Managing dangerous people with severe personality disorder: a survey of forensic psychiatrists' opinions

How personality became treatable: The mutual constitution of clinical knowledge and mental health law

In recent years, personality disorders – psychiatric constructs understood as enduring dysfunctions of personality – have come into ever-greater focus for British policymakers, mental health professionals and service-users. Disputes have focussed largely on highly controversial attempts by the UK Department of Health to introduce mental health law and policy (now enshrined within the 2007 Mental Health Act of England and Wales). At the same time, clinical framings of personality disorder have dramatically shifted: once regarded as untreatable conditions, severe personality disorders are today thought of by many clinicians to be responsive to psychiatric and psychological intervention. In this article, I chart this transformation by means of a diachronic analysis of debates and institutional shifts pertaining to both attempts to change the law, and understandings of personality disorder. In so doing, I show how mental health policy and practice have mutually constituted one another, such that the aims of clinicians and policymakers have come to be closely aligned. I argue that it is precisely through these reciprocally constitutive processes that the profound reconfiguration of personality disorder from being an obdurate to a plastic condition has occurred; this demonstrates the significance of interactions between law and the health professions in shaping not only the State’s management of pathology, but also perceptions of its very nature.

The dangerous and severe personality disorder experiment--review of empirical research

BACKGROUND

A pilot programme for the treatment of individuals with dangerous and severe personality disorder (DSPD) was established in the UK in 2001. A substantial investment had been made into research and evaluation of the initiative, but it is not clear what the outcomes of this research have been.

AIM

This study aimed to review empirical research on the DSPD programme.

METHOD

We conducted a systematic literature review by using electronic searches of the databases MEDLINE, PsycINFO and EMBASE, complemented by hand searches of key journals and websites.

RESULTS

We identified a total of 29 empirical research papers and three comprehensive research reports. Most studies were concerned with describing the DSPD population and confirmed that the projects targeted high-risk personality disordered offenders. Qualitative research identified a number of concerns regarding stigma, restrictiveness of the environment and indeterminate detention. Organisational enquiries recognised inefficiencies in assessment and treatment delivery. No high-quality trials were carried out of specific treatments or service environments.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The key question--what treatments are effective for high-risk personality disordered offenders--remains unanswered. More time would be needed to fully assess the impact of this programme, and similar future initiatives should allow longer observation periods.

Costs and outcomes of an intervention programme for offenders with personality disorders

BACKGROUND

The dangerous severe personality disorder programme was developed in high secure prisons and hospitals at great expense to identify and treat the most dangerous offenders with personality disorders.

AIMS

To evaluate whether the long-term costs of the programme are greater or less than the long-term outcomes.

METHOD

We used a Markov decision model with a cost-effectiveness analysis to determine the incremental cost of the programme per serious offence prevented and a cost-offset analysis to consider whether monetary benefits were greater than costs.

RESULTS

Costs were consistently higher for the intervention programme and the cost per serious offence prevented was over £2 million, although there was some evidence that adjustments to the programme could lead to similar interventions becoming cost-effective.

CONCLUSIONS

Little evidence was found to support the cost-effectiveness of the intervention programme for offenders with personality disorders, although delivery of the programme in a lower-cost prison would probably yield greater benefits than costs. There are frequent calls for mentally disordered offenders to be detained in secure hospitals rather than prisons; however, if reoffending remains the outcome of interest for policy makers, it is likely that the costs of detention in hospital will remain greater than the benefits for dangerous offenders with a personality disorder.

Dangerous and severe personality disorder

The Dangerous and Severe Personality Disorder (DSPD) initiative was introduced a decade ago against overwhelming opposition from psychiatrists and others concerned with the implications of extending the public protection agenda through the use of a questionable medical 'diagnosis'. As this initiative is now being scaled down, it offers an opportunity to consider the positive and negative aspects of the initiative together with its longer-term legacy.

Perceptions of diagnostic labels in forensic psychiatric practice: a survey of differences between nurses and other disciplines

This paper reports on a study of nurses' and non-nurses' perceptions of labels of mental illness and personality disorder in forensic services in the UK. The objectives of the study were to establish if differences in perceptions existed within, and between, the two groups of professionals. The research method was a survey design with 1,200 questionnaires distributed to nurses and 300 to other professionals in disciplines on forensic units in the UK, with response rates of 34.6% and 43%, respectively. The target population included clinical health care staff who had patient contact, including nurses, psychiatrists, psychologists, social workers, and occupational therapists. The results indicate that there are statistically significant differences within both nursing and non-nursing groups and also between the groups in relation to a "management" perspective for individuals labelled with a personality disorder and a "clinical" focus for individuals who are labelled as mentally ill. This paper adds research into the arena of forensic mental health in relation to the diagnostic labels of mental illness and personality disorders. It also adds evidence of a clinical response or a management response to such diagnostic labels which may impact on the practice of forensic psychiatry.

Dangerous and severe personality disorder: An investigation of the construct

Introduction of the construct "Dangerous and Severe Personality Disorder" (DSPD) by the UK Home Office and Department of Health has provoked strong debate and opposition. Its aims and that of proposed subsequent legislation was to enhance public protection by identifying and detaining a minority of persons with severe personality disorder who pose a high risk of serious sexual/violent offending. The most serious criticism was the ethical implication of allowing indefinite detention of people without criminal convictions. More recently, policy emphasis has shifted towards treatment. 1396 male prisoners serving sentences of 2+years for sexual/violent offenses were prospectively interviewed (personality disorders, psychopathy, and risk) at a mean follow-up of 2 years. The prevalence of DSPD was 15%. Significantly more re-offended. Five DSPD offenders would need treatment to prevent one violent act. Based on an estimate of attributable risk, successful treatment of DSPD could reduce violent re-convictions among DSPD offenders by 71% and violent/sexual re-offenses in the prison population by 27%. DSPD criteria correctly identify high risk prisoners but primarily through risk-related demographic features. DSPD does not accurately identify serious sexual/violent re-offenders. The DSPD programme may reduce major violent re-offending if treatment interventions prove effective.

An agitation of contrary opinions

Those people who are dangerous often have personality disorders. Should these individuals be dealt with by criminal justice or mental health services? England (note not Scotland) has taken the mental health route with the Dangerous and Severe Personality Disorder Programme. Is this bold move wise or foolish? To answer this question we have both evidence and opinion - neither is conclusive.