People with learning disabilities in the CJS
Glynis Murphy Tizard Centre, Kent University [email protected] Outline
Prevalence of ‘offending’ in pwld Vulnerabilities in the CJS with regard to understanding rights, being interviewed, making decisions, going to court Recent policy – Bradley et seq Assessment, treatment and support Conclusions Eugenics era (1900 on)
Massive anxiety here and in USA that ‘unfit’ people were in some way ‘polluting the stock’ In UK led to institutions; in USA to involuntary sterilisation laws Publicity around e.g. Kallikak family (Goddard, 1912) Terman (1916): ‘No investigator denies the fearful role played by mental deficiency in …crime, vice & delinquency… not all criminals are feeble-minded but all feeble-minded are at least potential criminals’ Early studies
Woodward 1955: Reviewed over 300 studies of crime and learning disabilities (1910 - 1950 in USA Before 1920: On average 51% of convicted criminals reported to have learning disabilities; by 1928: this was 20%; by 1950 this was 4% - why? Walker & McCabe: 90% sample of all hospital orders made by courts under MHA 1959 in 1 year (‘63-’64) in England Of 969 men: one third were detained under ‘subnormality’ & those with LD (1/3) had committed 2/3s of the sex offences and one half of the arson offences – so we can conclude??? Cohort studies of prevalence
Farrington & West studies: 411 boys born in 1953. ‘Working class’, S. London. Followed up for 32 years. Over a third convicted by 32 yrs. Convictions related to cognitive ability, school achievement, large families, poor parenting, etc Hodgins 1992 & 1996: Follow-up of 2 cohorts (15,117 born 1953 in Sweden & >324,000 in Denmark) showed risk ratios for convictions : 3 to 7 times higher for men & 4 to 6 times higher for women with LD. Both defined ID by service use – special schools in Sweden & hospital admissions in Denmark. So we conclude???? Community-based studies
McBrien et al. (2003) looked at community- based population in city (200k population ) Total on LD register n=1326 (all the people known to services with LD) Found that: 3% had had a CJS conviction 9% had had a CJS contact as suspect 26% had CB of offending type How does this compare to the general population? Police station stage & court stage
Cambridge study (Lyall et al ’95) 251 people screened at custody stage; 4% had attended special schools About half went to Court London study (Gudjonsson et al., 93) 156 people screened at custody stage;15% needed an Appropriate Adult (4% got one); 9% had intellectual disabilities (short IQ test used) Court studies Few studies in UK, apart from one in Berkshire (found no over-representation) In Australia, Hayes found 14% -21% acc to area Prison & probation in UK
Prison: Murphy et al (1995): - Screened 157 men S London prison - 33 men said they had LD or had been to special school - On testing no one had LD (but lots in borderline range) Similar results from Birmingham et al 96 (screened 569 men one prison) & Brooke et al, 96 (screened 750 men on remand in 13 prisons/YOIs) Recently Mottram: 7% with LD in NW prisons in UK (HASI) & Murphy et al (in press) found 7% of the 3000 men admitted to 3 English prisons screened positive for LD on the LDSQ Probation: Murphy & Mason: about 6% of people on probation in Kent had LD ( 2 studies) Conclusions so far
People with LD do appear in the CJS They may be over-represented, at least in some countries, at some stages in CJS In UK: - in community: about 3% of pwld have conviction; 9% have had contact with CJS as suspects - of those questioned by police as suspects 4-9% have an LD - very low numbers in prisons we think (but need care how measured) - very low numbers in hospitals, detained under MHA - about 6% of those on probation have an LD Who are the suspects?
Usually people with mild or moderate LD (actus reus; mens rea) Usually young men (around 15-20% women) Often have mental health needs Often have autism spectrum disorders Often from very deprived and chaotic family backgrounds May not be in touch with services for pwLD Tend to be ‘bounced’ from LD to MH to forensic services & back Poor services: often restrictive (do we need govmt push to develop these?)
Overlap of LD, mental health needs, CB and offending
People with mental health needs
People
with learning disabilities Offending
CB Vulnerability of suspects with LD in the CJS
Inadequate understanding of caution and legal rights Susceptibility to acquiescence, compliance, interrogative suggestibility and confabulation Lack of knowledge relevant to decision- making in police interviews - we will look at each of these in more detail Understanding of rights at police station (Clare & Gudjonsson)
ON ARREST: Caution Advised of right to legal advice, person informed, consult Codes of Practice Given Notice to Detained Persons
UNDERSTANDING THE “NOTICE”: General population – understood 68% of sentences Learning disabled – understood 11% of sentences
Understanding of rights at police station (cont’d)
UNDERSTANDING THE (OLD) CAUTION: 80% of general population understood 8% of people with learning disabilities understood
UNDERSTANDING RIGHT TO SOLICITOR: 53% of general population understood 17% of people with learning disabilities understood Current caution (introduced 1995 under CJPOA, 1994)
‘You do not have to say anything. But it may harm your defence if you do not mention when questioned something which you later rely on in court. Anything you do say will be given in evidence’ Clare & Gudjonsson found that even some policemen don’t understand this! Problems on interview (Clare & Gudjonsson1995)
People with intellectual disabilities on questioning (compared to people without disabilities) are: nearly 4 times as likely to acquiesce (answer questions in the affirmative regardless of content) nearly twice as likely to be suggestible (be led by questions and shift answers when pressed) twice as likely to confabulate (fabricate or distort material to fill in gaps in memory
Decision-making in police station (Clare & Gudjonsson, 95)
Film of false confession to murder showed: General population believed - Man would go to prison (95%) - would not be believed if retracted confession - needed legal advice (90%) Learning disabled group - man would go home (38% - may be believed if he retracted confession (25%) - would not need legal advice (48%)
PACE - Police Code C – what is in the revised Codes of Practice (2014)
‘If an officer has any suspicion, or is told in good faith, that a person of any age may be mentally disordered or otherwise mentally vulnerable, or mentally incapable of understanding the significance of questions or their replies that person shall be treated as mentally disordered or otherwise mentally vulnerable for the purposes of this Code’. Latest Code of Practice also says: ‘An ‘easy read’ illustrated version (of Notice) should also be provided if available’. Tasks of ‘Appropriate Adult’ in an interview
• To advise the person being interviewed • To observe that the interview is being conducted properly and fairly • To facilitate communication with the person being interviewed
Codes of Practice C (1995) – and v similar in revised Code 2014 AA studies: Bean & Nemitz (1994) Looked at 20,000 custody records across East Midlands area and interviews with custody officers. AA called or used for 38 adult suspects who were thought to be ‘mentally disordered’ (mental health problems or learning disabilities) - would expect 1400 (7% of suspects) Further 1% identified as ‘mentally disordered’ but did not get AA Long waiting times for AA: 1-18 hours (average 3 hours)
AA studies
Bean & Nemitz (contd): Police often seemed unclear about role of AA for adults – thought to be only ‘welfare’. Rights apparently rarely given again in presence of AA. Medford et al (2000): London study - showed still AA under-provided (less than 50%) Pearse & Gudjonsson (1996): most AAs don’t speak!
Court: Risks to people with LD in court in CJS
Not being represented by a lawyer (30% in Hayes, 1993) Not being identified as having an LD (eg 78% of ID suspects in Brown & Courtless, 1971; 53% in McAfee & Gural, 1988) Not understanding court language, eg. not even understanding the phrase ‘not guilty’ (22% in Smith, 1993 ) Not surviving cross examination (Kebbell et al., 2001)
More risks to people with LD in CJS
On probation - Not understanding contracts/warning letters (Mason, ‘00) - Not being able to enrol on treatment programmes In prison - Often not eligible for specialist / treatment programmes (Brown & Courtless, 1971; Hall, 1992; Linhorst et al, 2002; Talbot 2008) - Risk of abuse/bullying (Ellis & Luckasson, ’85; Talbot 2008) - Risk of execution in some countries – in US the Atkins decision means people with LD should not be executed but……..in Texas? Risks to people with LD in the CJS in hospital Usually under court order (MHA in UK; USA usually capacity to stand trial; in other countries ‘secure care’ eg Australia, NZ, Norway) Risk of being detained for very lengthy periods (McGarry, 1971, in USA; Grubin, 1991, in UK; Dell & Robertson) Risk of being subject to abusive practices Difficulty of proving they are no longer high risk Not receiving treatment relevant to their difficulties Being very long way from home & relatives
The No One Knows programme (Talbot 2008) Big research programme based at Prison Reform Trust Looked at what prison staff knew about prisoners with learning disabilities & learning difficulties (v little) & what was happening in prisons for pwld (v little) Interviewed prisoners – report = ‘Prisoners Voices’ Developed a large number of recommendations for prisons, CLDTs etc
No One Knows
At police station: <1/3 had had an AA In court: 1/5th said they didn’t understand what was going on & 1/3 said they wanted things explained to them In prison: ½ said scared, bullied; ½ scored above cut off for depression, even more for anxiety; 78% had trouble filling in prison forms (meals, visits, seeing doctor); X 5 as likely to be restrained; X 3 as likely to be in segregation No One Knows recommendations
Disability discrimination & human rights: maltreatment by police & prison officers, lack of AA, not understanding what is happening in court, prison info inaccessible Knowing who has an LD: LDSQ pilot project in 3 prisons (B’ham, Durham, Wormwood Scrubs); hope for it to be rolled out; need for ID screening in police stations Implications for CJS: Practice direction in 2007 by Lord Chief Justice re special measures; access to treatment & work in prison; indeterminate sentence issue Needs led approach & multi agency working – see checklists Workforce development – see checklists Bradley report 2009: review of people with mental health problems or LD in CJS
Early intervention, arrest & prosecution (awareness training, early intervention in communities, improving AA service, screening for LD at police station, NHS to run police health services, signposting to health & social care, conditional cautions, diversion++) The court process (vulnerable witness procedures to be extended, bail not remand in custody, LD training, SLAs for psychology reports, specialist courts) Prison, community sentences, resettlement (more CROs with treatment conditions, LD screening in prison, in-reach teams, CPAs, NOMS & NHS plan for rehab on leaving prison; mentoring for people leaving prison) Delivering change thru partnership – National Programme Board with National Advisory Group, local Criminal Justice Mental Health Teams, role of PCTs Improving Health Supporting Justice, 2009 – Govmt response to Bradley
The National Delivery Plan of the Health and Criminal Justice Programme Board 82 recommendations National Programme Board (reps from all govmt agencies) National Advisory Group (from wider range of bodies, independent of govmt) Criminal Justice Mental Health Teams: Liaison & diversion - Core minimum standards for each team; national network; reporting structure; national minimum dataset; performance monitoring; Local development plans; Key personnel.
Task
What changes do you think need to be made to the CJS to help people with learning disabilities at risk of offending? There is no easy way to know if people have Learning Disabilities (Mental Handicap, Learning Difficulties)
They may have difficulty Ask if they Speaking Carry special identification Moving Have a social worker or key worker Understanding Go to a Day Centre (‘ATC’, ‘RAC’, ‘SEC’) Get a disabled living allowance Telling the time Are a member of People First, Mencap, a Gateway club Remembering their date of birth, age, address, telephone Ask number ‘Do people say you have learning disabilities or are Knowing the day of the week, where they are, and who mentally handicapped? you are. They may If the pattern of answers suggests that a person has a Also have physical disabilities, visual or hearing learning disability, and you want more help, contact: impairments (but most people with physical disabilities do not have learning disabilities) …………………………………………………………… Appear very eager to please or repeat what you say Ask Or the duty social worker ……………………………. Where they live. Do they live in a group home, hostel, hospital or, as an adult, still live with parents? Where they work. Do they attend a special work scheme? Suspects with learning disabilities must have an Where they went to school. Was it a special school? appropriate adult present when questioned (PACE)
Resources
Books Beyond Words – series of books for pwld, not using words, but entirely in pictures: - ‘You’re Under Arrest’ about a man arrested for a crime, showing what happens in the police station - ‘You’re on Trial’, showing the same man and what happens in court Conclusions so far: People with LD at risk of offending They are a very vulnerable group They require a lot of emotional support with everyday life They need help with dealing with the CJS, in which they are disadvantaged They should have access to support (often considered not to meet eligibility criteria by health & social care) Should have access to treatment to assist them with underlying emotional & cognitive difficulties We need better research on types of treatment before we can say what really works for whom (see next section) Assessment, treatment & support for people (with LD) at risk of offending Should be available in secure services & community May be done jointly, with eg probation Should be based on interviews, assessments and formulations Should be accompanied by positive life style Should also be accompanied by risk assessment & management Details to follow!
Support & treatment Reminder: Overlap of needs
People with mental health needs
People
with learning disabilities Offending
CB Assessments
Direct observations not usually very helpful Instead: mainly self-report – eg the Glasgow LD depression & anxiety scales; specialist assessments for anger, for sex offenders with ID (eg the QACSO) & for arson Rating scales & diaries – eg feelings diaries Interviews with the person in question Interviews with family members Anxiety thermometer (or for anger) Feelings diaries Anger diary
Situation: Thoughts Feelings Actions
Watch out for these thoughts
Thoughts Feelings Actions
these Try
Psychological interventions
Psychoeducation – eg education about phobias, depression, sex education, etc Recognition of emotions & thoughts Self-monitoring of behaviour, thoughts & emotions Thoughts, feelings, actions: how thoughts affect emotions & determine behaviour Relaxation training / mindfulness training Learning coping skills Desensitisation Anger management training Cognitive restructuring – changing cognitive distortions & behavioural experiments
Intervention packages
Anger management Arson Sexual offending – SOTSEC-ID General offending – EQUIP; A-TSP
Anger & aggression
Assessing anger : - anger questionnaires (eg Spielberger, Benson, Novaco’s Provocation Index, etc) - anger diaries - anger thermometers - anger coping skills: new measure (Willner et al 2005) Interventions - teaching recognition of emotions - teaching coping skills (eg relaxation training) - anger management training (see later)
Novaco’s theoretical model of anger & aggression
Benson’s Anger management training (up-dated) Assessment of anger (eg the Benson anger inventory; feelings diary) Group anger management training: - psycho-education - recognising & labelling emotions - recognising & labelling thoughts - relaxation training - challenging maladaptive thoughts - self-instruction (coping vs trouble statements) - problem solving (what is my problem, what is my plan, am I using my plan, how am I doing?) - role play and practice +++ Does it work? Group studies with controls:
Benson et al 1986: very good early RCT, showed reduced anger but no evidence for reduced aggressive incidents Rose et al (2000): community setting; 25 people in CBT group; 19 in control group; 16 sessions X 2hrs; significant treatment effect (self-report of anger) Taylor et al (2002): in secure setting; RCT: 9 men in CBT, 10 in control group; 18 sessions of anger management; significant treatment effect (self-ratings of anger only)
Does it work? Group studies with controls: Willner et al (2002): community setting; RCT: 7 in CBT, 7 controls; 9 sessions X 2hrs; self- report and staff report of significant changes in treated group; more change if higher IQ More recent studies: Rose et al 2005 (larger), Willner & Tomlinson 2007 (generalisation); Lindsay et al 2004 (larger & included aggro measure); Taylor et al 2005 (larger) Newest study: RCT, n=180 –train the trainers approach (Willner et al 2013); limited effects Self-report of anger vs records of aggro incidents
Arson
Cost of fires in UK: > £ 1 million Deaths in fires in UK: > 1000 per year No. of fires attended by fire brigade in UK per year: > 500,000 No. of fires in occupied buildings in UK per year: > 90, 000 Fires in buildings: 40% electrical 9% malicious 7% due to children Psychological treatment (CBT) for arson Armchair typologies People who set fires often very unassertive & socially unskilled Some specific fire-related assessments exist for people with learning disabilities (FIRS & FAS – Murphy & Clare, 1996) Fire-setting often occurs when feel angry & not being listened to (Murphy & Clare, 1996) Motives for arson (Prins, 1980) 1. Financial gain / cover up for a crime 2. Political (incl self immmolation) 3. Pathological a. ‘dull/subnormal fire-raiser’ b. pathological self immolator c. psychotic fire-raiser d. revenge motive e. heroic and vain group f. disguised cry for help g. sexually motivated h. fire raising by children Faulk (1982): motives for arson
1. Fires as a means to an end: Few fires: - psychotic/deluded - revenge/anger/jealousy - cry for help - covering up a crime\ - insureance fraud - policital motive - gang activity (excitement) More fires - desire to be seen as hero - desire to feel powerful - desire to earn money (p-t fireman) 2. Fire as a thing of interest - irresistible interest - sexual excitement - to reduce depression/anxiety Evidence relating to adult ‘pathological’ arsonists Compared to other offenders Less able than other offenders Less schooling and more unskilled jobs Less assertive Less socially skilled More prone to depression and self injury More often drank alcohol before the offence Re-offending common (less often arson)
Fire setters with LD: the FAFS
Can setting conditions be identified? - depression / anxiety / anger - auditory hallucinations - boredom /low stimulation - low social attention - low peer approval - impending aversive event Can consequences be identified? - less depressed / anxious / less angry - hallucinations stopped - excited by fire/consequences - more social attention - peer approval - aversive event avoided
Fire Interest Rating Scale (7 point scale from horrible to very exciting)
Please ask the client to rate each situation. Ensure that the client has the rating scale in front of him and understands the scale. How would you feel: 1. Watching at ordinary coal fire (in a grate) in an ordinary house.
2. Watching a house burn down.
3. Seeing the firemen get their equipment ready.
4. Striking a match to light a cigarette.
5. Going to a police station to be questioned about a fire.
6. Seeing the firemen hosing the fire.
7. Watching people run from a fire.
8. Watching a fire engine come down the road.
9. Watching a person with his clothes on fire.
10. Watching a bonfire outdoors, like on bonfire night.
11. Having a box of matches in your pocket.
12. Striking a match to set fire to a building.
13. Seeing a hotel on fire on the TV news.
14. Giving matches back to someone else.
Arson: Does CBT work?
Clare al. 1992: single case - assertiveness training; coping skills; covert sensitisation. Offence free for 10+ yrs Taylor et al 2004 & Taylor et al 2006: - group treatment (no controls) for 4 men (2004) & 6 women (2006) - cognitions & emotions in arson; education & info; social skills training & coping skills; relapse prevention - scores on FIRS, FAS little change; anger & GAS improved How to show effective?
Psychological treatment (CBT): sexual offences Usually group cognitive-behavioural therapy Measures: usually include Lindsay’s QACSO, plus sexual knowledge measure plus empathy measure Treatment often lasts for one year or more (one session per week) Modules (usually): - sex education & relationships - the cognitive model - empathy training - the 4-stage model of sexual offending - relapse prevention Empathy training
Recognising emotions How did they feel when abused/bullied? How might a victim feel? (eg from stories/ pictures) How did their victim feel? Ripple diagrams Example of work on 4-stage model
Based on Finklehor’s 4 stage model of sexual offending
1. Not OK sexy thoughts I havent had a girlfriend for a long time. Feeling sexy & thinking I need one. See one on bus 2. Excuses I am just going to make friends 3. Planning Follow her. Tell staff I’m going to my mum’s. 4. Carrying it out Going to her house instead. Hammering on her door Example of relapse prevention
1. Good thoughts Remembering going bowling with my family & being top scorer 2. Excuses/ the truth I don’t want to make friends; I want sex; you cant have sex with someone you don’t know 3. Planning: new me I am not going back; I am going to go bowling or to the pub & play pool instead 4. Carrying it out: new me Im going to talk to staff about going bowling or to the pub
Sexual offences: Does CBT work?
Individual case studies abound (eg Griffiths et al 1989; O’Connor 1996; Lindsay et al 1998 a,b,c) Group treatment: - Lindsay & Smith 1998 showed men did better after 2 yrs of treatment than after 1yr (reconvictions) - Rose et al 2002: 5 men; some improved scores - Murphy, Sinclair et al 2007; & 2010; Heaton & Murphy, 2013: SOTSEC-ID group showed better sexual knowledge & empathy & lower cognitive distortions (1yr ttmt), maintained at 2.5 yr follow-up. Low rates further offences. Lindsay et al: reduction in harm in 29 repeat offenders Group treatment with controls or RCTs: none So overall does CBT work for pwld then? Some evidence CBT works, at least for depression, anger control & sexual offences CBT not suitable for all Very few studies include control groups Only a few are RCTs (anger only) Data often on cognitions or emotions, rather than behaviour Very, very little data on who benefits most (eg do people with autism benefit?) Very little evidence about which components in the packages work Very little evidence of long term benefits What do the SUs think?
Very few studies ask people what they think of treatment Taylor et al (2004): reported 83% enjoyed anger management sessions; 67% said they felt they had changed for the better; 83% felt less angry Murphy et al (2004): reported most men could say why referred for sex offender treatment; what they learned; what best & worst things were; very positive on whole Macdonald et al (2003): qualitative study of 9 people involved in psychoanalytical groups; valued group but found it painful; not aware of own progress Hassiotis et al (2013): again very positive views
What other supports do people with mld & CB need? Individual person-centred planning Social support from someone they trust, so that they can ask for help – eg in police station Day activities: supported employment and leisure in safe (risk assessed) integrated settings Residential support (flexible) - eg one person settings, 2 people flats, 3 people houses, with flexible staff support Staff training: For police, lawyers & judges, probation officers; residential, day services, health, Social Services staff Risk assessment & management
References to prevalence, vulner- abilities & policy *Dept of Health (2010) Positive Practice, Positive Outcomes. DoH, London Hollins, S., Clare, I.C.H., Murphy, G. & Webb, B. You’re Under Arrest. London: Royal College of Psychiatrists, 1996. Hollins, S., Murphy, G., Clare, I.C.H. & Webb, B. You’re On Trial. London: Royal College of Psychiatrists, 1996. McBrien, J. A., Hodgetts, A. & Gregory, J. (2003) Offending and risky behaviour in community services for people with intellectual disabilities in one local authority. Journal of Forensic Psychiatry and Psychology. *Murphy, G. & Mason, J. (2014) People with intellectual disabilities and offending behaviours. In Handbook of Psychopathology in Intellectual Disability (Eds E. Tsakanikos and J. McCarthy). New York: Springer Science *Talbot, J. (2008) Prisoners’ Voices: experiences of the CJS by prisoners with learning disabilities and difficulties. London: Prison Reform Trust Special issues of Clinical Psychology & Psychotherapy, ’04 and Journal of Applied Research in Intellectual Disabilities: issue 2, 2002 & issue 4, 2004 & issue 1 2006 & issue 5 & 6 2013 References to support & treatment
Whole issue of JARID 2006, vol 19 issue 1 & JARID issue 4/5 2013 Clare, I.C.H. & Murphy, G. (2012) Working with offenders or alleged offenders with intellectual disabilities. In E. Emerson, A. Caine, J. Bromley & C. Hatton (Eds.) Clinical Psychology and People with Intellectual Disabilities. Wiley Dagnan, D. Jahoda, A. & Stenfert Kroese, B. (2007) CBT. In Carr et al (eds) The Handbook of Intellectual Disability and Clinical Psychology Practice. Routledge Hassiotis et al (22013) Manualised individual CBT for mood disorders in people with mild to moderate ID: a feasibility RCT. Journal of Affective Disorders, 151 186-195 Heaton, K. & Murphy G.,H. (2013) Heaton K.M. & Murphy G.H. (2013) Men with intellectual disabilities who have attended sex offender treatment groups: A follow-up. Journal of Applied Research in Intellectual Disabilities, 26 489-500 SOTSEC-ID (2010) Effectiveness of Group Cognitive-Behavioural Treatment for men with ID at risk of sexual offending. JARID, issue 6 Peckham et al (2007) Evaluating a survivors group pilot for women with ID who have been sexually abused. JARID, 20, 308-322 Taylor et al. (2002) Cognitive-behavioural treatment of anger intensity among offenders with intellectual disabilities. JARID, 15, 151-165 Willner et al. (2002) A randomised controlled trial of the efficacy of a cognitive- behavioural anger management group for clients with learning disabilities. JARID, 15, 224-235. Vereenooghe, L. & Langdon, P. (2013) Psychological therapies for people with ID: a systematic review& meta-analysis. Research in Dev Dis 34, 4085-4102