\u201cWho needs secure services for personality disorder?\u201d Results of an expert Delphi study with professional staff

Zoe Foyston,Mark Freestone,Celia Taylor

doi:10.1186/s12888-019-2268-3

Abstract

BackgroundPersonality Disorder (PD) is an enduring, multi-faceted mental disorder, associated with adverse health effects, difficulties with interpersonal relationships and in some cases increased risk to others. A limited number of dedicated forensic mental health services are available for serious offenders with severe personality disorder. The recent Offender Personality Disorder (OPD) strategy aims to ensure that most such offenders are treated in prison rather than secure psychiatric services, except in highly complex cases where this is not possible. While the strategy sets out very broad criteria relating to this, greater clarity is needed to support decisions about appropriate transfer and hence enhance public protection. This study explored which characteristics professional experts associate with appropriate transfer from prison to forensic mental health services for high-risk offenders with PD.MethodA modified Delphi survey distributed through an online survey system was conducted in two-rounds with a group of professional experts recruited from forensic mental healthcare; criminal justice and specialist commissioning.ResultsFifty-one (56%) respondents completed stage one of the Delphi and 34 (61%) of these completed stage two. Consensus was reached for a total of 22 items indicating complexity, including co-morbid mental illness, high level of risk, lack of progress in prison and high motivation for treatment. A preliminary checklist for these factors was developed. Panel members consistently emphasised the importance of the individual’s presenting need, the overall clinical picture and formulation in their free text responses.ConclusionsProfessionals face a complex picture when making decisions regarding suitability for hospital admission for high-risk male offenders with PD, with varied opinions amongst professional experts as to priorities for intervention and a focus on individual needs through formulation. It was, nevertheless, possible to condense these views into a set of consistent variables that can be used to highlight the need for transfer into hospital-based treatment services.

Highlights

Personality Disorder (PD) is an enduring, multi-faceted mental disorder, associated with adverse health effects, difficulties with interpersonal relationships and in some cases increased risk to others
There has been a deficiency in the health service provision for individuals with PD [15], with inpatient beds in the UK overwhelmingly occupied by people with severe and enduring mental illness [16]
Based on a review of the literature and personal contacts, as well as the service directory maintained by the UK prison and probation service [39] we developed a matrix of services, and identified a population of 120 experts, clinicians, researchers and commissioners who linked to these services or active in the field of forensic personality disorder treatment or research. we believe the original population was representative of expertise in England and Wales at the time of the study

Summary

Introduction

Personality Disorder (PD) is an enduring, multi-faceted mental disorder, associated with adverse health effects, difficulties with interpersonal relationships and in some cases increased risk to others. A limited number of dedicated forensic mental health services are available for serious offenders with severe personality disorder. The recent Offender Personality Disorder (OPD) strategy aims to ensure that most such offenders are treated in prison rather than secure psychiatric services, except in highly complex cases where this is not possible. This study explored which characteristics professional experts associate with appropriate transfer from prison to forensic mental health services for high-risk offenders with PD. Treatment of PD in forensic mental health settings Offenders with PD are still considered one of the most difficult groups to treat, with many studies reporting engagement difficulties, high rates of attrition [19], and poor psychosocial and clinical outcomes [20]. It is important that offenders with PD receive treatment best suited to their needs, risk and presentation

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