Dr David Wilson

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Dr David Wilson

• The fair, the dreadful and the excellent!

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CONSENT CONFIDENTIALITY

• WRITTEN CONSENT REQUIRED
• Research Always
• Single Case reports Always
• Case presentations If practical, no patient
  identifiable material

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Case presentation

• Tony Smith
• The fair

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Personal Details

• Age 31
• Admitted 30.07.01
• Classification Psychopathic disorder
• Transferred on 47/49 now 41(5)
• Notional 37

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Family History

• Mother lives in Leeds
• Separated from husband when T was 2yrs
• Mental health problems
• Convicted of sexually abusing T (prison)
• Father whereabouts unknown
• 1 brother
• Foster mother son with Downs

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Personal History

• FTND Dev milestones normal
• Memory of childhood is of sexual abuse by mother
  and a lodger
• Poor inconsistent parenting
• Truanting, stealing shoplifting
• Fire setting

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Personal history (cont)

• Unhappy at school, bullied and teased
• Seen by educational psychologist at 12,
  recommended residential school for MLD children
• Hated it as he was sexually abused by staff and
  pupils
• After school YTS for 18/12
• No employment since
• Changed name 4 times

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Psychosexual history

• Early abuse
• Recognised homosexual preference at 13 yrs.
  Exclusively homosexual
• Casual encounters, worked as a rent boy
  Promiscuous
• 4 relationships, lived with two men
• Preference boys 13-15 yrs

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Forensic history

• 1992 attempting/procuring a man to commit
  homosexual act
• 1993 Indecent assault of 14 yr old boy
• 1995 Hoax phone calls to fire brigade
• Has disclosed many more

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INDEX OFFENCE

• Indecent assault of a male under 14
• Amusement arcades
• Heavy drinking
• Came across victim and offered him cash
• Admitted he would have dragged him back to flat
  or into bushes. Blackmailed victim
• Oral sex and masturbation told victim to meet him
  later
• Arrested, custody, admitted offence

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Past psychiatric history

• Regular contact from 13yrs, overdosing and SIB
• SIB to relieve tension, cope with ve emotions,
  anger, anxiety resentment
• Depression, PTSD, PD
• PMH mild Asthma

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Alcohol Illicit drugs

• Inhalants from 13yrs
• Amphetamine by 17yrs
• Cannabis ,LSD, cocaine, iv heroin
• Alcohol 10-12 pints beer or cider per day
  dependent with withdrawal
• Funded through prostitution

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Psychometric assessments

• IQ 69 Vineland- some deficits in social
  functioning
• Personality assessment inventory suggestive of
  PD, borderline antisocial
• PCLR 28
• HCR20 High risk of reoffending

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Progress

• Admitted July 2000 from HMP Wakefield
• Found it difficult after prison
• Needy not greedy
• Disclosures
• Attracted to young patients
• Assessment unit
• CPA

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Treatment pathway

• Individual psychotherapy (with an SpR)
• Intense named nurse sessions
• SOTG assessment
• Facilitated self harm group
• Few management problems (anal stimulation)
• Needed staff time
• Mixed day care programme

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Rx pathway (cont)

• 2001 moved to villa ward
• Female named nurse
• RMOs psychotherapy group
• SOTG with 1-1 follow up for 20 months
• Anger management group
• Substance misuse group

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Rx pathway (cont)

• Dialectical behaviour therapy
• Mindfulness
• CBT
• Psychotherapy
• SOTP relapse prevention
• Discharge planning for MSU

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Summary of Rx

• Close and enduring named nurse relationship
• Individual psychotherapy
• Group psychotherapy
• Intensive SOTG
• Anger management
• Drugs alcohol work
• DBT
• Relapse prevention
• High secure stay nearly 4 years
• Almost accepted for local MSU

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CASE PRESENTATION

• Wesley Price
• The failure

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Personal details

• Age 46
• Admitted 7.12.88
• Classification Mental impairment
• Section 37/41

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Family History

• Mother died aged 49 years
• Step father killed by W when 65
• Aggressive alcoholic, long criminal record
• Very disabled after RTA
• Youngest of 4 brothers

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Personal history

• FT slow delivery
• Delayed milestones. Cerebral palsy, LD and
  convergent squint
• Attended MLD school
• Behaviour problems. Seen at Harperbury
• Left school at 16, illiterate and attended an ATC
• Continued to look after father at home

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FORENSIC HISTORY

• 1982 Obtaining food by deception
• 1984 ABH Struck a 13 year old girl
• 1987 Inciting girl of 14 to commit gross
  indecency, ABH and theft
• 1987 Assault on a schoolgirl

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Index Offence

• MANSLAUTER OF STEP FATHER
• Varying accounts by Wesley
• 1. Killed to put him out of his misery due to his
  pain
• 2. Bought an cleaver to chop wood. Step father
  was abusive and cruel, he therefore decided to
  kill him as he was so evil
• His mothers voice told him kill your step dad
• Killed with blow to back of head and tried to
  dismember body

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Psychometric assessments

• IQ 63
• Vineland Severe social deficits
• HCR20 High risk of re-offending

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Treatment Pathway

• The road to nowhere!
• Assaulted staff Charged
• No engagement in offence related work
• Discharged to MSU but absconded
• Returned to Rampton
• The model patient
• Institutionalised and treatment resistant. Wants
  to die in Rampton and threatens to kill if moves
  to MSU are even discussed

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CASE PRESENTATION

• Vincent Jackson
• The success

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Personal details

• Age 34 years
• Admitted to Rampton 9.6.1992
• Classification Mental Impairment
• Detention Section 47/49

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Family History

• Confused about parentage
• Mother 70yrs Alive and well
• Father Afro-Caribbean Moved to America of
  Vincents birth
• Step father 60yrs retired. Alive and well
• 2X stepbrothers one with MLD and one with SLD

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Personal history

• FTND Neonatal jaundice
• Developmentally slow
• MLD schooling from 5yrs
• YTS course but expelled for fighting
• No paid work
• Lived at home with parents who tried to supervise
  him and keep him out of trouble

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PSYCHIATRIC/FORENSIC HISTORY

• No psychiatric contact until index offence
• No convictions prior to index offence
• 1989 broke into Uni building. Found by security
  guard and threatened him with a knife. Bailed,
  but while waiting for parents wandered off. 2pm
  Stole biscuits and coke from shop. Threw a large
  stone though a church hall window.

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Index Offence (cont)

• Entered 3 or 4 houses stealing things including a
  dog collar
• Drank 2 X Lager. V sensitive to alcohol
• Found himself in grounds of OPs Home
• 2 women sitting at garden table
• Put dog collar round one womans neck and
  proceeded to attempt to strangle her with great
  force
• Prevented from strangling her by friend and
  appearance of her husband

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Index Offence (cont)

• Arrested by police
• Pleaded guilty to charges of
• Attempted Murder
• Theft
• Attempted burglary
• Sentenced to Life imprisonment

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Behaviour in HMYOI

• 1989
• Initially in hospital wing but moved to normal
  location
• Unpopular with inmates
• Physically aggressive
• c/o depression and performed SIB
• Sexually exploited. Oral sex

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Referrals

• Referred 1990 but turned down by panel
• Admitted to Rampton 1992 following continued
  depression, SIB, aggressive behaviour and being
  sexually abused

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Progress at Rampton

• Severe problems with temper control
• Serious physical aggression
• Found with potters knife on leaving a workshop
• Stated he wished to kill someone
• Refused to engage in any form of Rx felt it was
  childish

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Treatment

• 1998 First engaged in Art Therapy Group
• Anger Management
• Self esteem group
• Sudden realisation of profound communication
  problems. Intense SALT
• Mixed day time programme of skill acquisition
• Individual psychotherapy
• DBT (Dialectical Behaviour Therapy)

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Behaviour

• No episodes of physical aggression since 1998.
  Uses anger management techniques well
• Engaging in all Rx well
• Generally pleasant and cooperative with peers and
  staff
• Interested in reading

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Discharge planning

• Accepted for Independent Sector medium secure
  unit
• Discharge CPAs were completed
• Home office permission for trial leave was
  granted
• Funding was secured
• 2 X visits took place
• CPA after 10 weeks. Excellent progress

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Summary

• 35yr old man sentenced to Life imprisonment for
  attempted murder
• Immense problems in prison
• Failure to engage in Rx for 6 years
• SALT central to improvement
• Now settled and risk lowered which has enabled
  trial leave to commence

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What do these people have in common

• All a grave and immediate danger
• All have personality disorder
• All have communication problems
• Varying motivation/treatment resistance
• If you look at the person and not the offence
  they are all likeable people