Pathways in the community

  1. Accredited community programmes

As with prison accredited programmes, standard accredited community interventions should be considered initially. They currently include:

  • Interventions to enhance pro-social competencies
  • Interventions for anger and aggression
  • Interventions for sex offenders
  • Interventions for substance misuse
  • Other interventions (e.g. One to One, Drink Impaired Drivers Programme (DIDP) and Video monitoring).

Example flowchart of community pathways
(fill in your local area)

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  1. Primary care (GP)

Primary care is the foundation for all health care, at the centre of which sits the GP. The GP, GP Consortia and/or the Primary Care Trust are all vital to an understanding of how to navigate health services. From this point referrals can be made to other services – including secondary mental health care – which cater for that particular catchment area. The GP should be the first port of call when considering a referral, and offenders should be supported to register with a local GP as a priority. This is particularly important as there is considerable evidence that offenders with mental health problems and PD are more likely to have physical health problems than other population groups and for those problems to be overlooked. Many people who present with personality difficulties may only require short-term input for acute emotional difficulties which can be provided at this level. GPs may commission their own short term counselling services or access IAPT (improving access to psychological therapies services), both of which are generally inappropriate for personality disordered individuals.

  1. Community mental health teams (CMHTs)

For offenders in distress, with a diagnosis of personality disorder, the first point of contact should be the local CMHT. An individual can present directly at the ‘duty desk’, or be referred by a professional (including probation). In practice, the reason for referral is likely to be a co-existing problem (e.g. distress and self harm) and the personality disorder may not be the focus of intervention. The most common personality disorder diagnosis considered by CMHTs is borderline personality disorder. CMHT’s consist of a multi-professional team and use a care programme approach. This is a four stage system of care which includes assessment of health and social care needs, a care plan to meet these needs, a care coordinator to monitor the care and regular reviews to ensure the plan is updated and progressing. The CPA reviews should invite all professionals involved in the client’s care to the meeting. This should include probation services, although it may help to remind the service of your desire to attend such meetings. The CMHT coordinates assessment, management plans, crisis plans, risk assessment, treatment and access to acute inpatient care when required.

CMHT’s vary in their approach to the care of patients with a diagnosis of personality disorder. This may be directed by the Trust’s policy or may be a local team decision. It is helpful to have an understanding of their approach to the care of personality disorder before making referrals – the CMHT may only see such patients in crisis, or may require referrals to be made via the GP. The CMHT may also coordinate referrals to other specialist services in the area and should have knowledge of local service provision.

  1. Local psychological therapies or personality disorder services

Access to outpatient services specialising in the treatment of personality disorder can be difficult. The core treatment should be psychotherapeutic ‘talking therapies’, however this may include prescribing and monitoring psychotropic medication. The service may work in collaboration with the local CMHT, who would continue to provide crisis interventions and social support. Different psychological therapies services provide different models of care, as there is no single accepted model of treatment. These services are likely to accept referrals from a variety of sources including CMHT’s, primary care, A&E, drug and alcohol services and probation. However, local services will have local policies and you will need to be aware of their referral procedures.

More intensive day care services may exist in areas where there is a high prevalence of personality disorder. They provide more intensive input for those with severe personality problems, who pose a risk to self or others, relieving demand on primary and secondary services. Whilst these services may not be set up to accept referrals for antisocial personality disorder, they may include outreach provision to criminal justice agencies (e.g. probation). Such input may involve support, clinical supervision, consultation and assistance with referrals to other mental health agencies.

  • Local PD services lead on providing specialist treatments, but often concentrate on borderline PD
  • Specialist PD day units: intensive input for severe cases, may offer outreach to criminal justice agencies
  • Regional residential units: inpatient treatment for severe PD including services for offenders
  • CMHT’s: first port of call, but mostly deal with crisis management and coordinating care.
  1. Forensic mental health services

Most forensic mental health services are hospital based (i.e. local medium secure units), and there is very patchy provision for personality disordered offenders. Some will only provide inpatient treatment and are likely to specialise in treatment for psychosis rather than personality disorder. Others will have community provision and may offer assessment and treatment for personality disordered offenders. Each forensic mental health service will have its own provision based on available resources and expertise and you will have to contact the service to find out what they can provide for your offenders. See the section on transfer from prison to health for information on the few specialist personality disordered offender inpatient units.