Young adult sexual offenders with emerging personality disorders: developmental and offence-related characteristics and treatment engagement

ABSTRACT

In the context of the UK Government’s Offender Personality Disorder (OPD) Strategy, large numbers of high-risk young adult sexual offenders with emerging personality disorders are being screened for inclusion onto specialist intervention pathways (the OPD Pathway). However, little is currently known about the clinical and offence-related needs of this population or their impact on treatment engagement. The current study investigated the developmental, personality and offence-related characteristics of 87 incarcerated young adult sexual offenders, comparing those screened in to the pathway and those not screened in. Fifty per cent of the sample were potentially eligible for the OPD pathway. OPD eligible cases were found to have significantly higher rates of parental difficulties, developmental trauma, and childhood behavioural difficulties and to present with significantly higher rates of previous violent and sexual offences, previous allegations of sexual offences, and to have used physical coercion in their offences. The OPD sample was also significantly less likely to have pre-pubescent victims and more likely to refuse treatment, with over 70% failing to engage with the Sex Offender Treatment Programme (SOTP). SOTP non-engagement among OPD cases was most strongly predicted by categorical offence denial. Comparisons are made with the broader adolescent sexual offender literature.     

Offender personality disorder pathway: the impact of case consultation and formulation with probation staff

The latest government policies for personality disordered offenders emphasise the importance of a formulation-based approach to rehabilitation and pathway planning. However, research into forensic case formulation is limited. This paper examines the impact of consultation and formulation, on probation staff working with personality disordered offenders. Staff rated their knowledge, confidence, motivation, and understanding (of offenders), and satisfaction with management plans at three stages: pre-consultation, post-consultation and after receiving a written formulation. The analyses revealed that ratings on all variables examined increased after attending a consultation meeting, with no additional increase in scores following receipt of the formulation letter. The findings provide evidence that consultation has a range of benefits for probation staff, and offer support for the current model of joint-agency working. Further research is needed to clarify the benefits of providing written formulations after consultations, and to explore what features of a formulation are most useful to probation staff.     

Coercion,competence, and consent in offenders with personality disorder

Competence to consent to treatment has not previously been examined in a personality disorder cohort without comorbid mental disorder. We examined competence and coercion in 174 individuals diagnosed with severe personality disorder using two validated tools (the MacArthur Competence Assessment Tool for Treatment and the MacArthur Coercion Assessment Scale – Short Form). Competence was not categorically impaired, but there were variations within the sample on dimensional competence measures. Further, there were significant negative correlations between experienced coercion and competence. Higher coercion scores were associated with two components of competence: lower understanding and reasoning. Patients who consented to treatment had higher scores on competence measures and experienced less coercion. These findings suggest that therapeutic approaches that decrease experienced coercion and increase competence may increase the engagement of individuals diagnosed with severe personality disorders in treatment.     

An integrated case formulation approach in forensic practice: the contribution of Occupational Therapy to risk assessment and formulation

Forensic services focus on risk reduction and extol the value of multidisciplinary working. Due to the complex relationship of personality disorder and risk, a multidisciplinary approach to risk assessment, formulation, management and reduction is essential. Occupational Therapists provide a unique perspective; however, current literature pertaining to the contribution of Occupational Therapy is negligible. This paper aims to initiate discussion of the value of Occupational Therapy contributions to risk assessment and formulation with personality disordered offenders. A new approach is described that integrates occupational adaptation and multiple sequential functional analysis to provide a structured framework for Occupational Therapy risk assessment and formulation. A single case report is presented to demonstrate the advantages of the approach for identifying offenders’ strengths and difficulties, predicting risk of reoffending, identifying offence paralleling behaviour and informing and evaluating efficacy of intervention, thereby supporting the aims of forensic practice settings to assess, manage, treat and reduce risk.     

Effectiveness of modified therapeutic community treatment within a medium-secure service for personality-disordered offenders

There is debate as to whether secure hospital treatment for offenders with personality disorder can be effective relative to criminal justice interventions. This study examines the evidence for long-term treatment of such offenders in hospital within in a modified therapeutic community model including accredited offending behaviour programmes. A panel sample of 47 patients were followed up on measures of violence risk (HCR-20, VRS) and symptom severity (SCL90-R). Intention-to-treat analysis with reliability thresholds showed significant positive change between assessment and discharge in both violence risk (VRS) and symptoms (SCL90-R) indicating a positive treatment effect. Threshold effects for treatment effectiveness seemed to occur at 1?year of treatment for risk and 3?years for symptom reduction.     

Sexual offenders with learning disabilities: risk,recidivism and treatment

Abstract

While the literature on the assessment, treatment and management of non-learning disabled sexual offenders is well established, it is only in recent years that researchers and clinicians have focused on sexual offenders with learning disabilities. In contrast to mainstream sex offender treatment programmes, there are few evaluated community-based treatment programmes for sexual offenders with learning disabilities, and of the small number of published studies that describe treatment programmes, most are based on small samples and few have been validated empirically. Sexual offenders with learning disabilities differ from their non-disabled counterparts in several important ways, having implications for management and treatment. Due to methodological differences between studies, the prevalence of sexual offending by men with learning disabilities is not clear. However, in some studies, the sexual recidivism rate of offenders with learning disabilities is 6.8 times and 3.5 times that of non-disabled sexual offenders at 2- and 4-years’ follow-up, respectively. Sexual offenders with learning disabilities are also at greater risk of re-offending in a shorter time period. There remains an urgent need for further research into the assessment of risk and whether components from mainstream treatment programmes can be adapted to meet the needs of learning disabled sexual offenders. Approaches to working with sexual offenders with learning disabilities and programme development are discussed.     

Self-control strength in prison inmates with antisocial personality disorder

The present study aimed to examine the difference in self-control strength between individuals with and without antisocial personality disorder (ASPD) in a Chinese male prisoner sample. Thirty-seven male inmates who met the criteria for DSM-IV ASPD and 38 who did not were asked to watch a four-minute silent videotape of an interview, and ignore the words displayed on screen during the videotape to deplete their ego strength. A handgrip task was conducted both before and after watching the videotape, with participants’ time squeezing the handgrip being the dependent variable. Result showed a significant interaction between group (ASPD/no-ASPD group) and time (baseline/post-manipulation measure). The post-manipulation result was significantly worse than the baseline result for the ASPD group, but not for the no-ASPD group. These results indicate that tasks that contribute to ego depletion lead to a deficit of self-control strength in prisoners with ASPD.     

Resettle: a significant new step in an emerging pathway that manages risk and addresses need in high-risk personality disordered offenders on their release into the community

Abstract

This paper will describe an innovative UK service development, Resettle, which is designed to address the needs and risks of personality disordered offenders who are released into the community from prison and whose high risks of harm and re-offending are linked to their personality disorder (PD). All the cases worked with are subject to Multi-Agency Public Protection Arrangements (MAPPA). This non-residential, intensive community-based service is nationally funded jointly by the Department of Health and Ministry of Justice, originally as part of the Dangerous and Severe Personality Disorder (DSPD) programme for high-risk offenders. Resettle became operational in 2008. It is currently being independently evaluated via a randomised control trial that is due to complete in March 2013. Formal outcome data are, therefore, not yet available, however, the developing model of intervention based on experience and learning to date is described alongside the policy and service context for this area of work.     

Screening for mental disorder using the UK national offender assessment system

Probation officers have large caseloads with high levels of psychiatric morbidity but receive minimal training in recognising/managing mental health problems. In the UK, there is no national screening procedure for mental illness among offenders that is considered effective. This study’s aim was to develop a screening system for mental/personality disorders using the Offender Assessment System. Seven screens for mental disorder were developed using items from assessments on 574 prisoners: alcohol misuse, drug dependence, antisocial personality disorder, psychopathy, learning difficulties, psychosis and severe mood disturbance. Internal validation showed that the screens performed well across accuracy estimates. Prevalence of mental disorders identified with the screens in test and validation samples was similar. However, the psychopathy and severe mood disturbance screens may be more effective in screening for true negatives. The screens are an economical method for prioritising mental health needs of the UK prison and probation population using routinely collected data.     

Characteristics and offences of women with borderline personality disorder in forensic psychiatry: a multicentre study

Although female forensic patients diagnosed with borderline personality disorder (BPD) are generally considered taxing in clinical practice, little is known about their specific characteristics or offences. In this study, 156 female forensic psychiatric patients diagnosed with BPD were compared to 113 diagnosed otherwise. Information on demographic and psychiatric characteristics, victimization, index offences, and incidents during treatment was gathered from patient files. Risk factors for recidivism were assessed using the PCL-R and historical items of the HCR-20, including items from the new Female Additional Manual (FAM). Compared to non-BPD women, BPD women were more likely to have been abused as children and to have a history of outpatient treatment. While less likely to be convicted for (attempted) homicide, a higher percentage of BPD women was convicted for arson. Comorbid substance abuse was more frequent in the BPD group and incidents towards others and themselves were more violent in nature. The PCL-R and the H-scale of the HCR-20/FAM indicated several risk factors especially important for BPD women, such as poor behavioural control, impulsivity, and irresponsibility. The results support the clinical impression that women diagnosed with BPD are a subgroup within the female forensic psychiatric population, with specific focus points for treatment and management.     

Factorial analysis of risk matrix 2000 on an Italian sample of sexual offenders

ABSTRACT

In order to assess the internal structure of Risk Matrix 2000 in an Italian sample of 308 adult males convicted for sex abuse, a principal component analysis with Promax rotation was performed. The results identified a structure with three factors that explained 53.8% of the total variance: the first factor concerned items referred to the criminal career of the offender; the second factor concerned the age of onset in committing crimes; the third factor was more strictly related to the offenders' attitude towards the sex crime/s, and reflects the aggravating items of the S scale. These results allows us to have the first validated tool on an Italian sample for assessing the level of risk for recidivism.     

Sexual offenders with serious mental illness: prevention, risk, and clinical concerns

Individuals with serious and persistent mental illness who have also engaged in illegal sexual behavior present a unique challenge for our legal and clinical systems. Frequently, these individuals may engage in problematic sexual behaviors which result in hospitalization rather than incarceration, and an overburdened and resource-deficient public community mental health system is ill-equipped to address the seriousness of these sexual behaviors. We have a rather limited understanding of how prevention programs, intervention strategies, and risk assessment would work with this population. Here we evaluate data from a sample of 245 inpatient psychiatric sexual offenders in a forensic mental health setting and compare these with what information has already been presented in some of the literature. Through an examination of seriously mentally ill sexual offenders and their clinical presentation, legal history, and risk management concerns, we illustrate a variety of tertiary prevention needs. Future directions in the area of prevention and risk management for seriously mentally ill sexual offenders are also discussed.     

Integrating risk,the Good Lives Model and recovery for mentally disordered sexual offenders

Abstract

Personality disordered and mentally disordered sexual offenders (MDSOs) with complex diagnoses such as schizophrenia, developmental disorders and mood disorders face challenges of restoring their mental health, living more safely with personality- and offence-related risks, while addressing concerns about their capacity to reintegrate into society; this has been termed “secure recovery”. This paper reviews the literature on recovery, demonstrating its commonality with the Good Lives Model (GLM) as applied to MDSOs' offending treatment. GLM appears to provide a better fit with the recovery needs of MDSOs than the Risk–Need–Responsivity model because it emphasises approach goals, enhanced responsivity and skills acquisition. Recovery needs to integrate coping with mental disorders with risk management and a healthy, future lifestyle. Both secure recovery and GLM support the need for client–clinician collaboration, promoting self-determination and a shared narrative about coping with enduring risk and the hope of sustained well-being.     

The personal impact of delivering a one-to-one treatment programme with high-risk sexual offenders: Therapists' experiences

Abstract

Previous research suggests that delivering treatment for sexual offenders can have both positive and negative effects on therapists. We know less about the specific impact of conducting such work in different ways; for example, individually rather than in groups. This study aimed to explore the experiences of sexual offender therapists delivering a one-to-one programme with clients. Eleven therapists delivering an individual intervention with high-risk sexual offenders in English prisons took part in interviews and focus groups about the impact this work has had upon them. One participant also completed a diary charting their experiences while delivering the intervention. Content analysis identified that participants felt they experienced changes in how they viewed themselves, others and the therapeutic relationship, in both positive and negative ways. They also described experiencing intrusive thinking and feeling overly responsible for the outcome of treatment. However, positive effects were also identified. Findings suggest that the provision of structured supervisory support was particularly key in mitigating the impact of treatment delivery.     

Long-term follow-up of criminal recidivism in young sex offenders: Temporal patterns and risk factors

Abstract

Recent studies indicate that risk for criminal re-offending in identified adult sex offenders may persist decades after the index offence, calling for inquiry into these issues also for younger sex offenders. The author studied temporal patterns for criminal reconvictions and the validity of 16 empirically motivated risk factors for recidivism among all young sex offenders (15–20 years of age) subjected to pre-sentence forensic psychiatric evaluations in Sweden during 1980–1995 (N = 126). The Ss were followed from release and for an average of 115 months. One-hundred-and-seventeen (115 male, 2 female) Ss were available for follow-up with a mean time-at-risk of 80 months. Base rates for sexual and violent non-sexual reconvictions were 30% and 42%, respectively. Using time-at-risk-adjusted hazard ratios derived from Cox regression, characteristics indicative of deviant sexual interest (any previous sex offending behaviour, an index sex offence in a public area, involving a stranger victim, offending on two or more offence occasions, and two or more victims) were found to increase the risk for sexual recidivism. Markers of antisocial lifestyle (early signs of DSM-IV Conduct Disorder and any prior violent conviction), sex offence-related characteristics indicating aggression proneness (use of threats or force and physical victim injury), and victim penetration, increased the risk for violent non-sexual reconvictions. Survival analyses indicated that the rate of sexual reconvictions as a function of time at risk decreased distinctly after 6–7 years whereas the rate for violent non-sexual reconvictions remained largely the same.     

The implementation of case formulation by probation officers: service user and carer views

Background: The recent UK Government strategy on high-risk offenders with personality disorders (PD) proposes improved identification of this group, assessment of their treatment needs through case formulation (CF) and the subsequent provision of treatment pathways. Little is known about service user and carer views on this strategy. Aims/Hypotheses: This study sought to identify the views of personality-disordered (PD) offenders and carers on the proposed role of Probation staff in CF. Methods: Three focus groups were carried out, two with service users and one with carers, with a total of 10 participants overall. Results: Five themes emerged: ‘power’, ‘conflicting roles’, ‘trust’, ‘building a relationship through consistency of care’ and ‘hope and possibility’. Conclusions/Practical implications: Offenders and carers were sceptical regarding the proposed role of Offender Manager (OMs) in CF and this could pose a potential barrier to the successful implementation of the strategy.     

The big 5 dimensional personality approach to understanding sex offenders

Abstract

Although previous research has reported that the incarceration of sex offenders does not significantly reduce re-offending, there is no adequate theory guiding remedial programs for this population. The aim of the present study was to examine whether normal personality variation provides useful theoretical insight into the nature of sex offences against children. The Revised NEO Personality Inventory (NEO PI-R), a measure of the five-factor model (FFM) of personality, was administered to 64 males incarcerated for child sex offences. Sex offenders were categorised into different offender groups comprising incest within the immediate family, incest within step-family and extra familial offence. A comparison group of 33 non-offender males also completed the NEO PI-R. Results indicated that the sex offender groups were significantly higher in Neuroticism and significantly lower in Extraversion and Conscientiousness compared to the non-offender group. Significant differences between the sex offender groups and comparison groups for NEO PI-R facets were also found. The implications of these findings in terms of early identification and treatment are discussed.     

Personality disorder and violence in the national household population of Britain

Background: Antisocial personality disorder (ASPD) is strongly associated with violence but the effects of other personality disorder (PD) categories are uncertain. Purpose: To investigate associations between 10 DSM-IV PD categories and effects of co-occurring disorders on self-reported violence. Method: Cross-sectional survey of 8397 adults aged 16–74 years in households in Great Britain. Results: ASPD contributed strongly to the burden of violence in the British population. Paranoid and obsessive–compulsive PD made additional independent contributions, and narcissistic PD contributed to intimate partner violence. The prevalence of violence correlated with the number of PD categories. Comorbid alcohol dependence further increased the risk. Conclusions: Risk of violence increases with increasing severity of PD, measured by the number of PD categories, and with co-occurring alcohol dependence. Not all PD categories are associated with violence, and avoidant PD was protective. Identification of targets for future interventions may be obscured using a classification based solely on severity.