeatedly have personality disorders, and the vast majority of
offenders managed under multi-agency public protection arrangements (MAPPA) at levels 2
and 3 have personality disorders. In Scotland it has traditionally been difficult for criminal
justice agencies to access appropriate specialist clinical input for such cases.
Over the last 5 years the NHS Lothian Sex Offender Liaison Service (SOLS), jointly led by
psychology and psychiatry, has provided such input for over 200 cases. The consultationliaison model used by the service has worked well and has potential as a model for working
with other personality disordered offenders. In this workshop we will describe the service, set
out the model we use, describe the cases we see, outline some research on the service,
consider why the service has been so successful, and look at potential future developments.
We will argue that there is a successful and cost effective solution for dealing with the
problem of managing difficult personality disordered offenders, which has worked well in a
Scottish context.
Title of workshop
Personality Disorder in Forensic Setting
Name(s) of
presenters
Paul Carter
DETAILS OF PROPOSAL
Although our understanding of personality disorder has and continues to increase as time
passes, it is surprising that although there is a need to understand the sufferer of a
personality disorder’s experiences, little attention has been given to the experiences of staff
and the toll working in a very difficult environment can have on them.
From the research that is available, it is clear that team dynamics, cohesion, shared vision,
fidelity to that vision, and an appropriate balance between a controlled environment and a
therapeutic environment is a fundamental cornerstone to a successful personality disorder
service.
There is a clear need for further research into the importance of staff needs in a secure
forensic personality disorder service, and this workshop aims to explore what we know so far
from the experiences of our own staff, but also from our workshop delegates. This will
hopefully provide the ingredients for further research into a very challenging area not just for
the patient, but for the whole Multi-Disciplinary Team working in this area.
It is hoped that conference delegates would benefit from attending a workshop led by
practicing clinicians from a secure in-patients personality disorder service in the north of
England. The final makeup of the team leading can be discussed with the organising
committee, as we would wish to stress the importance of a multi-disciplinary approach. Two
key clinicians will be Mr Paul Carter, Lead Psychotherapist, whose experience includes setting
up a Psychology service in Assertive Outreach, and working in Secondary and Tertiary Care
Psychology, and Dr Kim Fraser, Consultant Forensic Psychiatrist who has worked in a prison
DSPD setting and a medium secure NHS pilot site. Both now work in the low secure
Personality Disorder Service (24 beds across 2 wards) at Cheswold Park, an independent
Hospital in Doncaster.
We envisage involving the audience by starting by asking “What works in treating personality
disorder?” and anticipate a wide variety of answers, many of which we will acknowledge play
a part in our service:

Cognitive Behavioural interventions

Elements of Social Learning theory

Interventions based on behaviour therapy

Utilising principles of dynamic psychotherapy

Social Learning Theory

Family and Carer work

Service User active involvement

A rich programme of educational, recreational and vocational experiences

Psychotropic medication

A recovery model
Further interaction with the audience will confirm that this will require input from many
professionals from different backgrounds.
Much of the patient day however involves
interactions with “front-line staff” most of whom may have had little experience of mental
health settings, let alone a specialist Personality Disorder Service.
The workshop will therefore progress to explore how a diverse group of staff may be
developed to form a “team” that delivers safe and effective interventions in the context of
working with a patient group that we know will seek to undermine, split and frustrate staff
charged with dealing with their often high risk behaviours.
Title of workshop
Voices from Behind the Fence
Name(s) of
presenters
Tony Gammidge
DETAILS OF PROPOSAL
I propose to show a number of short animated films made in collaboration between myself
and residents with a personality disorder diagnosis on medium and low secure units at the
Bracton Centre and Memorial Hosptital over the last four years. The films deal with difficult
issues such as suicide, self harm, murder, the criminal justice sysyem, loss, escape, abuse
and mental illness but also touch on romance, comedy and recovery. They are made using a
stop-frame animation technique and using shadow puppets, plasticene as well as everyday
objects. The films might originate from life stories, screenplays or songs written by the
residents on the ward. As well as screen the films (which are of varying lengths) I would also
be putting the films into a context, talking about the the video and animation projects in
general, how they work, the timescales, the goals and expectations, what has been
successful and what hasn’t
There also will be time throughout the symposium for questions and responses from the
audience.
Title of workshop
Introducing a multi disciplinary model of care within a low secure
female forensic ward.
Name(s) of
presenters
Michael Steel
DETAILS OF PROPOSAL
Having already introduced “zoning”, a dynamic risk assessment system which helps staff prioritise high
risk patients by utilising a system which uses green, amber and red colours on a board to share
information about the state of patients risk / safety (Gamble 2006), and having recently introduced a
RAID system which supports interactive therapeutic activity and reduces the amount of time resolving
disputes and incidents within the ward, the next key change was to implement a more therapeutic
system of carrying out enhanced observations.
Contemporary enhanced observations are a core risk management and containment strategy currently
employed within mental health services across the UK. They are used to manage and contain risk by
restricting access to means and associated methods of high risk behaviours. (Cutliffe & Stevenson 2008)
As a containment method, contemporary enhanced observations are currently promoted as a safer
alternative to other strategies such as medication, seclusion and physical restraint in terms of harm
caused to the patient. (Prins 1993) Contemporary enhanced observation methods are however by their
very nature counterproductive and counter – therapeutic, viewed as custodial and therefore not
conducive to engagement or promoting recovery. (Bowles et al 2001)
Further studies by Cardell & Pittula (1999) have shown that up to one third of staff used for
contemporary enhanced observations may be bank or agency staff and therefore this paradoxically leads
to the highest risk, most complex and challenging patients being nursed within what is classed as a low
skill activity.
Based on a zonal observation approach the new system will be called Zonal Nursing. The fundamental
difference between the new system of observations and contemporary models is that in zonal nursing,
staff are assigned to individual specified zoned areas in the ward rather being assigned to an individual
patient. Zonal nursing is also characterised by enhanced environmental, procedural and relational
security control measures and increased opportunities for therapeutic engagement.
It is anticipated that this multi dimensional approach of combing zoning, RAID and zonal nursing will
complete a move away from the traditional model of security, patient and public safety and containment
within secure mental health settings to a culture where patient engagement, involvement in clinical
decision making, solution focused approaches and recovery are the key drivers in the patient journey
through the ward.
One of the key challenges of introducing zonal nursing however is that although there is clear evidence
to demonstrate its efficacy, the continued hegemonic status of individualistic and proximity focused
patient observation and a perception that no viable alternative method of enhanced observations exists
means that zonal nursing tends to be viewed as a fringe strategy and a less effective and less safe
method of managing patients on enhanced observations.
Title of workshop
Tethering Hale’s Kite? Working with personality disorder and
complex co-morbidity in a medium security
Name(s) of
presenters
Dr Dan Beales
DETAILS OF PROPOSAL
This paper takes its title from Hale and Dhar’s paper: “Flying a Kite – observations
on working with dual (and triple) diagnosis”1, which explores aspects of complex comorbidity involving personality disorder, mental illness and substance misuse. It
will report on attempts at addressing this presentation in a medium secure setting,
and review some of the practical and theoretical challenges involved in working with
patients with this presentation.
As Hale and Dhar explore, such patients can challenge our theoretical resources in
attempting to meet their needs and the challenges they can present. I will explore
some of the practical aspects of attempting to address this issue in a medium
security, and attempt to develop some of the theoretical themes in Hale and Dhar’s
paper, including the impact of such patients on team working and organisational
functioning.
Title of workshop
Utility of DSM & ICD personality traits versus criminogenic
needs.
Name(s) of
presenters
Dr Ewan Lundie
DETAILS OF PROPOSAL
Personality trait descriptions have historically been devised by mental health practitioners to assist with
the diagnosis of personality disorder (PD): they summarise the enduring ways of thinking, feeling and
behaving that tend to cause significant dysfunction for service users. This way of conceptualising cases
has significant implications, for mental health services in particular, in regards to assessment and
treatment as well as legislation that can be used to detain individuals diagnosed with PD.
In criminal justice services there is an awareness of PD but it has much less influence on how service
users are conceptualised and worked with. Instead, the Risk-Needs Responsivity model guides personal
change work; this recommends that service providers identify what are termed as the ‘criminogenic’
needs of each client (usually identified through factor analytic research) and make these the primary
focus of a treatment, evaluation and risk management process that also aims to improve client wellbeing.
This presentation will:
(i)
outline the criminogenic need concepts currently employed in the in-depth accredited standard
programmes for sex offending, non-sexual violence, and intimate partner violence that are
being widely used by criminal justice services (and some forensic psychiatric services) in
Scotland;
(ii) explain how these are used in assessment/case conceptualisation, intervention work/treatment,
evaluating progress and risk management plans;
(iii) consider how they relate to the PD traits as described in mental health diagnostic
categorisations; and
(iv) explore with delegates the utility of each approach.
In particular delegates will be asked to consider the pros and cons of each for assessment/case
conceptualisation, intervention work/treatment, evaluating progress and risk management plans. For
example, research has tended to show poor treatment effect for PD but more encouraging outcomes in
some areas of offending behaviour (e.g. sex offending).
At the close the apparent implications for
forensic psychiatric and criminal justice services of placing greater emphasis on each approach will be
summarised. More specifically, they will be asked to consider (a) whether forensic psychiatric services
are lagging behind their criminal justice counterparts in addressing risk of violence because of the
predominance of PD case conceptualisation, and (b) whether criminal justice services could improve their
‘responsivity’ skills (tailoring their approaches to the uniqueness of each individual) by becoming more
knowledgeable about PD.
Nb – the presenter is aware of developments with DSMV and ICD11 as well as current
critiques of the PCL-R.
Title of workshop
Mentalising in a high secure setting – “trying to think under
fire”
Name(s) of
presenters
Dr Jon Patrick, Dr Lynda Todd, Ms Patricia Cawthorne, Ms
Susan Brown & Dr Claire Maclean
DETAILS OF PROPOSAL
In this one and a half hour symposium, the MBT team at TSH will hope to do the following:
o
o
o
Give a brief outline of the model of MBT
Use clinical examples from the group at TSH to illustrate how MBT can be
delivered and its possible impact and limitations with this complex cohort
Using both recorded and live scenarios, the team will demonstrate some of
the techniques, situations and encounters that have proved challenging and
illuminating throughout the experience of delivering MBT
Additionally the team will use the last half an hour to take questions in what will hopefully be
a lively and stimulating discussion
Title of workshop
Multiagency training leading to improved treatment &
engagement
Name(s) of
presenters
Dr Dawn Carson, Donna Maguire, Christine Breslin, Carole
Montgomery
DETAILS OF PROPOSAL
The caseload of the community forensic mental health team (CFMHT) has always included a high
percentage of individuals with a personality disorder, whether this is explicitly documented, the primary
diagnosis, or otherwise. In recent years it is estimated that the percentage of these individuals on our
caseload has increased further. The difficulties relating to working with such a patient group has been
one of the main drains on resources of a relatively small team, and highest cause of stress.
Aside from the inherent difficulties working with this group of patients incurs per se a prominent issue
was communication between the various agencies working with the same person and the differences in
opinions and stance taken from them. As most will recognise, the inconsistencies this gave rise to did
nothing to enhance the patient’s ability to safely and healthily integrate into the community. It seemed
that all professionals working as part of the larger team had the best interests of the patient at the core
of their work, however the ability to deliver the best care was compromised by the conflicting
understanding of what a personality disorder is, how it should best be managed and what outcomes can
realistically be expected.
After consultation with various agencies and disciplines it was agreed that a multidisciplinary subgroup of
the CFMHT would offer specific education and training about personality disorder to professionals working
with such clients who felt their knowledge on the subject could be increased. The core training package
was developed but has been successfully adapted to best suit the individual audience requirements. It
has been relayed to third sector agencies as well as social services and health. Offers have been made
to police but there has been no acceptance of this to date.
Each training session lasts approximately half a day (although where time allows a more detailed
package is delivered over a full day, with more small group work) and incorporates the following areas:

Epidemiology and aetiology of personality disorder

How a personality disorder develops

How a personality disorder manifests itself

Management of a personality disorder crisis

Longer term management of personality disorder
o
Medication options in personality disorder
o
Psychological treatments for personality disorder

Prognosis of personality disorder

General principles of working with personality disorder
We will provide a summary of the formal feedback gathered from these sessions to date but will focus
mainly on fostering a discussion of the benefits we, as the CFMHT, considered there have been, the
benefits from a patient’s perspective; and from the view of a service who received the training (a support
worker organisation).
We hope to relay the benefits through anonymous case vignettes, qualitative changes as well as
quantitative.
The Future?
By the end of the workshop we hope to be able to demonstrate the tangible improvement in
multidisciplinary and multiagency working as well as enhanced treatment and engagement with the
patient. We may like to reflect how this improvement could be sustained, how it could be further
improved and whether it would be applicable in other areas.
Title of workshop
A psychological skills set for PD service workers
Name(s) of
presenters
Dr Gwen Adshead
DETAILS OF PROPOSAL
In this workshop I will set out the psychological skills needed to work effectively in
a pd service, both individual and group.
 Thematic Content: Psychological therapies for PD and their evidence case
 Developmental psychchopathology and formulation of risk
 Relational security in residential units
 Group dynamics and professional relationships
Objectives: Participants will have more knowledge of the above topics and be more
able to reflect on their own experience
Title of workshop
A Balancing Act: using protective factors to address risks on
community leave with personality disordered offenders.
Name(s) of
presenters
Corrine Spearing
DETAILS OF PROPOSAL
The Millfields Unit is a 15 bedded adapted therapeutic community within a medium
secure unit which specialises in the assessment and treatment of personality
disordered offenders.
The unit has successfully reintegrated a number of patients into the community and
currently has a 1/3 of the patients accessing community leave. A comprehensive
community leave pathway was developed in collaboration with all members of the
multi disciplinary team and the patient group. The pathway supports an integrated
treatment approach to: Preparing for community leave, addressing risk through the
development of protective factors and managing, monitoring and evaluating risk
and progress.
The patients progress through 3 stages of leave:
1. preparatory work and basic community living skills
2. lifestyle development and risk area work
3. community focussed living: productivity, structure and support
Protective factors need to be taken into account as part of risk assessments in order
to ensure a balanced evaluation (DeMatteo,Heilbrun,& Marczyk, 2005).Treatment
should not only be aimed at minimising risk but also on developing and highlighting
protective factors as a way of reducing recidivism (Resnick,Ireland,& Borowsky,
2004; Blum & Ireland, 2004)
This presentation will aim to explore how using the community leave pathway has
supported the process of reintegrating patients into the community. We will
evaluate the challenges and benefits that have been identified so far and finally we
will illustrate the process through the use of case studies both of those who are
living in the community and of those who are on community leave.
Title of workshop
The phase of transition in treating the murderer, revealing
the kind of personality disorder
Name(s) of
presenters
Dr Jan van der Leeuw (Netherlands)
DETAILS OF PROPOSAL
I am working as a forensic expert in Holland. Part of the job is to examine patients
who stay in forensic psychiatric hospitals due to a penal hospital order. I have to
advise whether they are prepared to put the first steps outside the hospital.
With the concepts of Margaret Mahler and J. Lacan, I will try to understand the
complexity of the rehabilitation phase, using R. as a clinical vignette. I will focus on
the psychodynamics in the patient and between the patient and the treatment staff.
I will challenge the conditions of release that are interwoven with implicitly ideas of
a “good enough” developed identity and a diminishment of the negative
manifestations of the personality disorder.
Title of workshop
3 Key Strategies to enhance clinical practice when working with
people diagnosed Personality disorder
Name(s) of
presenters
Des McVey, Dr Naomi Murphy, Karen Butler
DETAILS OF PROPOSAL
The diagnosis of Personality disorder is often (and without evidence) considered untreatable and many
clients are discharged from services for presenting with the symptoms of their condition e.g. early
disengagement from therapeutic interventions, anti-social behaviour, self-harm (in its many forms).
Some of these clients who have been discharged have gone on to seriously offend or damage themselves
(often fatally). This has resulted in several public enquiries and the government of the time setting up
services to challenge the concept of treatability.
Since 2004, The Fens unit at HMP Whitemoor has been running a treatment programme for prisoners
considered to have severe personality disorder. During this time the trans-disciplinary team within the
service have experienced significant success in both maintaining long-term engagement and achieving
successful treatment outcomes. These men (75 in total) are resident upon an adapted prison wing where
they have access to treatment within the framework of Cognitive Interpersonal theory. Therapy is
delivered in groups, individually and within the concept of a therapeutic milieu. The programme is
eclectic in nature and draws upon the principles of CBT, DBT, Schema Focused Therapy, Compassion
Focused therapy, Mindfulness Based Therapy and offence focused programmes. To date research
outcomes have been positive. (Saradjian et al 2011)
In order to facilitate meaningful engagement with this population and within all the treatment forums the
team have developed three key strategies that all staff have been trained within. These strategies are
discussed in detail in the book “Treating Personality Disorder” (Murphy & McVey 2010). These
adaptations are:
1.
Synthesising opposing Logics- This is an important strategy in the early stages of treatment
as it allows for validation and understanding. The key to this adaptation is to acknowledge that
the individual’s view of his self, his relationships and his expectations from relationships are
rational, based upon their life experiences.
2.
Explicit communication- People can only accept acts of generosity that are commensurate
with their self-esteem and cultural experiences. This population have been exploited or abused
for so long that they can be very suspicious of behaviours exhibited by others which a normal
population may consider to be healthy social skills. As such, they often perceive staffs caring
and non-judgemental approach as frightening and possibly grooming behaviour. Whilst
acknowledging the logic behind this perception, it is essential staff explicitly communicate; e.g.
“Despite my caring of you and my nurturing attitude, I have no intention of sexually abusing
you and I am aware that you may find this difficult to believe”.
3.
Emotional self-disclosure- This strategy is essential in many aspects of the programme being
employed within the service. All staff are encouraged to disclose their emotional experiences of
the clients when interrelating with them. This allows the clients to be exposed to healthy
disclosure and management of painful emotional states which in terms of role modelling makes
up for a deficit in their developmental years. It also enables the client to develop insight into
how he can emotionally impact upon others
This workshop will introduce the delegates to the aforementioned concepts and facilitate a discussion
regarding their usefulness in both treating distress and risk. It will be supported with rich clinical
examples and the opportunity for delegates to practice the techniques, question their validity, and be
offered examples of when the tools have been successfully employed to alleviate distress, address risk,
and maintain optimum engagement.
Title of workshop
CAT & multidisciplinary working to address personality
disorder.
Name(s) of
presenters
Dr Mark Ramm
DETAILS OF PROPOSAL
This presentation observes that the current Forensic Matrix proposes a formulation
driven stepped care approach which delivers low to high intensity psychological
interventions within a psychologically informed therapeutic milieu that incorporates
risk assessment. How is this to be done?
The presentation describes how at the Orchard Clinic medium secure
unit a CAT approach has proved useful particularly with patients who have a
diagnosis of personality disorder via:
a) Providing CAT training all clinical staff
b) Providing CAT as an individual therapy for patients
c) Using CAT to guide team based interventions
d) Using CAT to inform risk assessment
e) Using CAT to inform the wider interventions and evaluate the therapeutic milieu.
In particular, the ability of the CAT model to integrate all of these various
approaches is noted.
Title of workshop
Mentalization based treatment for anti-social personality
disorder
Name(s) of
presenters
Dr Jessica Yakely
DETAILS OF PROPOSAL
In this workshop, I would like to present work in progress with a pilot project offering mentalizationbased treatment (MBT) to men with a diagnosis of antisocial personality disorder in a forensic
psychotherapy out-patient setting. This pilot is part of a multi-site project with Anthony Bateman aiming
to evaluate whether patients with ASPD can benefit from MBT.
The recent NICE guidelines (2009) on ASPD were welcomed for legitimizing treatment for this group of
people who are often both treatment-rejecting and refused treatment, as well as focusing attention on
prevention and early interventions for this disorder. However, the narrow range of recommendations for
the treatment of adults with ASPD in the NICE guidelines highlights the need for more research into
effective treatments for this complex and costly disorder.
MBT is a psychoanalytically-based treatment approach that has been developed in the UK by Bateman
and Fonagy (2004) and shown in trials to be effective for patients with borderline personality disorder
(BPD). Mentalizing is an essential human capacity underpinning interpersonal relations that develops in
the first few years of life in the context of safe and secure child-caregiver relationships: “the process by
which we interpret the actions of ourselves and others in terms of underlying intentional states such as
personal desires, needs, feelings, beliefs and reasons” (Fonagy and Bateman, 2008). It is postulated that
patients with BPD have a deficit in the capacity to mentalize. An RCT of MBT for BPD in a partial hospital
setting was shown to significantly reduce the number of hospitalisations, use of medication and suicidal
and parasuidical behaviours compared to the control group (Bateman and Fonagy, 1999), and a
subsequent follow-up study (Bateman and Fonagy, 2000) showed that these substantial gains were
maintained over 18 months after completing treatment.
In the last few years there has been increasing interest in the forensic field in the application of MBT to
forensic patients, especially those with a diagnosis of ASPD. MBT is being increasingly delivered in high
secure, medium secure and community forensic settings. Like BPD, ASPD can be understood as a
disorder of attachment in which genetic precursors interacting with early environmental adversity result
in the abnormal development of mind in the areas of affect regulation, impulse control and ability to
mentalize. Bateman and Fonagy (2006) postulate that antisocial patients show some enhanced areas of
mentalization, for example, in their ability to deceive and exploit others, which necessitates an ability to
understand the mind of the other to predict what he will and will not believe. However, they caution that
this apparently highly tuned capacity to mentalize is actually very restricted and rarely generalizable to
complex interpersonal situations, and that psychopathy exemplifies a partial but fundamental impairment
of mentalizing, what Baron-Cohen (2005) called “mindreading without empathizing.”
In this workshop I will briefly discuss theories of the aetiology of ASPD, as well as outlining the main
principles of MBT, but will focus on our experience and the difficulties we have encountered in setting up
a service and treating this patient population, including issues of engagement, risk, boundary violations,
and substance misuse.
Title of workshop
The use of proportional scoring in personality disorder
Name(s) of
presenters
Hugh McGregor
DETAILS OF PROPOSAL
IPDE recognises that a person can have more than one of the described personality disorders at the
same time ( co-existence), however the process of diagnosis tends to push workers to determining the
definite presence of a disorder and the consequential behaviour traits of that disorder rather than taking
account of the inter-relationship of all of the factors scored either 1 or 2 during the assessment process.
To examine this issue thoroughly is difficult from the scoring methods, not least because there is an
inequality in comparing dimensional scores between different disorders due to the fact that the number
of factors applying to each of the disorders differs in quantity making graphical analysis difficult. An
example of a graph is attached to this abstract for illustration purposes.
I have developed a method of making the dimensional score proportionate for each of the disorders. This
enables a greater degree of analysis of the interplay between all of the behaviours scored in the
diagnostic process and in so doing better understand the behaviour generators for the individual. This is
an important consideration in understanding the behaviour traits of the 3 cluster groups of personality
disorders. For example what is the interplay between the anxious/ fearful behaviours, the
odd/eccentric/bizarre behaviours and the dramatic/unstable behaviours. This method creates the ability
to understand this interplay as it applies to an individual.
The symposium would be structured around a presentation of the methodology used here ( the
dimensional score as diagnosed as a percentage of the total available dimensional score) and from that a
formulation of the behaviour triggers. Examples will be given from a community setting ( social work
supervision of people at high risk of committing serious crimes causing serious harm to victims) in using
the method to formulate a risk assessment, risk management strategy and treatment strategy (
including use of pharmacological treatments). This is particularly appropriate for discussion in multi
agency forums such as MAPPA where a combination of information sharing, behaviour management
strategies and treatment come together. This presentation would then develop into a discussion of the
use of the method and more generally to the interpretation of IPDE scores in respect of treatment and
management. All of the case examples are of offenders who at the time of the assessment were in the
community, some having served a substantial prison sentence and others who have never been in prison
but have committed serous crimes or their behaviour cause for considerable concern. Some have had
contact with a forensic psychiatrist, while some have had contact with general or addiction psychiatry. All
have sever problems coping in the community and display a mixture of personality disorders, some with
multiple diagnosis and, with one exception, significant traits in more that one cluster area. I would
suggest that this method is universally applicable and would assist planning for re-integration from
institution to community.