- 11 April 2007
- NewScientist.com news service
- Peter Aldhous
Whether you think of them as mad or bad, they are certainly dangerous to know. All societies contain a few extremely violent individuals, who are either psychopaths or have a related severe personality disorder. With no concern about the harm they inflict, little can be done to change their behaviour, psychiatrists say.
Now the UK government is challenging this dogma in the hope of protecting the public from these highly risky people. It has already altered criminal law to allow certain violent offenders to be given indefinite jail sentences. Over the coming weeks, parliament will debate legislation that could broaden the definition of mental disorders and increase existing powers to detain such people for treatment (see "Doctors or jailers...", below).
Meanwhile, the government is rolling out an unprecedented treatment and research programme aiming to show it is possible to reduce the risks posed by the most dangerous violent offenders. Just like the changes to the law, the "Dangerous People with Severe Personality Disorder" (DSPD) programme is highly controversial. However, even critics concede that it holds the best chance yet of showing whether violent psychopaths can be reformed - and so psychiatrists worldwide will be watching.
Every country faces the dilemma of how to manage violent people with personality disorders, who are resistant to conventional treatments. The UK government's determination to address the issue stems in part from a brutal double murder in 1996, in which Lin Russell and one of her young daughters, Megan, were bludgeoned to death with a hammer. Michael Stone, a violent man with a history of drug abuse, was later convicted. He had been in and out of prison, and also diagnosed with antisocial personality disorder (ASPD), a pervasive disregard for the rights of others. Considered untreatable in hospital, he was left at large.
The case threw a spotlight on personality disorders, one of the most contentious areas of psychiatric medicine. These are enduring patterns of thought and behaviour that deviate markedly from cultural norms. There are many forms, and while most people with a personality disorder are not dangerous, some who - like Stone - are diagnosed with ASPD show a propensity for violence.
ASPD is related to psychopathy, but psychopaths must also exceed a score of 30 in a checklist called the PCL-R. They are rare, making up perhaps 0.5 per cent of the UK population, and are manipulative, lack empathy and disregard social obligations. Yet psychopaths and people with ASPD are not necessarily violent. To muddy the waters still further, the diagnostic criteria for some personality disorders overlap, and people may suffer from several at once.
In deciding which violent offenders to treat under the DSPD programme, UK officials therefore had to devise a complex set of criteria to define exactly what dangerous and severe personality disorder is (see "Defining DSPD"). This definition has come under widespread attack. "It's an amalgam of clinical disorders that makes no sense as a diagnostic category," says Robert Hare of the University of British Columbia in Vancouver, Canada, who devised the PCL-R checklist. In particular, he queries its potential to include people who may neither be psychopaths nor fit a diagnosis of ASPD.
The DSPD criteria also require that an offender's dangerousness is linked to their personality disorder. While it is possible to assess someone's likelihood of committing further violence, attributing this risk to an underlying disorder is difficult, as people can be violent for many reasons. "There is no accepted way of establishing that link," says Jeremy Coid, a forensic psychiatrist at the Wolfson Institute of Preventive Medicine in London.
UK government officials acknowledge the criticisms, but say that treatments are individually tailored, and focus on reducing the risk of reoffending rather than trying to effect a cure. Government officials also say that the difficulty of treating severe personality disorders should not become an excuse for not tackling the problems that they cause.
About 130 people who have committed serious violent offences are enrolled in the DSPD programme, which is based in specialist units at two prisons and two secure hospitals. It should eventually include 300 subjects, and the programme's success will be evaluated by a team led by Tom Burns and Jenny Yiend of the University of Oxford. They will examine subjects' attitudes, emotional regulation, and other factors that can vary with treatment, to estimate the risk of further violent offences. Burns and Yiend expect to have initial results by 2009.
One DSPD treatment project in particular, which specifically focuses on psychopaths, is attracting interest from forensic psychiatrists. Psychopaths at a specialist unit within Frankland prison in Durham, UK, are being subjected to the most intensive treatment plan yet devised. Known as Chromis, it employs individual and group therapy to try to shift ingrained patterns of thought and behaviour. Rather than just relying on short sessions of therapy, it recruits the entire staff of the unit to turn prisoners' lives into a continuous exercise in cognitive-behavioural therapy.
Chromis pays particular attention to engaging psychopaths by identifying things they want from life that might be obtained by taking part. This focus on "what's in it for me" may be vital, because psychopaths typically see no problem with their behaviour. "Most of the time they just refuse treatment," explains Sheilagh Hodgins, head of forensic mental health science at the Institute of Psychiatry in London. "If they do take part, they tend to take over and disrupt it."
Although still in its pilot stages, psychiatrists familiar with Chromis say that no other project has a better chance of challenging the notion that violent psychopaths are beyond help. "If, with the resources they're throwing at it, they don't get a change, it will be very discouraging," says Hodgins.
From issue 2599 of New Scientist magazine, 11 April 2007, page 8-9
Offenders are eligible for treatment under the UK's DSPD programme if they are deemed more likely than not to commit a future offence that could cause serious harm from which a victim would find it difficult or impossible to recover. They must have a severe personality disorder, and there must be a link between that disorder and the risk of violent offending. "Severe personality disorder" is:
- A Score of 30 or above on PCL-R, the checklist used to assess psychopathy.
- A PCL-R score of 25 to 29, plus diagnosis of at least one personality disorder other than antisocial personality disorder.
- Two or more personality disorders.
Doctors or jailers...
In 1999, the UK government released a consultation document that had civil liberties campaigners and psychiatrists up in arms. "Managing Dangerous People with Severe Personality Disorder" proposed using mental health law to detain such people on the grounds of public protection, whether or not they had actually committed a crime.
After years of acrimonious debate, the Mental Health Bill now before parliament has retreated from this goal. Instead it broadens the definition of mental disorder and removes the "treatability" test that would allow psychiatrists to detain someone only if they were likely to benefit from treatment. In its place is a looser requirement that "appropriate treatment" should be available.
The UK's Mental Health Alliance, which represents 79 organisations, opposes the bill, arguing it could be used to detain a wide variety of people - not just those posing a risk to the public or to themselves. "There is every reason to believe that these new broad powers will also be used on other groups of people for whom detention is not the best option," says Andy Bell, who chairs the alliance.
The House of Lords amended the bill in response to such complaints, but the government intends to push the original version through the House of Commons. "The accusation that... the 'appropriate treatment' test will turn doctors into jailers is nonsense," a Department of Health spokeswoman told New Scientist.
The condition known as dangerous and severe personality disorder has, in fact, no legal or medical basis. Yet the government is pouring £126m over three years to develop a variety of DSPD services. David Batty explains
What is dangerous and severe personality disorder?
Personality disorder refers to patterns of behaviour or experience resulting from a person's particular personality that differ markedly from those expected by society and lead to distress or suffering to that person or to others. The government first introduced the term DSPD in a consultation paper Managing Dangerous People with Severe Personality Disorder in 1999, which proposed how to detain and treat a small minority of mentally disordered offenders who pose a significant risk of harm to others and themselves. Specialist services to deal with these people, most of whom are thought to be serious violent and sex offenders, were proposed in the white paper Reforming the Mental Health Act in December 2000.
What are the traits associated with DSPD?
The condition's characteristics have yet to be clearly defined. But it is thought to be an extreme form of antisocial personality disorder (ASPD) - the diagnosis most commonly associated with psychopathy. The key traits of ASPD include failure to make intimate relationships, impulsiveness, lack of guilt, and not learning from adverse experience. 'Psychopathic disorder' is a legal term used in the current mental health legislation to refer to people who have "a persistent disorder or disability of mind... which results in abnormally aggressive or seriously irresponsible conduct."
How many people have DSPD?
The white paper to reform the mental health act states that 2,00-2,400 people in England and Wales are estimated to have DSPD, although some government officials say there are up to 2,500. According to the Home Office, about 1,400 are estimated to already be in prison. A further 400 are estimated to be patients in high security psychiatric hospitals, with between 300 and 600 at large in the community. About 98% of those with DSPD are believed to be men. However, with the new disorder's definition still unclear, many psychiatrists contend these figures are just speculation.
Where will people with DSPD be treated?
By 2004 there will be 300-320 high security places to detain, assess and treat DSPD. The 92-bed unit on D-wing at Whitemoor prison, Cambridgeshire, began assessing prisoners last September, offering treatment from March. Another 80 places will be provided at a newly built unit at Frankland prison, Durham, from early 2004. There will be 140 additional places for those with DSPD in special hospitals by April 2004. A new 70-bed unit at Rampton hospital, Nottinghamshire, is due to open in October 2003. Another unit will be built at Broadmoor hospital, Berkshire. DSPD services will also be set up at medium secure prisons and hospitals and in the community to treat and support those assessed as safe to be released or discharged. Community programmes are expected to be piloted in south London and the north-east.
How is DSPD diagnosed?
Assessment on the DSPD unit at Whitemoor high security prison lasts 14 weeks. Inmates undergo psychometric tests to assess their dangerousness and to measure the severity of their personality disorder. They also have a series of interviews with a psychiatrist, while care staff record how disturbed and challenging their behaviour is from day to day. The clinical team then evaluates whether a connection can be made between dangerousness and severe personality disorder by examining the inmate's past and current offending behaviour and how they interact with other prisoners and staff. Jamie Bennett, head of the Whitemoor DSPD unit, said prisoners would need a long history of sex or violent offences to meet the criteria.
What treatment is there for DSPD?
Inmates at Whitemoor and Rampton receive a psychological therapy called dialectical behavioural therapy (DBT), which aims to help them respond to everyday situations in a problem solving manner rather than emotionally and aggressively. This more positive mindset should enable them to take part in rehabilitation programmes, such as reoffending reduction courses. However, DBT has predominantly been used to treat women with borderline personality disorder who deliberately harm themselves and there is little evidence it will prove effective in helping those with DSPD.
What prompted the DSPD programme?
Much of the impetus for the DSPD programme has come from high-profile cases such as that of Michael Stone, who in 1996 attacked Josie Russell and killed her mother and sister several years after his personality disorder was deemed untreatable. The Home Office regards those with DSPD as "a group hitherto poorly served by criminal justice or mental health services" and believes "the serious nature of the crimes they typically commit has a disproportionate impact on the public's fear of crime." The Mental Health Act 1983 only allows people to be committed to hospital where psychiatrists believe the person is treatable and many do not believe personality disorder is. But proposed reform of the mental health act would allow detention of people with PD - even, in some cases, if they had committed no crime.
How much will the programme cost?
The government has set aside £126m over three years to develop high security, medium security and community DSPD services. The prison service has been allocated £70m and the NHS £56m. Although Home Office officials were unable to estimate treatment costs in high security settings, Dr Ian Keitch, head of DSPD at Rampton, said treatment at the hospital was projected to cost £180,000 per bed per year. Although this is £30,000 more than current treatment costs for patients believed to have DSPD, Dr Keitch said this was less than treatment costs for female self-harmers - £200,000. However, he admitted the cost could not be justified on current evidence. Peter Tyrer, professor of community psychiatry at Imperial College, said a £2m three-year research programme to assess the effectiveness of the treatment programmes, should lead to improved cost efficiency.
Why is the term so controversial?
DSPD currently has no legal or medical basis and many doctors regard it as a political invention. A survey of nearly 1,200 psychiatrists published in the British Journal of Psychiatry in 2000 found almost two-thirds disagreed with the plan for detaining people with personality disorders, and almost a third said they might boycott it. There is no firm evidence base for the disorder or the new assessment and treatment programmes. The Royal College of Psychiatrists says there is no "entirely satisfactory" diagnosis of antisocial traits that threaten public safety. A recent study in the Lancet warned DSPD is so vaguely defined that six people would have to be detained to prevent one from acting violently, raising major concerns about civil liberties.
Dangerous Severe Personality Disorders: England's Experiment in Using Psychiatry for Public Protection
Paul S. Appelbaum, M.D.
Oscar Wilde, writing in the late 19th century, noted that England has "really everything in common with America nowadays except, of course, language." Were one of Wilde's literary descendants to update that comment today, he might add "and mental health law." Despite a shared common law tradition, England and the United States have gone their own ways in recent decades with regard to such issues as civil commitment and the impact of mental illness on sentencing (1). But England (along with Wales) is now embarking on an experiment in using psychiatry as an instrument for the control of dangerous persons that it behooves us on this side of the Atlantic to watch with care.
In the late 1990s, England set in motion a process to revise its current commitment statute, the Mental Health Act 1983 (2). American psychiatrists who read the 1983 act will be reminded of the pre-1970s statutory framework in this country. Persons with mental illness can be involuntarily hospitalized on the grounds that "it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained" (part 2, section 3). "Health or safety" is interpreted in practice to include the mental health of the person, essentially embodying a "need for treatment" approach to commitment criteria (3). Commitment can be effected by the attestation of two physicians that the criteria have been met, and review is provided by a mental health tribunal only if requested by the patient (part 5, section 66), a process that only a minority of patients pursue.
An unusual aspect of the English law lies in its definition of what conditions constitute a mental disorder that renders a person eligible for involuntary hospitalization. The statute specifically includes "psychopathic disorder," which it defines as "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned" (part 1, section 1). U.S. statutes uniformly avoid explicit inclusion of psychopathy or its cognate conditions (sociopathy and antisocial personality disorder), and American psychiatrists generally view psychopathic patients as untreatable and hence unsuitable for hospital admission. But British psychiatrists have been more optimistic about their ability to treat at least some persons with "psychopathic disorder" and more willing to use their facilities to do so. To prevent English psychiatric hospitals from being flooded with unruly and untreatable psychopaths, the statute requires that "in the case of psychopathic disorder or mental impairment, such treatment [to be provided as a consequence of hospitalization] is likely to alleviate or prevent a deterioration of his condition" (part 2, section 3a)the so-called "treatability" criterion.
One of the most contentious questions to arise as the process of revising the Mental Health Act has unfolded involves the government's proposal to expand the use of psychiatric facilities for the treatment of psychopathy and similar conditions. Largely ignoring the recommendations of an expert panel it had appointed in the late 1990s (4), the government issued a series of documents laying out the approach that it proposed to take. In a 2000 "white paper" to which responses were invited, the government described a new category of persons"dangerous people with severe personality disorders (DSPD)"for whom broadened commitment criteria were proposed (5). Citing public protection as one of the key priorities of any reform, the white paper noted that "[i]ndividuals who present a risk to others because of their severe personality disorder are rarely detained under the Mental Health Act 1983 because they are assessed as being unlikely to benefit from the sorts of treatment currently available in hospital" (5, part 2, page 9). This was the loophole that the proposal sought to close. Thus the government indicated its intent to develop legislation that would eliminate the treatability criterion for the commitment of persons with personality disorder, allowing involuntary hospitalization solely for the purpose of managing the problematic behaviors presented by these persons.
Psychiatrists and other groups concerned with the mental health system in England mounted an immediate attack on the government's proposal. A survey of British psychiatrists found 62 percent opposed to the plans and only 20 percent in favor; moreover, 31 percent of respondents indicated that they would refuse to implement new legislation that included the controversial provisions (6). The Royal College of Psychiatrists, in its formal response, expressed concern about the conversion of psychiatrists and psychiatric facilities into instruments of social control, without therapeutic intent, and about the accuracy of long-term predictions of dangerousness on which detention of dangerous persons with severe personality disorders would be premised (7). Additional concerns were raised about the lack of an evidence base for treatment of this population (8). Critics waited with trepidation for the introduction of formal legislation to implement the proposal.
When a draft bill finally appeared in 2002, it was clear that the government had decided to downplay the white paper's focus on public protection and the DSPD population (9). Indeed, no specific mention was made of the DSPD group. But the key pieces remained in place for the government's proposals to be implemented. A broad and essentially circular definition of mental disorder was introduced: "any disability or disorder of mind or brain which results in an impairment or disturbance of mental functioning" (part 1, section 2). Although a variant of the previous treatability language was retained, its impact was reduced by broadening the definition of treatment to include "nursing, care, habilitation (including education, and training in work, social, and independent living skills), and rehabilitation" (part 1, section 2). As a consequence, just about anyone who could be said to have a mental disorder, psychopaths included, for whom basic care or training would be provided, would probably qualify for commitment under the new law.
In response, more than 50 organizations, including the Royal College, formed the Mental Health Alliance to lobby against the act, and more than 1,000 protesters marched to Parliament to oppose the bill's passage (10). Thousands of comments were received from critics of the proposed law. With the bill's forward motion stalled, the government rethought its approach and came back in late 2004 with a revised draft (11). Although the key definitions of mental disorder and treatment were modified, they remain problematic in precisely the same ways and continue to leave the door open to use of commitment powers for essentially untreatable persons with personality disorders. British psychiatrists and other stakeholders remain opposed to these aspects of the bill, which at this writing is being reviewed by a specially appointed joint committee of the houses of Parliament.
Legislation, of course, is not the only waynor, often, the best wayto change behavior. During the tumultuous, and so far unsuccessful, process of revamping England's mental health act, the government has taken significant strides toward its goal of increasing the use of psychiatric detention for dangerous people. A joint program of the Home Office (which oversees the prison system) and the Department of Health has been established to develop services for dangerous persons with severe personality disorders under the ambit of existing legislation (12). High-security units are being opened in two prisons and two forensic hospitals, with a total of 300 beds, to accommodate referrals from the penitentiaries and psychiatric hospitals, respectively. Criminal law has been modified to permit indefinite detention of persons who are thought likely to represent a continuing serious threat, and it seems probable that much of the DSPD population for the prison facilities will be drawn from this group. To be eligible for the DSPD program, a person must have a severe disorder of personality that renders him or her "more likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover (12)." Treatment programs are being developed.
Regardless of the outcome of the debate over the new Mental Health Act, then, England seems determined to move dangerous persons with severe personality disorders into psychiatric facilities. The opposition of the psychiatric profession and many other groups has not been able to stop this response to the perceived risks to public safety. But the critics have offered some potent objections that the government does not seem to have persuasively countered. Identification of persons who are likely to commit violent acts in the future is a fraught process, despite the new assessment instruments on which the DSPD program is relying. Given the low base rate of violence in society, even relatively accurate assessment will result in large numbers of persons who are falsely identified as at high risk of violence. The British government estimates that up to 2,400 people in England and Wales would meet its DSPD criteria, eight times more than the facilities under construction could begin to accommodate, and a figure that does not take into account the problem of false-positives.
Difficulty in identifying persons who are at risk of continuing violence will not be limited to the initial assessment process. The newly built facilities risk rapid "silting in" as they fill with committed patients to whose readiness for release no one may ever be prepared to testify. However hopeful the administrators of the new program may be with regard to the effectiveness of treatment, they are sailing out onto largely uncharted waters where the public may be highly intolerant of error. Thus even the substantial amount of funding now being provided for constructing and staffing the new facilities is unlikely to be sufficient, as more secure settings become necessary. Persons who are concerned with the mental health system in England as a whole express understandable alarm over the consequences for the vast majority of persons who are in need of psychiatric treatment, as resources are diverted to a small group that is not likely to benefit from care.
Moreover, the question of fairness cannot be avoided. In contrast with persons who are transferred to the new units from prisons, those who are committed from the mental health system may never have been convicted of a crime. Nonetheless, on the basis of a prediction of uncertain validity about their future behavior, they face indefinite detention without strong prospect of therapeutic gain. Psychiatry's collaboration with this process risks corrupting its treatment orientation and making the field subservient to the government's public safety agenda.
Here in the United States, we have taken tentative steps down a similar road. Our statutes in many states that allow civil commitment of sex offenders who have completed their prison sentences are analogous to the English proposals, although less extensive in scope. We might want to pause on our journey to watch the results of the process developing across the Atlantic. As different as our two nations may be, there seems little reason not to learn from the English experience.
This is the text of the Dangerous People with Severe Personality Disorder Bill, as presented to the House of Commons on 14th March 2000.
Dangerous People with Severe Personality Disorder Bill
ARRANGEMENT OF CLAUSES
This directory - created by an approved social worker and team manager for a community support andmental health team in West Lancashire - covers the Mental Health Act, mental health law and related matters. A comprehensive archive of mental health policy and legislation in England and Wales, including reports and inquiries, clinical research, policy briefings and news. There are directories on severe personality disorder and mentally disordered offenders. Updated regularly.
Official information on the DSPD (dangerous severe personality disorder) programme
This website provides information about the government's controversial treatment programme for people with severe antisocial personality disorders, commonly known as psychopaths. It provides regular updates on the project's development in prisons, secure hospitals and the community, with news, research and details of conferences.
Home Office proposals for dealing with high risk patients.
Proposals for policy development.
Scotland's approach to mentally disordered offenders
National programme on forensic mental health research and development. The programme aims to develop research on forensic mental health issues, such as special hospitals and treating personality disorder.
The institute brings together 11 academic departments, covering criminology, forensic psychiatry and nursing, from England and Wales to develop research and produce reports on severe personality disorder.
Responses to the government's plans for dangerous mentally disordered offenders
First report on DSPD proposals.
Summary of consultation proposals.
Response to the white paper on reform of the Mental Health Act 1983.
Parliamentary briefing on DSPD (January 23 2001).
Understanding prejudice and discrimination against people with mental illness (1997). An online version of the Royal Society of Medicine's psychiatry section lecture programme on the stigmatisation of people with mental illness.
This paper concerns psychiatrists' ambivalence about whether personality disorders constitute medical conditions and considers how treatable they are.
Clear and detailed information of the types, diagnosis and treatment of personality disorders.