“Who needs secure services for personality disorder?” Results of an expert Delphi study with professional staff

Background 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. 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. Method A 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. Results Fifty-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. Conclusions Professionals 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. Electronic supplementary material The online version of this article (10.1186/s12888-019-2268-3) contains supplementary material, which is available to authorized users.

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Assessing Offenders Transfers from Prison to Forensic Mental Health Services 1. Unique identification number * 2. Please enter your job role and speciality: * As you will be aware, there are numerous different diagnoses of Personality Disorder. As part of this survey we wish to further understand how each disorder responds to treatment, helping us to gain further insight into what diagnoses are more responsive to treatment in a hospital setting, thinking about what works and with whom.
In this section we will ask your thoughts on a number of Personality Disorder diagnoses: ASPD; EUS: BPD; PPD; DPD; Psychopathy, asking you to consider each diagnosis across three different domains: 1) Suitability for hospital admission 2) Successful treatment outcome in a hospital setting (i.e. reduction in symptoms, distress and/or psychopathology) 3) Reduction in the likelihood of reoffending We acknowledge there are large individual differences between each patient and within each disorder, however for the purpose of this study we ask that you think holistically. 2. Are there any personality disorder diagnoses that you consider less amenable to treatment? If so, please list below:

Assessing Offenders Transfers from Prison to Forensic Mental Health Services
The following characteristics have been identified by a systematic review of the literature as key features in offenders diagnosed with personality disorder. The below questions ask how specific characteristics impact on a persons suitability for admission to a hospital setting, how they impact on the likelihood of successful treatment outcome (i.e. reduction in symptoms, distress and/or psychopathology) and the likelihood of future re-offending. Likely to be a risk factor in future re-offending Please add your comments, provisos and/or qualifying remarks 4. Individuals who have a negative relationship with their personality disorder diagnosis: * The following characteristics have been identified by a systematic review of the literature as key features in offenders diagnosed with personality disorder. The below questions ask how specific characteristics impact on a persons suitability for admission to a hospital setting, how they impact on the likelihood of successful treatment outcome (i.e. reduction in symptoms, distress and/or psychopathology) and the likelihood of future re-offending. Likely to be a risk factor in future re-offending Please add your comments, provisos and/or qualifying remarks 4. Suicidal ideation: * The following characteristics have been identified by a systematic review of the literature as key features in offenders diagnosed with personality disorder. The below questions ask how specific characteristics impact on a persons suitability for admission to a hospital setting, how they impact on the likelihood of successful treatment outcome (i.e. reduction in symptoms, distress and/or psychopathology) and the likelihood of future re-offending. Likely to be a risk factor in future re-offending Please add your comments, provisos and/or qualifying remarks 3. Higher levels of perceived motivation for treatment: * Offence history was identified as a contributing factor when considering the management and treatment of offenders with personality disorder. The below questions ask more specifically of how a person's offence history impact on a persons suitability for admission to a hospital setting, the likelihood of successful treatment outcome (i.e. reduction in symptoms, distress and/or psychopathology) and the likelihood of future re-offending. Likely to be a risk factor in future re-offending Please add your comments, provisos and/or qualifying remarks 4. Violent index offence: * The below questions ask you to consider an individuals engagement with previous treatment, thinking about how this impacts on the following: suitability for admission to a hospital setting; the likelihood of successful treatment outcome (i.e. reduction in symptoms, distress and/or psychopathology) and the likelihood of future re-offending. 3. What staff qualities are important when working with offenders with personality disorder who are admitted to a hospital setting? Thank you for taking the time to complete this survey, your response has now been recorded. We truly value the information you have provided.

Assessing Offenders Transfers from Prison to Forensic Mental Health Services
As this survey is the first part of a two-stage Delphic process the responses will now be synthesised to create the second part of the survey where contact will be made with you again.
If you have any comments on the survey, please contact Zoe Foyston, z.n.z.goodwin@smd16.qmul.ac.uk Once again, thank you.

Thank You
Assessing Offenders Transfers from Prison to Forensic Mental Health Services 1. Please check off below if you do NOT want to be contacted to complete the second survey Please do not contact me