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The Edenfield Centre, Prestwich Hospital, Bury New Road, Prestwich Hospital, Manchester M25 38L
Fromeside Clinic (MSU), Bristol
See editorial, pp. 282-283, this issue. 
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Abstract |
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To canvass the opinions of psychiatrists working in forensic settings on the recent proposals relating to dangerous people with severe personality disorder (DSPD). Psychiatrists from secure settings were invited to a series of meetings. A questionnaire was circulated and the discussions recorded.
RESULTS
Opinion remains divided over diagnosis, treatability and assessment of risk in personality disorders. The medicalisation of DSPD to allow indeterminate detention in unconvicted cases is unacceptable to the majority (75%). There is no consensus on the Government proposals relating to DSPD. Only a minority (20%) of psychiatrists would work in a new specialist service, which has significant implications for service development.
CLINICAL IMPLICATIONS
The involvement of psychiatrists in preventative detention solely for public protection requires greater discussion.
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Introduction |
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In July 1999 a Government consultation paper (Home Office & Department of Health, 1999) introduced proposals for the minority of people with severe personality disorder who, because of their disorder, pose a risk of serious offending. Dangerous severe personality disorder (DSPD) was not defined in the document, but two options were proposed (see Box 1).
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Method |
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Results |
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Definition/assessment issues
Sixty-eight per cent (n=104) of psychiatrists felt confident in
their ability to diagnose personality disorder, but only 34.6% (n=53)
felt severe personality disorder was identifiably different. Seventy-one per
cent (n=109) were not confident in the interrater reliability of
personality disorder diagnosis. Of the 109 respondents who attempted to define
DSPD, 48 (44%) included ICD—10
(World Health Organization,
1992) or DSM—IV (American
Psychiatric Association, 1994) definitions of personality
disorder, 21 (19%) felt it was not systematically definable. Severity was
defined in a variety of ways, including: risk of offending (n=28;
26%); effect on functioning (n=23; 21%); number of traits of specific
personality disorder diagnoses (n=13; 12%); the number of personality
disorder diagnoses (n=12; 11%); lack of response to treatment
(n=10; 9%); and level of emotional instability (n=6;
6.5%).
The majority (125, 82%) reported that available risk assessment procedures are inadequate to reliably identify potentially dangerous individuals, and 70% (n=107) admitted that the Government proposals would make them more cautious about making a diagnosis of personality disorder. Many psychiatrists questioned the validity of the Government's estimate of the numbers involved, given the lack of clarity.
A total of 22.2% (n=34) felt that doctors should be involved in the assessment of personality disorder and 93% (n=142) saw a medical role in assessing for intercurrent mental illness. One-hundred (65.4%) reported that psychiatrists should be involved in risk assessments on DSPDs, but five respondents (3.3%) felt psychiatry has no role. Overall, 18.3% (n=28) believed psychiatrists should take a lead role in these services, 31% (n=47) thought that psychologists should be the team leaders.
Treatability
Eighty-three (54%) considered personality disorder in general as being a
treatable condition. Psychiatrists working in the South of England and in
Wales were significantly more likely than those in the North to hold this view
(66% v. 47%, 
2=4.975, d.f.=1, P=0.026).
Special hospital psychiatrists were also significantly more likely to consider
personality disorder treatable (66% v. 46%, 2=5.928,
d.f.=1, P=0.015). Considering those with severe personality disorder,
only 28% (n=43) reported that this group are treatable. Special
hospital psychiatrists were again significantly more likely to view severe
personality disorder as treatable (37% v. 22%,
2=4.172, d.f.=1, P=0.041). Many commented on the lack
of evidence that there are effective treatments for those at the extreme end
of the spectrum.
Nearly two-thirds (62.7%, n=96) objected to the removal of the
‘treatability criteria’ from civil powers to detain DSPDs. Those
viewing personality disorder as treatable were significantly more likely to
accept this (37% v. 13%, 2=11.797, d.f.=1,
P=0.001).
Services for those with DSPD
Most respondents (45.1%, n=69) believed that services for those
with DSPD should be the joint responsibility of the Home Office and the
Department of Health. Half (50.3%, n=77) of the sample believed the
key emphasis of services should be treatment, but 27.5% (n=42) felt
public protection should be the main focus. The majority (78.4%,
n=120) believed that DSPDs should be managed in units that are
separate from the units for those with mental illness. Fifty per cent
(n=77) felt that current facilities are satisfactory if given
sufficient resources.
The vast majority (88%, n=134) did not concur with the
Government's suggestion that the new units could be staffed by the current
workforce and only 21% (n=32) reported a willingness to work in DSPD
units. However, 58.2% (n=89) stated that they would undertake
assessments of diagnosis and risk in DSPDs. Those who believed personality
disorders were treatable were significantly more likely to show a willingness
to work in the new services for DSPDs (34% v. 6%,
2=18.026, d.f.=1, P=0.000).
The proposals
Overall, there was no consistent view as to which option is preferable.
Eighteen per cent (n=28) supported Option A, 21% (n=32)
Option B and 28% the Fallon recommendations (see
Box 1 and
Table 1), but 13% expressed a
preference for ‘no change’ in the current position.
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There was greatest disagreement over the proposed changes in civil legislation (Table 1). The notion that unconvicted DSPDs could be detained solely on the basis of public protection, rather than individual mental health, caused particular disquiet with some drawing parallels with the role of psychiatrists as agents of social control in the former USSR. Several commentators also suggested that the Government was ‘medicalising’ DSPD to achieve this.
For DSPDs involved in criminal proceeding, psychiatrists agree with the suggestion that there should be increased use of discretionary life sentences as suggested in Option A. Many commented that the necessary legislation to detain convicted individuals with DSPD already exists in criminal justice legislation, but that judges have been reluctant to utilise it. Furthermore, many pointed out that indeterminate medical detention without effective treatment might be in direct conflict with the General Medical Council (GMC) guidelines (1998) stated in Duties of a Doctor.
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Discussion |
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This survey illustrates the continuing concern over the lack of clarity in the term DSPD. Most psychiatrists are aware of the low level of agreement over personality disorder diagnoses, even using structured interview schedules. Furthermore, they are uncomfortable with the concepts of severity and dangerousness. While the North American literature on violence risk prediction suggests that instruments such as the Psychopathy Checklist—Revised (PCL—R; Hare, 1991) and Historical, Clinical, Risk Management (HCR—20; Webster et al, 1995) are useful, they are not fail safe (Douglas et al, 1999). Our study shows that psychiatrists advise caution when diagnosing severe personality disorder.
There is the further issue that DSPD is ill-defined, meaning the figures cited in the Government document may be inaccurate. The numbers detained will undoubtedly grow as admissions outpace discharges given the emphasis on public protection.
Many felt that any doctor involved in the detention of these individuals for public protection alone would potentially breach the GMC's guidelines (1998) that state "make the care of your patient your first concern", and that doctors are abusing their professional position if they "give patients, or recommend to them, an investigation or treatment which you know is not in their best interests". Advice from the GMC may be welcome at this time.
The majority of respondents believed that sentencing and detention should fall within the remit of the courts and that psychiatrists should restrict themselves to assessments of suitability for specific interventions. There is clearly and rightly more reservation over the contribution of psychiatry in those with a primary diagnosis of antisocial personality disorder. This is based on extensive literature that suggests that antisocial personality disorder with high PCL—R scores (Hare, 1991) does appear to benefit from current therapeutic strategies (Losel, 1998). Although there is evidence that some individuals with personality disorder can benefit from treatment in therapeutic communities it must be recognised that these programmes generally only take on those who are willing and likely to benefit from the treatments available.
The low numbers of psychiatrists willing to work in DSPD services seems likely to create significant recruitment problems. Furthermore, these units may become isolated and standards could be hard to maintain. The survey findings, however, do suggest that a substantial number are willing to assess individuals for these units. A split between those assessing and those treating personality disorder may cause problems. The concept of preventative detention in health care settings of those who had not been convicted and are untreatable is considered unethical practice (Mullen, 1999).
The role of psychiatry in the assessment and treatment of personality disorders has always been controversial (Collins, 1991; Cope, 1993; Moran, 1999) and this is likely to continue in the absence of a sound research base.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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COLLINS, P. (1991) The treatability of psychopaths. Journal of Forensic Psychiatry, 2, 103-110.
COPE, R. (1993) A survey of forensic psychiatrists' views on psychopathic disorder. Journal of Forensic Psychiatry, 4, 215-235.
DOUGLAS, K. S., COX, D. N. & WEBSTER, C. D. (1999) Violence risk assessment: science and practice. Legal and Criminological Psychology, 4, 149-184.
EASTMAN, N. (1999) Public health psychiatry or crime
prevention? British Medical Journal,
318,
549-551.
GENERAL MEDICAL COUNCIL (1998) Duties of a Doctor. London: GMC.
HARE, E. H. (1991) The Hare Psychopathy Checklist—Revised. Toronto: Multi-Health Systems.
HOME OFFICE & DEPARTMENT OF HEALTH (1999) Managing Dangerous People with Severe Personality Disorder: Proposals for Policy Development. London: Stationery Office.
LOSEL, F. (1988) Treatment and management of psychopaths. In Psychopathy: Theory, Research and Implications for Society (ed. D. J. Cooke), pp. 303-354. The Netherlands: Kluwer Academic Publishers.
MORAN, P. (1999) Antisocial Personality Disorder. An Epidemiological Perspective. London: Gaskell.
MULLEN, P. E. (1999) Dangerous people with severe
personality disorder: British proposals for managing them are glaringly wrong
— and unethical. British Medical Journal,
319,
1146-1147.
WEBSTER, C. D., DOUGLAS, K. S., EAVES, D. et al (1995) The HCR-20 Scheme. The Assessment of Dangerousness and Risk. Vancouver: Simon Fraser University & British Columbia Forensic Psychiatric Services Commission.
WORLD HEALTH ORGANIZATION (1992) The ICD—10 Classification of Mental and Behavioural Disorders. Geneva: WHO.
The Fallon enquiry. Report of ‘The Committee of Inquiry into the Personality Disorder Unit, Ashworth Special Hospital’ (1999) London: Stationery Office.
This article has been cited by other articles:
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  T. Seddon Dangerous liaisons: Personality disorder and the politics of risk Punishment Society, July 1, 2008; 10(3): 301 - 317. [Abstract] [PDF]
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 P. T Tyrer An agitation of contrary opinions The British Journal of Psychiatry, May 1, 2007; 190(49): s1 - s2. [Abstract] [Full Text] [PDF]
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 P. Moran Editorial: Dangerous Severe Personality Disorder Bad Tidings from the UK International Journal of Social Psychiatry, March 1, 2002; 48(1): 6 - 10. [PDF]
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 D. Chiswick Dangerous severe personality disorder: from notion to law Psychiatr. Bull., August 1, 2001; 25(8): 282 - 283. [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
