Mental Disorder and Trauma in Female Personality Disordered Offenders

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1 Mental Disorder and Trauma in Female Personality Disordered Offenders Sarah McCrory & Annette McKeown Forensic Psychologists Primrose Service Tees Esk & Wear Valleys NHS Foundation Trust

2 Aims & Objectives Inform understanding of prevalence mental disorder and trauma in female personality disordered offenders. Present research findings on a prison-based study exploring prevalence of mental disorder in female prisoners in a specialist personality disorder service. Present case studies of female prisoners response to trauma treatment within prison setting. Consider practical implications of findings to guide treatment provision.

3 Mental Disorder Literature I Corston Report (2007) emphasised role of mental health difficulties in women s pathway into the criminal justice system. Psychiatric comorbidity found at higher levels in female offenders than male offenders (Butler, Allnutt, Cain, Owens, & Muller, 2005). Mental health as a key consideration in understanding the violence risk of women (Espinosa, Sorensen, & Lopez, 2013). Importance of adequately treating mental health difficulties to help reduce violence risk in this domain (Bartlett et al., 2015).

4 Mental Disorder Literature II In general terms, men have been found to present a higher likelihood of violence than women across different psychiatric diagnoses (Cross & Campbell, 2011). Gender difference in violence reduces in women presenting with psychosis and/or antisocial personality disorder (Coid et al., 2006). High prevalence of psychosis and depression has been found in mothers who have killed their children (Friedman, Horwitz & Resnick, 2005)

5 Mental Disorder Literature III Interpreting research is complicated by definitions, time periods and assessment measures. Mental disorders are more frequently found in prison populations in comparison to community samples (e.g., Prins, 2014). Mental disorders are also more prevalent in female prisoners in comparison to male prisoners (Andreoli et al., 2014). In women prisoners, lifetime prevalence rates of 68%, and current mental disorder prevalence rates of 59% were found (Parsons, Walker, & Grubin, 2001)

6 Mental Disorder Literature IV Prevalence rates of mental disorder in female offenders are approximately double that of male offenders (e.g., Brooke, Taylor, Gunn, & Maden, 1996; Steedman et al., 2009). Higher prevalence in remand populations in comparison to sentenced forensic populations (Singleton et al., 1998). Meta-analysis including over 30,000 prisoners (Fazel & Seewald, 2012). Females marginally higher rates of psychosis (3.9% vs. 3.6%) Females higher rates of depression (14.1% vs. 10.2%)

7 Post-Traumatic Stress Disorder (PTSD) High prevalence rates of post-traumatic stress disorder (PTSD) have been found in female prisoner populations (e.g., Lynch et al., 2014). Prevalence rates of PTSD have ranged from 4% to 40% with female prisoners more likely to suffer from this mental health condition than male prisoners (Goff, Rose, Rose, & Purves, 2007) Findings have identified trauma as a significant predictor of mental health and personality difficulties in female offenders (e.g., Gunter, Chibnall, Antoniak, McCormick, & Black, 2012).

8 Provision for Women with Personality Disorder and Comorbid Mental Disorder I It was noted the primary reason over half of the women were located in specialist healthcare settings in prison related to self-harm (Hales, Somers, Reeves, & Bartlett, 2015). For women located in secure hospital settings, research identified for 1 in 20 women self-harm was the primary reason for detention in this setting (Bartlett et al., 2014). For return transfers from secure hospital back to prison, higher prevalence of personality disorder and lower levels of motivation (Doyle et al., 2014).

9 Provision for Women with Personality I Disorder and Comorbid Mental Disorder II Few studies comparing female offenders on hospital orders to female prisoners in the main prison population. Logan and Blackburn (2009) Similar patterns of mental health conditions in both populations of violent women. Women in prison, higher levels of affective disorder, substance use disorder an generealized anxiety disorder. Higher prevalence of NPD, APD and OCPD. Women in hospital, higher levels of psychosis, PTSD, panic disorder and OCD.

10 Current Study

11 Current Study I Notable lack of research in specialist forensic settings in the UK comparing prevalence of mental disorder to other settings. The current cross-sectional study presents descriptive statistics on Axis I mental disorders with female personality disordered prisoners assessed by the Primrose Service. Prevalence of transfers to secure hospital settings will be presented and compared to existing findings with male offenders, Characteristics of women transferred to secure hospital settings will be presented.

12 Population: Current Study II All women assessed by the service between 2006 and 2015 (N = 45) were invited to participate in the research study. Overall 30 women (66%) consented to engage in the broader research project. Of this sample, twenty eight women were assessed for mental disorder using SCID-I and were included in the current study. Offence Types: 93% incarcerated for violent offence (n = 26) 7% incarcerated for sexual offences (n = 2)

13 Measures: Demographic Information Current Study III Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I; First et al., 1997) Psychopathy Checklist - Revised (Hare, 2003) International Personality Disorder Examination (IPDE; Loranger, 1999)

14 Current Study III Table 1 Prevalence of Current and Lifetime Disorder in Primrose sample Current Mental Disorder n (%) Lifetime Mental Disorder n (%) Psychotic Disorder Mood Disorder Substance Use Disorder 2 (7.1%) 3 (10.7%) 5 (17.8%) 17 (60.7%) 2 (7.1%) 21 (75%) PTSD Panic Disorder 3 (10.7%) 9 (32.1%) 2 (7.1%) 6 (21.4%) OCD 1 (3.6%) 3 (10.7%) Generalised Anxiety Disorder 1 (3.6%) 4 (14.2%)

15 Current Study IV Table 2 Comparison of current/recent diagnosis of mental disorder across Primrose sample, female sentenced and male sentenced sample Primrose Sample n (%) Female Sentenced Male Sentenced % 6 % 6 Psychotic Disorder 2 (7.1%) 14% 7% Mood Disorder PTSD Panic Disorder 5 (17.8%) 15% 8% 3 (10.7%) 5%** 3%** 2 (7.1%) 4% 3% OCD 1 (3.6%) 7% 4% Generalised Anxiety Disorder 1 (3.6%) 11% 8%

16 Current Study V Overall, 17.8% (n = 5) of the sample were transferred to secure hospital settings. The primary reasons for secure hospital transfer included; escalating self-harm (n = 3), psychotic disorder (n = 1) and autism (n = 1). Secure hospital transfers is notably higher than transfers in male specialist personality disorder service based in custody where prevalence figures of 4.3% (n = 8) have been identified (Kirkpatrick et al., 2010).

17 Trauma

18 Addressing trauma in the Primrose Service Wellness Recovery Action Planning(WRAP) Trauma Recovery Empower Model (TREM) Women & Anger Dialectical Behaviour Therapy (DBT) & DBT informed skills Eye Movement Desensitisation & Reprocessing (EMDR)

19 Eye Movement Desensitization & Reprocessing (EMDR) Theoretical underpinning is based on the Adaptive Information Processing (AIP) model Heightened emotional state leads to a memory getting stuck Imbalance in the our system results in natural healing not being possible Not processed so can still feel present Eye movements or tapping help to move the stuckness through processing the memory Nice guidelines - PTSD & Psychosis

20 Phase 1 History taking The process of EMDR Phase 2 Stabilisation skills work, install skills, peaceful place. Strengths, wise figures Phase 3 Assessment Target memory, subject level of distress (SUDS), Negative cognition, emotion, sensation, positive cognition E.g. I m weak, fear, stomach, I m strong

21 Phase 4- The processing bit.. Eye Movements or tapping Processing can only take place when someone is within their window of tolerance Too hot hyper- arousal Too cold freezing/numbing Use skills to seek optimal arousal zone to process

22 Phase 5 & 6 Installation of positive cognition & body scan Phase 7 & 8 Closure and re-evaluation In complex trauma, memories can be clustered if linked with similar negative cognitions If two or more memories are targeted phases 4-8 are repeated each time Protocols for pain, phobias, OCD Is used with grief, depression, anxiety

23 Two case examples; Both females aged EMDR Case Studies Both sentenced for violent offences Both had personality disorder, self-harm, attempted suicide and substance misuse Both had diagnoses of PTSD Both completed the trauma symptom inventory (TSI-2; Briere, 1995) Both completed screening for dissociation

24 SELF TRAUMA EXT SOMA AA AA-A AA-H D ANG IE DA DIS SOM SOM-P SOM-G SXD SXD-SC SXD-DSB SUI SUI-I SUI-B IA IA-RA IA-RS ISR ISR-RSA ISR-OD TRB Pre & Post EMDR Trauma Symptom Inventory II 120 Client 2 TSI-2 Pre & Post Pre 2 Post 2

25 Pre & Post EMDR Subjective level of distress reduced to 0 for both Chose to work on one memory so only 6-8 sessions in total for each Could have worked on more client centred and responsive Considerations include: (i) stage of sentence, (ii) fear/anxiety of unknown, and (iii) fear of getting worse.

26 Future Directions Exploration of prevalence of mental disorder within the broader female personality disorder pathway. Further evaluation of treatment directions for mood disorder, substance abuse and PTSD. EMDR positive preliminary findings, further embedding within service and evaluation required. Potential of expanding EMDR for broader comorbidity concerns. Importance of comparing effectiveness of different treatments.

27 Thank You Any questions?

Female Psychopathic Offenders: Personality Disorder and Offence Types

Female Psychopathic Offenders: Personality Disorder and Offence Types Dr Annette McKeown Highly Specialist Forensic Psychologist Tees Esk & Wear Valleys NHS Foundation Trust Aims & Objectives Inform understanding