Dangerous and Severe Personality Disorder

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Dangerous and Severe Personality Disorder (DSPD) (1500)

Dangerous and Severe Personality Disorder (DSPD) is a new policy that was established in England in 1999, the UK government introduced this policy in the view of a heart-breaking and unprovoked assault happened on a mother and two children in which causing two fatalities and one of the child faced permanent disability (Home Office & Department of Health, 1999). The DSPD programme was inspired by the Dutch TBS system (De Boer et al., 2008) and is targeted for high-risk offenders with personality disorder, to be eligible for this programme an individual have to meet all of the three criteria. Firstly, a Psychopathy Checklist-Revised (PCL-R) score has to be over 30, or between 25-30 plus at least one DSM-IV personality disorder diagnosis (other than antisocial personality disorder) or two DSM-IV personality disorders. Second, they are more likely than not to re-offence within five years and that offence would cause serious physical or psychological harm to victim whom would find it difficult or impossible to recover. Thirdly, their risk of re-offending should be linked to significant personality disorder (DSPD Programme, 2005).

There are four pilot sites including two special hospitals and two high security (Category A) prisons in England take part in the assessment and treatment of the DSPD programme. The first high-security prison is HMP Whitemoor and then it has subsequently extended to another high-security prison HMP Frankland. After that are the two special hospitals, Broadmoor and Rampton Hospitals.

No doubts that one of its key aims is to increase public protection, however the effectiveness of it have been questioned by different group of people. Over many years, this group of people were standing at the boundary of the criminal justice system and the health systems, whether we should treat them as a prisoner or a patient is questionable and confusing. If it is dealing with prisoners the role of the system acts as a punishment to them with an aim of safeguarding in order to enhance public safety; whereas if we treat them as a patient we will have to provide services dealing with their mental issues and the goal of the programme is to assist in their therapeutic recovery. It is one of the reasons why it would be challenging in dealing with this group of offenders, do we simply punish them or do we seek to understand their needs that lead them to offend and to tailor made the treatment programme to treat them?

There is a wide range of treatments for personality disorders people, the DSPD programme mainly use Cognitive Behaviour Therapy (CBT) in the treatment programme along with some other emotional regulation therapies such as anger management, sexual offending programmes, motivation, psycho-education and so on (Ministry of Justice, 2011). Existing theoretical and empirical evidences shown that cognitive-behavioural treatments are the most effective programme (McGuire, 1995; Maden, 2007); it is believed that offenders have learned inappropriate ways of behaving and their values and beliefs may support those antisocial behaviour, therefore by addressing their beliefs and thinking, new ways of controlling their behaviour can then be developed (McGuire, 2002). However whether it is one specific therapeutic approach that is effective or it is other factors that contributed to the effectiveness are remains to be evaluated.

Is DSPD successful?

Many researches have been conducted to review the successes and failures of the DSPD programme, as it is a pilot scheme programme, its effectiveness and its cost highly determined and affect in the future planning or programmes. But how do we define ‘successes’ among DSPD programme? By looking at the re-offending rate after releasing those offenders or by looking at their recovery from personality disorder? Among all the criticisms, they can be grouped in the following areas:

  1. Planning & hypothesis

First of all, in one of the review articles it states that public protection is the main agenda of the DSPD programme. Although it was not surprising to have this objective in planning treatment for severe offenders with personality disorder, it was suggested that it should not be the main motive (Tyrer et al, 2010). Duggan (2011) also found there is a natural tension between combining treatment and public protection (Duggan, 2011). It is true that if the agenda is to increase public protection then there is no need to have such programme established with such a high cost, keeping them in prison would have reached the objective equally and even with a much lower cost. Hence the DSPD programme has been challenged as being neither a criminal concept nor a clinical one (De Boer et al., 2008) and it is fundamentally subjective (Corbet, 2005).

Second, the hypothesis of higher costs would lead to better outcomes was not significant, though it was believed that by improving their quality of life it would make a different yet the outcomes shown it was not (Barrett et al., 2009; Barrett & Tyrer, 2012). The fact is that the DSPD patient group have a very low treatment readiness and hence the effectiveness on this patient group is more difficult to be seen (Howells & Day, 2007; Ward et al, 2004). Even though the Ministry of Justice has been defending the DSPD shows evidence of warehousing, some researches shown that the amount of those patients’ time spent in related to therapeutic activities were little (Barrett et al, 2009; Barrett & Tyrer, 2012; Tyrer et al, 2009).

  1. Assessment and diagnosis

The criteria of the DSPD programme has been critiqued as the screening for those offenders with a severe personality disorder was lacked of scientific reliability and have even ignored some empirical work (Duggan, 2011). It was argued that in preventing future dangerous behaviour, the offenders’ criminological and impulsive characteristics play a more important role than the personality features itself (Yang, Wong & Coid, 2010). In addition, in reviewing the effectiveness of the programme, the numbers of patients or prisoners included in the DSPD programme was indeed inadequate (Barrett et al, 2009; Tyrer et al, 2009). And the reliability of the assessments in full DSPD programme was relatively low, in order to be qualified for the DSPD programme, their PCL-R scores have to be at least 25 or above with one (or more) personality disorder classified under the DSM-IV, however the statistics shown that about 25% was discordance (IMPALOX Group, 2007)[1].

Thirdly, in regard to the assessment and diagnosis area was that the assessment period appeared to be longer than expected. It was initially planned to be 16 weeks and was increased up to 20 weeks later on, yet it turned out the average length of time for DSPD assessment was 24 weeks (Barrett & Tyrer, 2012). The delayed for the assessment means the extension of the length of their stay for patients, and in calculating the cost-effectiveness of the whole programme it would be increasing the whole cost per individual. REFERENCES?

Another criticism was that the word dangerousness is a tricky term, from different perspective it can be interpreted differently. For example, from the legal perspective, dangerousness is viewed as a relatively enduring characteristic of an individual (Pollock & Webster, 1990). Yet from the clinical perspective, dangerousness has been considered to be “a propensity to cause serious physical injury or lasting psychological harm” (HMSO, 1975). Apart from that the diagnosis of personality disorder has also been critiqued as a failure because there were no satisfactory measurements of dangerousness (Tyrer et al., 2010). Therefore not only is it important to distinguish the differences between legal and clinical dangerousness, it is also important to have satisfactory measurements of it.

  1. Staffing

Another area of criticisms was related to staffing issues, as the therapeutic relationship hold a key element in all the therapies, it is the same within the DSPD programme. However the staffing levels within the DSPD programme have not been satisfying, the difficulties of recruiting and retaining suitable staff have directly affected the occupancy numbers in each of the four sites, particularly Broadmoor Hospital suffered a net loss of 22 staffs within one of the research study period and it is also the only unit of which mean core therapy staffing levels fell below the baseline levels (Ministry of Justice, 2011). This atmosphere and high turnover of staffing was in fact implying the gap between their expectations and the exact job duties, moreover the shortage of staff is indeed increasing the stress of the current staffs within the programme, research shown that Broadmoor staffs had a significantly higher ‘psychological demand scores’ than those in the other three sites (Ministry of Justice, 2011).

In addition to the staffing level, the staffs themselves were not confidence enough about the assessment and hence it rose as another disadvantages within the randomised trials (Tyrer et al., 2009). The treatments for antisocial personality disorder (which is the nearest to DSPD) is still very new and does not seems to be helpful to deal with patients and offenders who have the most severe form of personality disorder (Tyrer et al., 2010). Given that the treatment for antisocial personality disorder patients is still at its early stages of development, it seems to be more challenging for the DSPD programme to have benefited from it and staffs maybe confused on the methodology being applied, in other words the consistency is not guaranteed as well and should be reviewed in the future (Ministry of Justice, 2011; Tyrer et al., 2010).

  1. Outcome evaluations

Outcome evaluation was one of the main critiqued among all the reviews of the DSPD programme. Firstly, in order to have an accurate evaluation, there should be a follow-up period of time to ensure the outcome can be validated, which means those offenders have to be given an opportunity to reoffend, however for the DSPD programme it is not what can be done and therefore they have to depend on the intermediate outcome measures to find out the outcome of the programme (Barrett & Tyrer, 2012).

Moreover, it is difficult to decide when is the best time to move an individual from the DSPD service to a lower level of security treatment cite, various definitions were made about the appropriate ‘treatment’ however it was suggested that a reduction in the quantity of treatments shall be considered to use on the same patient group in order to increase the accuracy of testing the effectiveness of that particular treatment (Burns et al., 2011).

In addition, in one of the assessment of the experience of patients and prisoners, most of them shown negative perceptions of the programme regardless the facts that they have received more attentions from both the officers and medical staffs (Tyrer et al., 2010). It was expected that patients who took part in this programme would show less aggression, better functioning and a better quality of life, but to be fair, some of the aggression happened within the programme was in fact a consequence of frustration that they faced at the early stage of the programme (Tyrer et al., 2009). For example, the inadequate level of staffing lead to a longer wait for assisting their wants and/or needs; the prolonged assessment as a result extend their lengths of stay in the prisons or special hospital, and so on. These factors are causing distressed to them and shall take into account in the future management planning.

Finally, it is important to highlight the fact that those who admitted to the DSPD services were in fact the group of the most challenging group to manage, they were either resistant to any intervention or they were very aggressive and difficult to manage in lower secure settings (DSPD Programme, 2005), therefore in evaluating the effectiveness of the programme, it should also assess whether the treatment programme is creative and innovative enough working with these group of individuals.

Apart from the above four main areas of criticism about the DSPD programme, many have challenged on the cost of the programme (Barrett et al, 2009;Barrett & Byford, 2012; Barrett & Tyrer, 2012; Chambers et al., 2009; Tyrer et al, 2010). It is not surprising to know that the cost of managing an individual in the DSPD programme is higher than in the prison, especially for the two special hospitals, the average cost is almost four times the cost of treatment in prison (Barrett & Tyrer, 2012). Given that the cost for the programme is very high, it is understandable to have such a great debate on its effectiveness and outcome evaluation as people would have high expectations from it.

Although the effectiveness of the DSPD programme has been challenged from different perspectives, there are also successes contributions that the DSPD programme has made.

First of all, the programme has targeted a group of individuals who have been neglected or ignored by the psychiatrists (Duggan, 2011; Tyrer et al., 2010). Most of the countries dealing with dangerous and severe person with personality disorders are just locking them up and to protect community safety but did not provide any treatments. Apart from Netherlands, in which they have been using a system to keep those personality disorder offenders in a secure setting as long as providing treatment to them (De Boer & Gerrits, 2007). This system will be discussed later in this article.

Another achievement for the DSPD programme was that it has enhanced the development of treatment and personality services in England for this patient group. Since this programme was introduced, various treatment programmes have also been presented with the same goal of preventing re-offending and managing distress (Tyrer et al., 2010).

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[1] Appendix 1: Agreement between PCL-R scores for DSPD prison assessments and IMPALOX assessments in 33 prisons in trial

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