Part 1 book “Forensic psychiatry - Clinical, legal and ethical issues” has contents: Criminal and civil law for the psychiatrist in england and wales, mental health and capacity laws including their administering bodies, mental health and capacity laws including their administering bodies, forensic psychiatry and its interfaces outside the UK and Ireland,… and other contents.
Edited by John Gunn Pamela J Taylor forensic Psychiatry clinical, legal and ethical issues Second Edition Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business K17373.indb 3/31/14 6:16 PM CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Version Date: 20131004 International Standard Book Number-13: 978-1-4441-6506-7 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or 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advise and treat patients appropriately The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents List of Contributors ix Acknowledgementsxxiii Prefacexxvi Legislationxxxi List of Abbreviations xxxiii 1 Introduction Forensic psychiatry A victim-centred approach Context3 Medical language Achieving the knowledge and skills 16 Further enquiry 17 Criminal and civil law for the psychiatrist in England and Wales Common law and civil or Roman law 18 European courts 20 Court structure, England and Wales 20 Criminal law in England and Wales 20 Agencies of the law 48 Civil law 50 The Coroner’s court 53 Mental health and capacity laws including their administering bodies Preamble56 Human rights legislation 57 Historical background 57 Mental capacity 60 Mental Health Act 1983 amended by the Mental Health Act 2007 61 Mental Capacity Act 2005 (MCA) 77 Legal arrangements in the rest of the British Isles and Islands Preamble86 Scotland87 K17373.indb Northern Ireland 101 Military law in the United Kingdom 103 Isle of Man 105 Channel Islands 105 Republic of Ireland 106 Concluding comments 110 Forensic psychiatry and its interfaces outside the UK and Ireland The scope and limits of the comparative approach 112 The scope and limits of this chapter 112 National, subnational and supranational legal structures 113 Controversial issues and shifts in public and professional opinions 114 3/31/14 6:16 PM Contents Forensic mental health (FMH) services and interventions under criminal and civil law: Germany and the USA 116 Forensic psychiatric services and interventions under criminal and civil law: The Nine Nations (SWANZDSAJCS) Study 125 Specialist recognition in europe and swanzdsajcs countries 141 Research in forensic psychiatry, psychology and allied professions 143 Illustrative cases 144 Conclusions146 Further reading 146 Psychiatric reports for legal purposes in England and Wales The forum of the court: Background issues 148 Constructing a report 153 The use of reports in criminal proceedings 158 Civil matters 165 Examples of other documents which may be consulted 168 The psychosocial milieu of the offender Introduction170 Measurement and epidemiology 172 The natural history of offending 172 Factors associated with delinquency and offending 173 Explaining the development of offending 179 Implications for prevention 181 Conclusions184 8 Genetic influences on antisocial behaviour, problem substance use and schizophrenia: evidence from quantitative genetic and molecular genetic studies Introduction186 Basic genetics 186 Genetic study 187 The genetics of antisocial behaviour, problem substance use and schizophrenia 195 Conclusions210 9 Violence 10 Theoretical background 211 Violence as a health issue 217 Crimes of violence 229 Disordered and offensive sexual behaviour Sex offending, sexual deviance and paraphilia 244 Sex offending by females and adolescents 252 Psychiatric questions 252 Risk assessment 253 Sex offender treatment 256 Treatment or control 264 iv K17373.indb 3/31/14 6:16 PM Contents 11 The majority of crime: theft, motoring and criminal damage (including arson) Introduction266 Recording of crime 268 Acquisitive offending 269 Criminal damage 272 Arson272 Motoring offences 277 Overview279 12 13 Disorders of brain structure and function and crime Expectations and advances: Conceptualization and measurement of brain structure 283 Epilepsy in relation to offending 284 Sleep disorders 289 Amnesia and offending 292 Brain imaging studies as a route to understanding violent and criminal behaviour 297 Serotonergic function in aggressive and impulsive behaviour: Research findings and treatment implications 306 Implications of current knowledge of brain structure and function for forensic mental health practice and research 312 Offenders with intellectual disabilities Clinical and legislative definitions 314 People with intellectual disability detained in secure health service facilities in the UK 315 Crime and people with intellectual disabilities 315 Theories of offending applied to people with intellectual disabilities 316 Offenders with intellectual disabilities and additional diagnoses 317 Genetic disorders, intellectual disability and offending: Genotypes and behavioural phenotypes 319 Alcohol and substance misuse 324 Care pathways for offenders with intellectual disabilities 324 Assessment and treatment of anger and aggression 326 Assessment and treatment of sexually aggressive behaviour among people with intellectual disability 328 Fire-setting behaviour among people with intellectual disability 329 Assessment and management of risk of offending and/or harm to others among offenders with intellectual disabilities 330 Legal and ethical considerations in working with offenders with intellectual disabilities 331 Conclusions333 14 Psychosis, violence and crime Vulnerable to violence and vulnerable to being violent 334 Psychosis and crime: The epidemiology 336 Pathways into violence through psychosis: Distinctive or common to most violent offenders? 341 Psychosis, comorbid mental disorders and violence 345 Clinical characteristics of psychosis associated with violence 348 Environmental factors which may be relevant to violent outcomes among people with functional psychosis 354 v K17373.indb 3/31/14 6:16 PM Contents Management and treatment 357 Conclusions366 15 Pathologies of passion and related antisocial behaviours Erotomanias and morbid infatuations 367 Jealousy368 Stalking373 Persistent complainants and vexatious litigants 380 Conclusions382 16 17 Personality disorders Concepts of personality disorder 383 Personality disorder assessment tools 386 How common are disorders of personality? 389 Clinical assessment and engagement in practice 390 Causes and explanations of personality disorders 393 Treatment of personality disorder 398 Dangerous and severe personality disorder (DSPD): The rise and fall of a concept 413 Personality disorder: Some conclusions 417 Deception, dissociation and malingering Deceptive mental mechanisms 418 Pathological falsification 420 Dissociative disorders 424 Deception429 18 Addictions and dependencies: their association with offending Alcohol437 19 Other substance misuse 448 Pathological gambling 467 Juvenile offenders and adolescent psychiatry Juvenile delinquency 474 UK comparisons 480 Mental health 481 Pathways of care and the juvenile justice system 485 Government policy for England 488 Special crimes 494 Adolescent girls 496 Conclusions496 20 Women as offenders Why a chapter on women? 498 Women and crime 499 Women, mental disorder and offending 512 Services for women 515 Conclusions521 vi K17373.indb 3/31/14 6:16 PM Contents 21 Older people and the criminal justice system How many older offenders? 523 What sort of crime? 524 Associations between psychiatric disorder and offending in older age 525 Older sex offenders 526 Service and treatment implications 527 22 Dangerousness Introduction529 Theoretical issues 530 Risk assessment and structured judgment tools 533 Threat assessment and management 542 Communicating about risk 547 Risk assessment and management: Bringing it all together 548 Conclusions549 23 Principles of treatment for the mentally disordered offender Creating a therapeutic environment within a secure setting 552 Occupational, speech and language, creative and arts therapies in secure settings 558 Pharmacological treatments 558 Physical healthcare 567 Psychological treatments 568 Attachment and psychodynamic psychotherapies 579 Conclusions585 24 25 26 Forensic mental health services in the United Kingdom and Ireland Cycles in fear and stigmatization: A brief history of secure mental health services 589 Specialist forensic mental health services: Philosophies and a theoretical model 590 The nature of hospital security 592 Specialist community services within an NHS framework 606 Health service based forensic psychiatry service provision in Scotland 611 Health service based forensic psychiatry service provision in Northern Ireland 614 Health service based forensic psychiatry service provision in Ireland 616 Offenders and alleged offenders with mental disorder in non-medical settings Working with the police 619 People with mental disorder in prison 625 Working with the Probation Service 638 Working with voluntary agencies 646 Service provision for offenders with mental disorder in Scotland 651 Service provision for offenders with mental disorder in Northern Ireland 654 Offenders and alleged offenders with mental disorder in non-medical settings in Ireland 656 Ethics in forensic psychiatry Codes and principles 658 Teaching and learning ethics 660 Some contemporary questions 661 vii K17373.indb 3/31/14 6:16 PM Contents 27 Heuristic cases 671 The death penalty 677 Deviant and sick medical staff The medical power balance 680 Boundaries and offences 680 Abuse in institutions 682 Sexual assault 684 Clinicide and CASK 686 Commentary690 28 Victims and survivors Learning from victims and survivors 695 Voluntary and non-statutory bodies inspired by victims 706 The growing centrality of victims of serious crime in the criminal justice system 709 Reactions to trauma and forms of post-traumatic disorder 711 Psychological understanding of post-traumatic stress disorder 717 From victim to survivor: Help and treatment 724 From victims to survivors: Conclusions 731 Appendices Appendix 1: ECHR 732 Appendix 2: MHA 1983 735 Appendix 3: Experts’ Protocol 785 Appendix 4: Hippocratic Oath 792 Cases cited 795 References801 Index955 viii K17373.indb 3/31/14 6:16 PM List of Contributors Tim Amos, MA(Oxon), MSc, MB, BS, MRCPsych, DPMSA Senior lecturer in forensic psychiatry at the University of Bristol, consultant forensic psychiatrist at Fromeside, the medium secure unit in Bristol Previously Tim worked on the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Now involved in research studying homicide and violence linked to mental illness, suicide and self-harm; risk assessment and management; and the evidence in various areas of clinical practice in forensic mental health He has written a number of papers and book chapters Main contributor to chapter 11 Sarah Anderson, MSc., MPhysPhil Development officer for the charity Revolving Doors Agency which aims to improve systems and services for adults with poor mental health and multiple needs who are in contact with the criminal justice system Sarah has an MSc in criminal justice policy from the London School of Economics, where she was awarded the Titmuss Prize She also has an MPhysPhil in physics and philosophy from the University of Oxford She previously worked as a prison resettlement worker for the charity St Giles Trust and has been awarded a Churchill Fellowship to explore approaches to complex needs in Australia Contributor to chapter 25 Sue Bailey, OBE PRCPsych President, Royal College of Psychiatrists, professor of adolescent forensic mental health at the University of Central Lancashire Consultant, adolescent forensic psychiatrist Greater Manchester West NHS Foundation Trust Sue’s research and clinical practice have centred on evidence based service delivery to young offenders, developing age appropriate needs, risk assessments and innovative treatment interventions She has worked with governments to shape child centred effective policies to prevent antisocial behaviour in children by working with families and multi-agency teams Main contributor to chapter 19 Roger Bloor, MD, M.PsyMed, FRCPsych, DipMedEd A former RAF psychiatrist, Roger returned to the NHS in 1984 as a consultant with special responsibility for drugs and alcohol He was medical director of an NHS trust and senior lecturer in addiction psychiatry at Keele University Medical School until he retired in 2009 His research has been in a variety of addiction-related topics and he is co-author of several chapters in textbooks on addiction Roger is currently a teaching fellow at Keele and a part time consultant in addiction psychiatry with North Staffordshire Combined Healthcare NHS Trust Co-author of the illicit drug section, chapter 18 Frederick Browne, BSc(Hons), MB, BCh, BAO, FRCPsych Consultant forensic psychiatrist Belfast, member of the departmental steering group that is forming new mental health and capacity legislation for Northern Ireland Fred was one time chair of the Royal College of Psychiatrists in Northern Ireland and the All-Ireland Institute of Psychiatry He has taken a lead role in the development of forensic mental health services in Northern Ireland, including establishing prison multidisciplinary teams, a police station liaison scheme, and the Shannon Clinic medium secure unit Fred was a major contributor to the Bamford Review of mental health and learning disability services in Northern Ireland, and chaired the Forensic Services Committee and Forensic Legal Issues Subcommittee Contributor to Chapters 4, 24 and 25 on legislation and forensic services in Northern Ireland Peter F Buckley, FRCPsych, MD Professor and chairman in the Department of Psychiatry at the Medical College of Georgia from 2000 and now dean of the Medical College Peter qualified at University College Dublin but joined the faculty at Case Western Reserve University, School of Medicine, Cleveland in 1992 Peter is a distinguished fellow of the American Psychiatric Association He has published 340 original publications and is senior author of a postgraduate textbook of psychiatry He has also authored or edited twelve other psychiatric books He is editor of the journal Clinical Schizophrenia & Related Psychoses and was the Journal of Dual Diagnosis His research focuses on the neurobiology and treatment of schizophrenia Lead author pharmacotherapy sections, chapter 23 ix K17373.indb 3/31/14 6:16 PM List of Contributors Jenifer Clarke, RMN, MSc Deputy Head for Mental Health and Vulnerable Groups/ Nursing Officer for Mental Health and Learning Disability Services for the Welsh Government Jenifer has worked as a consultant nurse in both the public and independent sectors and within acute, community, forensic/ prison settings and specialist Personality Disorder Services She completed her post graduate diploma in forensic psychotherapy and MSc in institutional and community care at the Portman/ Tavistock Clinic London Jenifer has developed a ‘Secure Model of Nursing Care’ which integrates a psychodynamic understanding into nursing practice and co-edited Therapeutic Relationships with Offenders with Anne Aiyegbusi Co-author of the nursing sections, chapter 23 Julian Corner, BA, PhD Chief executive of the Lankelly Chase Foundation, and formerly chief executive of the Revolving Doors Agency, Julian twice worked as a civil servant, mainly in the Home Office but also in the Department for Education and Employment and the Social Exclusion Unit (SEU) While at the SEU he led its report on reducing re-offending by ex-prisoners which led to the creation of the National Reducing Re-Offending Strategy He is a trustee of Clinks, the membership body for voluntary organisations that work with offenders and their families Author voluntary sector section, chapter 25 Jackie Craissati, DClinPsy Consultant clinical and forensic psychologist, clinical director at the Bracton Centre, Oxleas NHS Foundation Trust and project lead for a number of related community projects run in partnership with probation and third sector agencies Jackie’s special interest is the assessment and treatment of sexual and violent personality disordered offenders She has published widely in this area and is the author of ‘Managing High Risk Sex Offenders in the Community’ and ‘Managing Personality Disordered Offenders in the Community’ Author specialist community services section, chapter 24 Ilana Crome, MA, MPhil, MB, ChB, MD, FRCPsych Professor of addiction psychiatry at Keele University and St George’s Hospital, Stafford, Ilana is a past chairman of the Faculty of Substance Misuse (Royal College of Psychiatrists), past president of the Alcohol and Drugs Section of the European Psychiatric Association and a past member of the Advisory Council on the Misuse of Drugs She chaired ‘Our invisible addicts’ report (RCPsych 2011) Her clinical Interests include adolescents and older people and the enhancement of training in substance misuse in health professionals Her research includes mental and physical comorbidity, smoking cessation trials, decision making in substance misusers, suicide and substance misuse, pregnant drug users, and addiction across the life course Lead author illicit drugs section, chapter 18 Rajan Darjee BSc(Hons), MBChB, MRCPsych, MPhil Consultant forensic psychiatrist, The Orchard Clinic, Edinburgh, lead clinician for multi-agency public protection arrangements and sexual offending in the NHS Scotland Forensic Mental Health Services Managed Care Network, Rajan’s clinical interests also include the multi-agency management of the personality disordered in the community, and the risk assessment and management of serious violent and sexual offenders He is accredited by the Scottish Risk Management Authority to assess risk in serious violent and sexual offenders being considered for indeterminate sentencing His research interests include mental health legislation, schizophrenia, risk assessment and the psychiatric characteristics of sex offenders Lead author Scottish section, chapter Felicity de Zulueta, BSc, MA(Cantab), MBChB, FRCPsych, FRCP Emeritus consultant psychiatrist in psychotherapy at the South London and Maudsley NHS Trust and honorary senior lecurer in traumatic studies at Kings College London Felicity developed and headed the Traumatic Stress Service in Maudsley Hospital which specialises in the treatment of people suffering from complex post traumatic stress disorder(PTSD) including borderline personality and dissociative disorders She has published papers on bilingualism and PTSD from an attachment perspective and is the author of From Pain to Violence: The Traumatic Roots of Destructiveness Author, attachment disorder sections, chapter 28 Roderick Lawrence Denyer QC called Inner Temple 1970 (bencher 1996) Senior judge, Bristol Civil Justice Centre Roderick was lecturer in law at the University of Bristol 1971–1973 after which he practiced as a barrister at the common law Bar until 2002, taking silk in 1990 and becoming a recorder x K17373.indb 10 3/31/14 6:16 PM Treatment of personality disorder Main activities Anxiety level of staff Therapeutic expertise Phase Phase Phase Establishing therapeutic engagement Managing dissocial behaviour Integration of self-states Containment Maintaining engagement Preparing for transition Therapeutic Alliance Schema Formulation Initial Assessment Medication Unpredictable Significant Training Social Skills CBT Low Minimal Training Psychodynamic Schema focused CBT Cognitive analytic therapy High Significant Training Figure 16.1 A stepped approach to the treatment of personality disorder and reviews There is, however, a tendency not to structure transitional and discharge arrangements with the same rigour for people who have personality disorder Small wonder, then, that from an early general overview of the evidence on treatment of personality disorder (Dolan and Coid, 1993) to more recent systematic reviews (see below), the overall answer to questions about the effectiveness of treatment for personality disorder is equivocal Drug treatments for personality disorders Medication is commonly prescribed for people with personality disorder, at least at times Early estimates were that from about half (Soloff, 1981) to more than three-quarters (Andrulonis et al., 1982) of people presenting for treatment would be prescribed something There is no specific ‘personality disorder drug’, so an ever present question is whether any medication is really treating aspects of the personality disorder per se or, rather, helping with comorbid conditions which may have been the trigger to a period of decompensation, and, in the presence of personality disorder, may not always present in classical form Perhaps this doesn’t matter as long as the patient improves, and, in this context, if it can be said that any medication appears to be helpful, then it may at least not be contraindicated In the UK, however, no drug has been licensed as a specific treatment for personality disorder, so drug use must still be regarded as experimental except when treating comorbid conditions This does not mean that drugs cannot be used, but rather that they should be used with caution and with particularly systematic monitoring of any positive and/or negative effects Stein (1993), in what is not styled as a systematic review, but appears to be so, examined the evidence for the effectiveness of the range of substances which had been studied in this context up to that date – treatment with low doses of neuroleptics, tricyclic antidepressants for people with borderline personality disorder, monoamine oxidase inhibitors (MAOIs), lithium, benzodiazepines, anticonvulsants, psychostimulants and even electroconvulsive treatment He was positive about progress in the field, since he considered that both medications available and evidence on their effects had improved so much during the 1980s, albeit starting from a state of almost no knowledge at all of this particular aspect of treatment Most of the evidence, however, appeared to relate to people with borderline personality disorder, and a range of methods of study had been applied, including simple observational accounts of naturalistic studies He discussed the difficulties in completing trials with people who have such problems, not least because of difficulties, inherent to the disorders, with drug compliance and retaining people in trials, and because some drugs which appeared to confer benefit might be just too risky; an example of the latter would be the MAOIs, which for the patient’s physical safety require abstinence 403 K17373.indb 403 3/31/14 6:17 PM Personality disorders from alcohol, and a good many other substances – legal and illegal. Nevertheless, even by 1983, several randomised controlled trials (RCTs) had been completed By 2006, then with the aid of 15 electronic databases, 35 RCTs of pharmacological treatments for personality disorder could be located (Duggan et al., 2008) The range of treatments tried showed little difference from the Stein study; atypical neuroleptics were added, electroconvulsive treatment not mentioned, and one experiment had been conducted each with a hypotensive agent (clonidine) and a dietary supplement (omega-3 fatty acids) The studies included are shown in table 16.4 Probably the most striking features are the small sample sizes in most studies and also the brevity of treatment in the majority A few of the studies had targeted a particular behaviour, such as substance misuse or suicidal acts, but among people with personality disorder; again, trials were most commonly with people who had borderline personality disorder Multiple meta-analyses were performed with the data to take account of the nine classes of drugs trialed and the range of behavioural features measured The latter were cognitive perceptual symptoms, affective dysregulation (including depression, anxiety, anger and hostility), impulsive behavioural dyscontrol, global functioning – this area including perhaps the most typical of personality disorder features in interpersonal symptoms/signs – physical function, and leaving the study early Reduction of aggression in the context of anticonvulsant prescription and modulation of cognitive perceptual and other subjective mental state disturbance with anti-psychotic medication were the only two domains of significant success Lieb et al (2010) set out to update the review specific to treatment of borderline personality disorder They found Table 16.4 Summary of completed randomised controlled trials of pharmacological treatments for people with personality disorder Study Sample Drug tested Usable outcomes1 Duration of trial Authors’ claims * Arndt et al.,1992 29 men with ASPD among 59 substance misusers Desimipramine v placebo, both with standard methadone treatment Days with psychological problems, opiate use, or medical problems 12 weeks2 Those with ASPD made few gains with desimipramine or placebo * Battaglia et al., 1999 32 men 25 women repeated self-harm with PD Low dose v ‘ultra-low’ dose fluphenazine Leaving the study early; suicidal behaviour months Marked reduction in self-harm in both groups * Bogenschutz and Nurnberg, 2004 15 men, 25 women with BPD Olanzapine v placebo Leaving the study early 12 weeks Olanzapine superior on BPD measures on BPD-clinical global impressions scale * Coccaro and Kavoussi, 1997 28 men 12 women, any PD with aggression and irritability Fluoxetine v placebo Leaving early; sideeffects; quality of life; mental state3; aggression/irritability 12 weeks Sustained reduction in irritability and global rating of improvement with fluoxetine, regardless of depression, anxiety, or alcohol use * de la Fuente and Lotstra, 1994 men 14 women BPD Carbamazepine v placebo Leaving early; behavioural dyscontrol 32 days Carbamazepine: no significant positive effects Zanarini et al., 2011 119 men 322 women 2.5 mg olanzapine v 5–10 mg olanzapine v placebo Mental state, self-harm, core BPD symptoms (Zanarini scale) 12 week trial + 12 week open label Higher dose olanzapine superior on ZAN-BPD total score, but not depression nor self-harm; 2.5 mg superior on self-harm and identity disturbance only Schulz et al., 2008 91 men 223 women with BPD Flexible dose olanzapine v placebo Mental state, self-harm, core BPD symptoms (Zanarini scale) 12 week trial; 12 week open label extension Olanzapine superior on aggression and irritability measures, but not core BPD measures * Frankenburg and Zanarini, 2002 27 women with BPD Divalproex sodium v placebo Leaving early, mental state, behaviour, sideeffects months Divalproex superior in reducing anger and interpersonal sensitivity * Goldberg et al., 1986 21 men 29 women with BPD and/or schizotypal PD Thiothixine v placebo Leaving early 12 weeks Significant thiothixene effect on psychotic, obsessive–compulsive and phobic anxiety symptoms, ‘more than an antipsychotic effect’ 404 K17373.indb 404 3/31/14 6:17 PM Treatment of personality disorder Table 16.4 (Continued) Study Sample Drug tested Usable outcomes1 Duration of trial Authors’ claims Hallahan et al., 2007 men 15 women Omega-3 fatty acid v placebo, both with standard psychiatric care Depression, self-harm, impulsivity, aggression, daily stresses 12 weeks Omega-3 fatty acids superior on depression, self-harm and daily stresses, not impulsivity or aggression * Hollander et al., 2001 10 men 11 women BPD Divalproex v placebo Leaving early; global state; mental state; behaviour 10 weeks Divalproex superior to placebo for impulsive aggression, irritability and cluster BPD global rating * Hollander et al., 20034 91 (63% men) Divalproex v placebo Leaving early; behaviour 12 weeks Divalproex superior for impulsive aggression * Joyce et al., 2003 40 men 43 women, 30 BPD, 53 other PD, all major depression Fluoxetine v nortryptyline Leaving early; mental state weeks + months followup Poor outcome for depressed patients with BPD on nortryptiline * Koenigsberg et al., 2003 19 men women with schizotypal PD Low dose risperidone v placebo Leaving early, global state, mental state, schizotypal symptoms weeks Risperidone superior on PANNS negative and general scale by week and positive symptoms scale by week * Leal et al., 1994 11 men women ASPD + cocaine abuse Amantidine v desimipramine v placebo, all + standard care Leaving early; money per week spent on cocaine 12 weeks ASPD poor prognostic indicator; medication no advantage * Leone, 1982 32 men 48 women with BPD Loxapine succinate v chlorpromazine Symptom changes; leaving early; sideeffects weeks Both drugs improved symptoms with loxapine being superior, sideeffects occurred in a third * Loew et al., 2006 56 women with BPD Topiramate v placebo Leaving early, sideeffects, mental state, quality of life 10 weeks Significant advantage for topiramate on mental state and PD measures * Montgomery et al., 1983 20 men 38 women with BPD and/or histrionic PD + selfharm Mianserin v placebo Suicide attempts months No improvement; no significant difference between groups * Nickel et al., 2006 men 43 women BPD Aripripazole v placebo Mental state (SCL-90); self-injurious outcomes weeks Aripripazole superior on most mental state scores and state-trait anger but not self-harm * Nickel et al 2005 44 men with BPD Topiramate v placebo Leaving early, mental state weeks Topiramate superior in treating anger in men with BPD * Nickel et al., 2004 31 women with BPD Topiramate v placebo Leaving early, mental state weeks Topiramate superior in treating anger in women with BPD * Oosterbaan et al., 2001 48 men 34 women, 50% with avoidant PD, all with social phobias Moclobemide v CBT v placebo Leaving early, sideeffects 15 weeks + and 15 month follow-up CBT superior (but for social phobia rather than PD) Pascual et al., 2008 60 patients with BPD Ziprasidone v placebo Clinical Global Impression Scale for BPD 12 weeks No significant advantage for ziprasidone * Philipsen et al 2004a women with BPD Naloxone v placebo Dissociative symptoms 15 before and after naloxone/placebo Given twice in double blind cross-over design during 6–35 days No significant advantage for naloxone, but the more BPD criteria the better the naloxone response * Philipsen et al 2004b 14 women with BPD Clonidine 75 µg v clonidine 150 µg None 4–16 days Acute inner tension, dissociation, suicide related behaviours reduced in both groups (within the hour) (Continued) 405 K17373.indb 405 3/31/14 6:17 PM Personality disorders Table 16.4 (Continued) Study Sample Drug tested Usable outcomes1 Duration of trial Authors’ claims * Powell et al., 1995 65 men ASPD + alcohol dependence Nortryptiline v bromocriptine v placebo Leaving early; alcohol abstinence months (postdetox) Only significant advantage of active drugs was with nortryptiline in the ASPD group * Rinne et al., 2002 38 women with BPD Fluvoxamine v placebo + Leaving early, sideeffects, mental state, behaviour weeks double blind; weeks single blind; 12 weeks follow-up Fluvoxamine superior for sustained reduction in rapid mood shifts, but not impulsivity or aggression * Salzman et al., 1995 men 14 women with BPD/BPD traits Fluoxetine v placebo Mental state 12 weeks Fluoxetrine superior in reducing anger * Serban and Siegal, 1984 36 men 16 women BPD and/or schizotypal Thiothixene v haloperidol Leaving early, sideeffects months 84% patients markedly improved at months in both groups * Simpson et al., 2004 20 women with BPD Fluoxetine v placebo, both + DBT Leaving early; global state; mental state; impulsive aggression, suicide related behaviours, ER visits 12 weeks No added benefit for fluoxetine * Soler et al., 2005 men 52 women with BPD Olanzapine v placebo, both with adapted BPD Leaving early, global state, mental state 12 weeks Improvement in both groups; olanzapine superior for depression, anxiety and impulsive aggression * Soloff et al., 1993 26 men 82 women with BPD Haloperidol v phenelzine Leaving early, global state, mental state weeks Phenelzine superior for anger and hostility; no other drug advantages * Soloff et al., 1989 22 men 68 women with BPD Haloperidol v amitryptiline v placebo Leaving early, global state, mental state, impulsivity weeks Haloperidol superior to placebo in depression, hostility, schizotypal symptoms, impulsivity global function; amitriptyline only superior for depression Steiner et al., 2008 24 women with BPD Olanzapine v placebo, both with DBT Standard measures or irritability, aggression, self-harm and depression months More rapid reduction of irritability with olanzapine; self-injury tended to decrease more with DBT alone * Tritt et al., 2005 24 women with BPD Lamotrigine v placebo Leaving early, mental state weeks Lamotrigine superior for all aspects of anger except internally directed anger * Verkes et al., 1998 37 men 54 women, recent suicide attempt, 84 with PD Paroxetine v placebo Leaving early Up to 52 weeks Paroxetine superior in reducing suicide related behaviours; not other behaviours/symptoms * Zanarini and Frankenburg, 2001 28 women with BPD Olanzapine v placebo Leaving early weeks Olanzapine superior in rate of improvement in all areas except depression * Zanarini and Frankenburg, 2003 30 women with BPD Omega-3 fatty acids v placebo Leaving early, mental state, behaviour weeks Omega-3 fatty acids superior in reducing aggression and depression * Zanarini et al., 2004 45 women with BPD Olanzapine (o) v fluoxetine (f) v o + f Leaving early; sideeffects weeks All three conditions effective, but fluoxetine alone least so Usable outcomes refers to all those outcomes measured systematically and reported sufficiently transparently to allow for meta-analysis; Times all refer to periods of active treatment; many studies explicitly added baseline periods; Reference to mental state as an outcome means that a systematic measure was used; A later publication (Hollander et al., 2005) is not included here, it overlapped with other Hollander studies It analysed borderline personality disorder data separately, suggesting divalproex superior for impulsive aggression *Included in Duggan et al (2008) meta-analyses ASPD, antisocial personality disorder; BPD, borderline personality disorder; DBT, dialectical behaviour therapy; ER, emergency room; PANNS, positive and negative symptoms of schizophrenia; PD, personality disorder; SCL-90, symptom checklist 90 items 406 K17373.indb 406 3/31/14 6:17 PM Treatment of personality disorder just four new trials, two of olanzapine (one of these a drug company trial of its own product), one an additional study of omega-3 fatty acids, and a study of ziprasidone These have been added to table 16.4 There was really no update of conclusions possible, and the article drew somewhat acid observations from Kendall et al (2010) It is hard to see why this update justified a major publication; what is needed is a simple system of notes to provide clinicians with periodic updates For the USA, the American Psychiatric Association (APA) does this in the form of a ‘guideline watch’ (APA, 2005), which updates its position on the treatment of borderline personality disorder (APA, 2001) This is the only APA guidance on treatment of personality disorder In England, the National Institute of Health and Clinical Excellence (NICE) guidelines on treatment of antisocial personality disorder and borderline personality disorder are more recent (NICE, 2009a,b), with their cautious recommendations that for antisocial personality disorder ‘prescribers will use a drug’s summary of product characteristics to inform their decisions for each person’ and the slightly more specific, additional advice with respect to borderline personality disorder on use of drugs to manage crises, comorbid conditions and insomnia Time limited psychological treatments for offenders with personality disorder A major consideration influencing the take-up of an effective treatment is the amount of effort and skill needed from care providers and the amount of technical back-up that they require (Marks, 1991) Brief, simple and effective treatments will have a much greater impact in the population overall than those that require a great deal of technical knowledge and expertise Most treatment offered to offenders with personality disorder – if they are fortunate enough to be offered any at all – is likely to be of this brief type, although the national guidance for England on treatment both of antisocial personality disorder (NICE, 2009a) and borderline personality disorder (NICE, 2009b) both express caution about the need for a full and appropriate clinical framework whenever brief psychological treatments are given; such guidance draws on advice from an international collaboration of researchers from elsewhere in Europe, Canada, New Zealand and the USA (http://www.agreecollaboration.org) The idea, however, of time limited treatment for personality disorder may read like a contradiction in terms After all, surely people with a personality disorder are, by definition, suffering from a long-term disturbance, so how could, say, 10–20 sessions of treatment be adequate? Could it even be harmful? Further, if people with a personality disorder are also offenders, they have not been found to be especially responsive to interventions of any type (Woody et al., 1985; Huband et al., 2007) It could be argued that forensic mental health services in particular, and prisons more generally, are dealing with such complex presentations that similarly complex interventions are needed in response Reconciling this tension between simple, brief interventions available to many versus complex interventions available only to the few is the leitmotif of current service provision There are, however, many types of brief psychological interventions Given the current state of the evidence on effectiveness, how does one choose? Frank et al (1991) and Wampold (2001), among others, have observed that many specific types of psychotherapeutic treatments achieve virtually the same effects, largely because of a common set of curative processes While few disagree that this is true, many, nonetheless, feel uncomfortable with its implications Does this emphasis on the non-specificity of any one treatment, not discredit that treatment’s effectiveness? Glass (2001), for example, wrote: There are those health policy analysts who argue that any therapy that uses non-specific diagnoses and non-specific treatments is somehow bogus witchcraft lacking indications of when to begin and when to end, and its application should be excluded from third-party coverage Rachman and Wilson (1980), drawing on Alice in Wonderland and the Dodo Bird’s verdict on the caucus race that ‘everyone has won and all must have prizes’, wrote trenchantly on results of clinical trials in the field, which usually arrive at the conclusion that there is little difference between the various psychological treatments: If the indiscriminate distribution of prizes carried true conviction … we end up with the same advice … ‘Regardless of the nature of your problem seek any form of psychotherapy.’ This is absurd We doubt even the strongest advocates of the Dodo Bird argument dispense this advice (p.167) How, then, does one reconcile the research evidence supporting importance of common factors on the one hand with the clinical reality that practitioners choose specific therapies for certain specific problems? This dilemma may be resolved at two levels Frank and Frank (1991), who were among the first to develop the common factor position, deal with one of these levels: [our] position is not that technique is irrelevant to outcome Rather, as developed in the text, the success of all techniques depends on the patient’s sense of alliance with the actual or symbolic healer This position implies that ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem Also implied is that therapists should seek to learn as many approaches as they find congenial and convincing Creating a good therapeutic match may involve both educating the patient about the therapist’s conceptual scheme and, if necessary, modifying the scheme to take into account the concepts the patient brings to therapy Given that the therapist’s person is, in part, the therapeutic tool, a partial solution to this dilemma that differing 407 K17373.indb 407 3/31/14 6:17 PM Personality disorders psychological therapies may be equally effective is to accept that treatments are only likely to be effective when used by a practitioner who finds that therapy congenial, believes in it and practises it consistently Hence, the choice of therapy has to fit the therapist as well as the patient for it to be effective The wide range of psychological therapies available for personality disorder may appropriately reflect the wide range of practitioners in the field A further important issue along these lines, which is almost never considered in the research literature, is the fit not only between therapist and therapy, but also between therapist and patient Early observations suggested that this was critical for people with schizophrenia – that therapists with certain personality styles did not or could not engage such patients and treat them successfully (Whitehorn and Betz, 1954, 1960) Similar work would be important to explore fit between personal style of the therapist and patients with the main types of personality disorder presenting for treatment A second possible solution to this dilemma over postulated lack of specificity of treatments is that, while a range of therapies may be applied, each will only work when there is a clear rationale for its use – both for those who deliver the treatment and for the patient making use of it Most forensic psychiatrists will have limited opportunity for consistent, long-term, individual psychotherapeutic contact with their patients, indeed it may be inappropriate for the same person to have the overarching management responsibility in the case and be the therapist (see also chapters 23 and 26) Thus, forensic psychiatrists require an understanding of the strengths and weaknesses of the various approaches and the strengths of their colleagues in this particular respect, in order to be able to integrate this information into the decisions on therapy Thus, specific psychological treatments may be provided as the mainstay of short-term intervention or, perhaps more commonly, as an element of a treatment package, as already described Another important argument for short-term treatment is that people with personality disorder struggle to complete treatment, although the data are largely restricted to those with borderline personality disorder Figures as high as 60% early withdrawal rates have been reported in some trials (Waldinger and Gunderson, 1984; Gunderson et al., 1989), although a systematic review of 41 studies of treatment completion specifically relating to people with borderline personality disorder was more encouraging (Barnicot et al., 2011) For interventions of less than 12 months, they found that a random effects meta-analysis gave an overall completion rate of 75% (95% confidence interval (CI): 68–82%); it was barely different for longer interventions (71%, CI: 65–76%) Factors predicting dropout were low commitment to change, poor therapeutic relationship and high impulsivity; sociodemographics were not relevant Another metaanalysis of non-completion for people with personality disorder more generally yielded slightly worse completion rates, with patient c haracteristics and need together with some environmental factors influencing this (McMurran et al., 2010) The four studies that investigated the relationship between non-completion and treatment outcome showed adverse outcomes for non-completers One even showed a higher rate of re-offending among those who disengaged than among those who were never offered treatment in the first place (McMurran and Theodosi, 2007) Hence, there is an ethical obligation to consider the risks of disengagement, and what can be done to minimise it Motivational interviewing (Rollnick et al., 2008) is one way of reducing the risk of dropout from treatment, psychoeducation (Livesley, 2001) is another, either way helping the patient into a position whereby s/he can make accurate observations about her/his own behaviour rather than this coming more directly from the therapist and carrying a sense of threat Methods have also been developed specifically to encourage these observations and help cooperation over prioritising the individual’s difficulties so that they seem less overwhelming (e.g D’Silva and Duggan, 2002) Such interviewing styles also help to direct the therapist’s attention as to where possible fault lines in the therapeutic alliance are likely to develop, so that these can be anticipated and worked through Thus, for instance, the therapist might say to someone with a paranoid personality disorder: ‘I realise that it is part of your personality to feel suspicious of strangers, and perhaps that they might wish to take advantage of you – so, you may from time to time feel like that about me too This is something that we both need to be aware of, and we need to be able to work together on finding ways to increase your confidence in our working relationship so that your concerns don’t get in the way of treatment.’ Preventive measures are not invariably successful, however, so it is important, as well, to have strategies for dealing with therapeutic ruptures if they occur Safran and Muran (2000) offer suggestions for identifying early ‘rupture markers’, which may include increased irritability or other change within or outside the sessions, or decreased involvement in homework, and note that they must immediately be actively explored in the here and now This is often daunting for both patient and therapist, as the tendency for both is to ignore the rupture, so the therapeutic alliance needs constant monitoring Confrontation and interpretation should be used sparingly at this stage, as these approaches provoke anxiety and are likely to be interpreted as attacks, increasing the risk of withdrawal Such anxiety is better contained by helping the individual to observe and explore his/her own behaviour Giving feedback to a patient with clinically significant narcissistic traits is particularly difficult; in one case, one of us (CD) found that no matter what was said, the patient interpreted it as a ‘put down’, and so became extremely angry and sullen for the rest of the day He was helped by encouraging him to examine this recurrent pattern for himself He then started to recognise his need for unequivocal admiration, and that no matter 408 K17373.indb 408 3/31/14 6:17 PM Treatment of personality disorder what was said, it would never be sufficient He saw that other patients were also being provided with feedback at the same time, but he was envious of them, believing that they were seen as performing better than he He began to move forward when he agreed that this was beginning to interfere with his capacity to work in therapy Collating the evidence for psychological treatments for personality disorder A number of useful systematic reviews have been published of studies evaluating the main psychological treatments for personality disorder These range from the more specific, for example randomised controlled trials of psychodynamic psychotherapy (Gerber et al., 2011), through comparing psychodynamic therapy with cognitive behavioural approaches but incorporating a range of trial designs (Leichsenring and Liebing, 2003), to those confining themselves to RCTs but covering a wider range of treatments The latter include the psychodynamic therapies and their developments such as mentalization therapies, the cognitive behavioural therapies (CBT), and their developments, such as dialectical behaviour therapies (DBT), and schemafocused therapies (SFT), and practical, holding therapies such as social skills training, psychoeducation and supportive therapies (Brazier et al., 2006; Duggan et al., 2007) The NICE guidelines on treatment of antisocial personality disorder (NICE, 2009a) and borderline personality disorder (NICE, 2009b) while the Brazier (2006) review incorporates evidence on cost as well as effectiveness Leichsenring and Leibing (2003) came to an optimistic conclusion, that there was evidence for the effectiveness of both dynamic and cognitive therapies, but a larger overall effect size for the dynamic therapies Other reviewers are more cautiously positive Gerber et al (2011) note the superiority of psychodynamic therapy to non-specific work or waiting list conditions, but equivalence with other therapies Table 16.5 builds on and updates material from the Duggan et al (2007) review of randomized controlled trials Therapeutic communities will be dealt with separately, below The most striking thing about the randomised controlled trials summarised in table 16.5 is that there have been few evaluations of treatment for any personality disorder other than borderline personality disorder, and there is also a heavy bias towards women as patients Most of the trials were of treatment in an outpatient setting The table gives little flavour of the very wide range of outcome measures used, but it must be noted that, in many cases, Table 16.5 Summary of completed randomised controlled trials of psychological treatments for people with personality disorder Study Sample Therapy Usable outcomes1 Duration of trial Authors’ conclusions * Bateman and Fonagy, 1999; 2001 44 women with BPD Psychoanalytically oriented partial hospitalisation v general psych care Leaving early2; quality of life; psych service use 18 months + 18 months follow-up Psychoanalytically oriented treatment better on range of measures from months, maintained through follow-up Bateman and Fonagy, 2009 27 men 107 women with BPD; many with axis I comorbidity and add PDs Mentalization based treatment v structured clinical management Suicide/selfharm attempts, hospitalisations, length of hosp Up to 18 months Improvement in both groups, more in the mentalisation group Blum et al., 2008 21 men 103 women with BPD Systems Training for Emotional Predictability and Problem Solving (STEPPS) +TAU4 v TAU Zanarini BPD scale; depression, selfharm, impulsivity, crisis service use; global function 20 weeks + 12 months follow-up Discontinuation rate high in both groups; advantage for STEPPS group on BPD and other measures except for self-harm or hospitalisations * Brooner et al., 1998 35 men women with opioid dependence and ASPD Contingency management intervention v methadone substitution Leaving early; return to routine care 13 weeks Both groups did well, n.s difference between them Clarkin et al., 2007 men 83 women with BPD Transference focused psychotherapy v DBT v supportive therapy Mental state, suicidality, impulsivity, aggression and violence 12 months Improvements in all groups, most in transference based * Colom et al., 2004 men 28 women with bipolar disorder and any PD Psychoeducation v unstructured intervention, both + medication Global state 20 weeks; add follow-up 6, 12, 18, 24 months 100% control group relapsed: 67% psychoeducation; latter longer to relapse (Continued) 409 K17373.indb 409 3/31/14 6:17 PM Personality disorders Table 16.5 (Continued) Study Sample Therapy Usable outcomes1 Duration of trial Authors’ conclusions * Davidson et al., 2006 17 men 89 women with BPD CBT + TAU4 v TAU Self-harm, mental state, quality of life, service use, leaving early 12 months, add follow-up 18 and 24 months CBT group less likely to be hospitalised or use A&E; reduced no of suicidal acts Doering et al., 2010 104 women with BPD Transference-focused psychotherapy v treatment by community psychotherapists Leaving early, self-harm; general mental state; personality organisation, global function 12 months Transference-focused therapy superior on most measures (including specific PD) * Emmelkamp et al., 2006 30 men 32 women with PD CBT v brief dynamic therapy v waiting list Behaviour avoidance scale; mental state; quality of life months; followup at 12 months At end of treatment and followup: CBT best; brief dynamic therapy equivalent to waiting list * Evans et al., 1999 34 men and women (proportions not stated) cluster B PD MACT (manualassisted cognitivebehaviour therapy) v TAU Leaving early; global mental state; quality of life months MACT superior in reducing suicidal acts and depression * Giesen-Bloo et al 2006 men 80 women with BPD Schema-focused v transference focused therapies Leaving early, mental state, behaviour years Both therapies significantly reduced BPD specific and general psychopathology * Gratz and Gunderson, 2006 22 women with BPD Emotional regulation groups v TAU Leaving early, mental state, behaviour 14 weeks Emotional regulation groups advantage for self-harm, BPD specific and general psychopathology * Kool et al., 2003 49 men 79 women with depression, 128 with PD Short psychodynamic supportive therapy + antidepressants v antidepressants Mental state, global state months Combined therapy was more effective for depressed PD patients but not for depressed patients without PD * Koons et al., 2001 28 women with BPD DBT v TAU Service admissions; parasuicide, mental state, leaving early, no BPD criteria months Decrease in parasuicide, experienced anger and dissociation * Linehan et al., 1991 63 women with BPD DBT v TAU Parasuicide; early leaving 12 months + 12 months follow-up Less parasuicide, more treatment engagement and fewer inpatient days with DBT * Linehan et al 1999 28 women with BPD DBT v TAU Leaving early; death; substance use 12 months + months follow-up DBT group greater reductions in drug abuse in treatment year and at follow-up; in treatment longer; better global and social adjustment at follow-up than TAU group * Linehan et al 2002 23 women with BPD DBT v comprehensive validation therapy + 12 step Leaving early; time spent in prison 12 months + months follow-up Both treatments effective; small differences between them * Linehan et al 2006 101 women with axis I and II disorders DBT v ‘community treatment by experts’ Quality of life; behaviour; mental state 12 months + 12 months follow-up DBT uniquely effective in reducing suicidal behaviours; not a general effect of psychotherapy McMain et al., 2009 15 men 165 women with BPD and + selfinjuries in past years DBT v general psychiatric management Frequency and severity of self-harm 12 months Both groups improved significantly on self-injury and other clinical measures * Messina et al., 2003 34 men 14 women with ASPD and substance misuse CBT v contingency management (CM) v CBT + CM, all with methadone maintenance (MM) v MM alone Substance use 16 weeks + up to 40 weeks follow-up CM most effective 410 K17373.indb 410 3/31/14 6:17 PM Treatment of personality disorder Table 16.5 (Continued) Study Sample Therapy Usable outcomes1 Duration of trial Authors’ conclusions * Oosterbaan et al., 2001 48 men 34 women with social phobia, 50% avoidant PD CBT v moclobemide v placebo Leaving early; sideeffects 15 weeks + up to 15 months follow-up CBT superior (but for social phobia rather than PD) * Springer et al., 1996 10 men 21 women with PD several types DBT-based creative coping group v wellness and lifestyles group Mental state; behaviour Not stated Both groups improved, n.s differences between them * Stravynski et al 1994 18 men 13 women with avoidant PD Social skills training in the clinic v training ‘in vivo’ Leaving early weeks; months follow-up Both groups showed benefits but the ‘in vivo’ training did not enhance the social skills training * Svartberg et al., 2004 25 men 25 women with cluster C PDs CBT v short-term psychodynamic therapy Mental state; quality of life 40 weeks; follow-up @ 12 and 24 months Both groups improved; n.s differences between them * Turner, 2000 men 19 women with BPD DBT v client centred therapy (CCT) Mental state, no of new admissions; leaving early 12 months DBT more improvement than the CCT group on most measures Quality of therapeutic alliance accounted for significant variance for both treatments * Tyrer et al., 2004 154 men 326 women with deliberate selfharm, 202 with PD MACT v TAU Number with PD having at least one self-harm incident Up to treatments; follow-up @ and 12 months No difference in self-harm rates; MACT more expensive than TAU for patients with BPD, but less so with other PDs * van den Bosch et al 2005 58 women with BPD DBT v TAU Parasuicidal and selfmutilation; substance use; behaviour scale scores 52 weeks; followup @ 78 weeks Advantage for DBT in self-harm and impulsive behaviours and alcohol use, sustained @ months; no difference for illicit drug use * van den Bosch et al., 2002 64 women with BPD DBT v TAU Leaving early; behaviour; substance use 12 months BPD as Verheul et al 2003; this article confirmed no effect on substance misuse * Verheul et al., 2003 58 women with BPD DBT v TAU Suicidal and self-mutilating behaviours; service engagement 12 months DBT better retention rates and more reduction in self-harm than TAU * Vinnars et al., 2005 49 men 107 women with PD Manualised supportive expressive psychotherapy (SEP) v psychodynamic psychotherapy (PsDP) Global state; mental state SEP 40 weeks; 21 sessions PsDP Improvement in global function, reduced prevalence of PD both groups; SEP group fewer followup visits to community mental health teams * Weinberg et al., 2006 30 women BPD MACT + TAU v TAU Suicidal acts and behavioural scale 6-8 weeks, follow-up @ months Reduced frequency and severity of deliberate self-harm with MACT; no reduction in suicidal ideation * Winston et al., 1994 33 men 48 women with PD Brief adaptive psychotherapy v shortterm psychodynamic v waiting list Leaving early; mental state; social function months; up to 4.5 years followup (mean 1.5 years) Both treatment groups had significant advantage over waiting list group Usable outcomes refers to all those outcomes measured systematically and reported sufficiently transparently to allow for meta-analysis Leaving early refers to leaving the therapy and/or the study before complete Abbreviations: as table 16.4 and add., additional; A&E, accident and emergency; psych, psychiatric; hosp., hospitalisation; n.s., not significant; TAU, treatment as usual 411 K17373.indb 411 3/31/14 6:17 PM Personality disorders any advantage found for a therapy was in reduction in selfharm rate or some specific symptom change rather than fundamental personality change This is perhaps unsurprising as in under half the cases was treatment given for 12 months or more, but examination of briefer interventions does offer some help with our starting point – that brief therapies may be most desirable for reasons of access and economics Comparison of one active treatment against another brought less clarity, which takes us back to our non-specificity discussion It is reassuring, at least, that all trials of active treatment against placebo favoured the active treatment in some respect Therapeutic communities The term ‘therapeutic community’ (TC) is generally attributed to Main (1946), however in initial concept it was rather similar to the Quaker reforms to mental health institutions introduced in the late eighteenth century, for example at the Retreat, York, in England Much later, this interpretation of the idea was taken up by the anti-psychiatry movement to create ‘alternative asylums’, with flattened hierarchies within and between staff and residents and, often, commitment to a particular philosophical style Two more specific approaches are relevant to treatment of personality disorder The ‘true therapeutic community’ was originally a principally British development led by Maxwell Jones ( Jones, 1968, 1982) It is a small, cohesive, ‘democratic community’ in which there is a clear distinction between staff and residents, although little hierarchical difference, and they work together at all times in a spirit of co-operation, jointly setting the rules and procedures for the community – and the sanctions if broken – and commonly sharing decisions about who should become residents While therapeutic expertise may lie with the staff, the whole community is expected to take a part in the therapeutic process, and in supporting community members through crises The Henderson hospital model is probably the best known example of a democratic therapeutic community in the UK (Whitely, 1980; Dolan, 1997) The ‘concept based community’ was originally founded in the USA, when a recovering alcoholic, Charles Dederich, set up Synanon in response to the perceived needs of addicts In his hands, this form of community relied on membership for which people qualified through their abuse of drugs, and were sustained in conformity by aggressive confrontation; in the absence of professionals, and reliant on the charisma of its leader, this pioneer of the model lost its way, amid law suits about cruelty and coercion (Galanter, 1999) The principle of the concept based community, however, survived through more openness to external review, with the Phoenix House model (De Leon, 1973) perhaps best known for its incarnations in the UK While the US route to introducing TC models for offenders through the correctional system generally followed the conceptual TC route (e.g Wexler, 1997), in the UK, even in prisons, the democratic TC has been the leading model (e.g Gunn et al., 1978; Morris, 2004; Genders and Player, 2010) Lees et al (1999, 2004) conducted a systematic review of studies of the effectiveness of therapeutic communities for people with personality disorder, covering the literature from the inception of TCs up to 1997 The search located over 8,000 studies, but just 10 randomised controlled trials to that date, 10 cross-institutional, crosstreatment or comparative studies and 32 other studies using some sort of control; 41 of the total of 52 studies related to democratic TCs and 11 to concept-based TCs; 29 studies were amenable to meta-analysis This indicated a positive effect, with an effect size of 2.5, which it has been suggested is what is required to indicate a clinically significant, but small outcome (Haddock et al., 1998) Another way of looking at their findings is to observe that four of the eight RCTs and 15 of the 21 other controlled studies favoured TCs Restricting consideration to the RCTs, the US study of a secure democratic TC suggested that its graduates did about twice as well as those from a conventional setting (Auerbach, 1977; odds ratio (OR): 0.524, 95% confidence interval (CI) 0.28–0.98), but the British counterpart was equivocal (Cornish and Clarke, 1975); open, democratic TCs fared little better Results were better for the concept based therapeutic communities We cannot find a more up-to-date review of therapeutic communities Most of the controlled studies of TCs are, therefore, quite old, and we are not aware of current trials in this field with people who explicitly have personality disorder A later systematic review and meta-analysis of concept TCs (Smith et al., 2006), albeit here strictly for substance misuse rather than personality disorder, found results of RCTs to be equivocal overall, but observed that the two prison studies were positive in finding lower recidivism rates for the TC men for up to 12 months after release (Sacks et al., 2004; Wexler et al., 1999) This, however, leads to another word of caution Long-term follow-up was for up to 10 years in a US prison-based TC study Therapeutic community graduates had an early advantage compared with youths in an ordinary prison environment, but, after 10 years there was a cross-over, with the TC graduates faring worse (McCord and Sanchez, 1982) Speculation was that this could be explained by the development of new skills and ways of thinking in the TC having been outside the participants’ own cultural context There is a great deal more to learn about the place of therapeutic communities, but results of their evaluation to date are sufficiently promising that this should be attempted Managed Clinical Networks Life events literature confirms that people commonly find major transitions in relationships or accommodation 412 K17373.indb 412 3/31/14 6:17 PM Dangerous and severe personality disorder (DSPD): The rise and fall of a concept extremely difficult, with a higher chance of becoming psychologically distressed or ill at these times (Holmes and Rahe, 1967) It is arguable that most people who have attachment difficulties as a fundamental part of their personality disorders are going to find change exceptionally difficult, particularly if they have just made a healthy attachment in therapy, or to the therapeutic community It is important, therefore, that treatment is not happening with one person in isolation, but a system, or network is in place to support the individual in all his or her areas of difficulty, and that it is particularly robust at times of transition Furthermore, the importance of the network in supporting the therapist and other key workers is not to be underestimated Baker and Lorimer (2000) define a managed clinical network (MCN) as: a linked group of health professionals and organizations from primary, secondary, and tertiary care, working in a coordinated way that is not constrained by existing organizational or professional boundaries to ensure equitable provision of high quality, clinically effective care….The emphasis … shifts from buildings and organizations towards services and patients The MCN has the following functions: ●● monitoring and updating core standards of care; ●● developing and updating skills and knowledge; ●● audit and research; ●● leadership and authority; ●● coordinating and managing change MCNs are important for offenders with personality disorder for several reasons First, personality disorder is an enduring condition, so it is important that provision is made seamlessly across the life span Secondly, and this especially applies to offenders with personality disorder, many agencies are likely to be involved, fielding personnel with different philosophies and priorities Thirdly, psychological therapies, the mainstay of treatment if available, are delivered by ‘…a range of sometimes rivalrous professionals – psychologists, psychiatrists, nurses – who are currently managed in different ways’ (Holmes and Langmaack, 2002) Fourthly, there are few practitioners who have particular skills in this field, so it is difficult to build up a critical mass of them Finally, assessment, management and treatment of personality disorder are still developing, so, not only is time needed to keep abreast of scientific advances and adapt service provision accordingly, but also it is an advantage to bring together people with different knowledge bases and skills A formal MCN builds on informal arrangements and professional relationships It is fundamental that there should be defined areas of accountability between the individuals within the network and that boundaries are clearly defined The idea has been promoted particularly strongly in Scotland, where the Scottish Office (1998c) has provided the following guidance on framework: one person to be appointed with overall responsibility for each patient’s network: a clinician, manager or other professional; the purpose is to improve equality and convenience of access to care and its co-ordination; expected service improvements (and cost savings) are made explicit from the outset, and effectiveness of the MCN measured against these; adherence to evidence-based treatments, and support for research wherever these are lacking; support for professional development; audit is an integral part of the network; each network makes an annual overview of its activities available to the public; all members of the network, including the patients/ service users, are involved in shaping it Dangerous and severe personality disorder (DSPD): The rise and fall of a concept The term ‘dangerous and severe personality disorder’ (DSPD) is uniquely English, having been created by politicians and civil servants in 1999 to define a group of offenders who often fell uncomfortably between the criminal justice system on the one hand and forensic mental health services on the other As perceived by the government, the problem was that mental health services wanted to deal only with psychotic or seriously mentally ill offenders – whilst growing public concern about sexual and violent recidivism had no regard for diagnostic niceties This perception was thrust into the spotlight by the case of Michael Stone, who was convicted of killing a mother and daughter in an unprovoked attack in rural Kent, the second daughter making a miraculous recovery from potentially fatal injuries Does the Home Secretary believe that further measures will be needed to deal with offenders who are deemed to be extremely violent because of mental illness or personality disorder, but whom psychiatrists diagnose as not likely to respond to treatment? Alan Beith, MP Yes, I entirely agree with the Right Honourable gentleman that there must be changes in law and practice in that area We are urgently considering the matter with my Right Honourable friends in the Department of Health … the psychiatric profession … 20 years ago adopted what I would call a common sense approach … but these days go for a much narrower interpretation of the law Jack Straw, MP (Hansard 26 October 2000) These politicians had not seen, at that stage, the report of the independent inquiry into the killings: The Panel is of the firm view that the policy debate concerning the adequacy of the law, policy and guidance should take place in the context of the actual 413 K17373.indb 413 3/31/14 6:17 PM Personality disorders facts of the case of Michael Stone, as opposed to the incomplete and in some cases inaccurate accounts that have appeared to date (Francis, Higgins & Cassam, 2006; South East Coast Strategic HA, Kent County Council, Kent Probation Area commissioned independent report, 30 November 2000, published October 2006.) The issues are, in fact, better illustrated by a series of killings by predatory paedophiles (Oliver and Smith, 1993) When some of them came to medical attention towards the end of prison sentences, there was general agreement on the presence of mental disorder and continuing risk, yet psychiatrists refused to detain them in hospital because they considered that the problems of these offenders were ‘untreatable’ in terms of the Mental Health Act 1983 A fierce debate ensued The government charged the profession with evading its responsibilities for dangerous and difficult patients, whilst the profession took the supposed moral high ground, arguing that doctors should not become jailers There was and is a moral and philosophical argument, but there are also practical and economic dimensions Mental health services operate at full capacity and, except for a handful of tertiary services such as the high security hospitals, generally have little or no expertise in treating personality disorder So, the government took the initiative, not only by creating this new category of disorder, and proposing radical new services, but also providing funds for developments The concept of DSPD was born, and 300 new beds were created, half in high security hospitals and half in prisons; later developments extended to medium secure hospitals and the community DSPD: An Operational Definition The DSPD service was defined as being for offenders who met the following criteria: severe personality disorder, severe meaning a score of 30+ on the PCL-R for men or 25 for women, or a score of 25+ and one or more personality disorders other than antisocial personality disorder, according to international classification of mental disorder, or two or more such personality disorders; high risk of committing a further serious sexual or violent offence, this risk to be informed by standardised instruments at a cut-off indicating a greater than 50% risk over the time frame of the instrument Serious, here, to be defined as likely to cause physical or psychological harm from which the victim was unlikely ever to recover fully; a functional link between the personality disorder and the risk; absence of major mental illness The problems with this definition arise from its nonclinical origins It was intended that standardised measures of personality disorder and risk would allow precise identification of a population with so-called DSPD It took hard lobbying by clinicians to force an acceptance that standard measures, particularly on risk, have been validated for groups, and translation from this to the individual is not straightforward It is not possible to avoid a measure of clinical judgment as the final arbiter for admission to any treatment service, and, given a scarce and costly resource, hospital staff must also consider clinical treatment needs as well as diagnosis and risk DSPD services were implemented in 2003 Evaluation was built in to the pilot projects Preliminary evaluation reports fuelled further debate, in 2007 a whole issue of the British Journal of Psychiatry (190:49) being allocated to this It has become possible to identify strengths and weaknesses of the programme A Critique of DSPD The term DSPD may be unique, but the problems it attempts to encompass are not, nor are methods of assessing and treating personality disorder The origins of the programme can be traced to four major influences: decreasing tolerance of the risks associated with crime and violence; growth of standardised risk assessment and the PCL-R; the Dutch TBS (Terbeschikkingstelling) system (van Marle, 2002; McInerny, 2000); the development of cognitive behavioural programmes for sexual and violent offenders Decreasing tolerance of risk of crime Over the last two or three decades, most developed countries have become less tolerant of the risks associated with sexual and violent offending, as reflected in changes to criminal justice legislation and sentencing The reasons for these changes are complex It is a mistake to see them as the whims of authoritarian governments; they owe far more to populist democracy, the growth of feminism, and increasing respect for the rights of children and of victims of crime DSPD was also consistent with a strategy to combat social exclusion Furthermore, knowledge has changed substantially since the 1980s, with greater and more widespread understanding of predatory paedophiles (D’Arcy and Gosling, 1998; Oliver and Smith, 1993) and of the lasting psychological harm done to many survivors of physical and sexual assault These social changes had their greatest impact on the criminal justice system, but mental health services could not expect to remain isolated from these evolving values and expectations Indeed, over the same period there has been growing demand that professionals become more responsive to the needs and concerns of their clients or patients In this context, psychiatrists’ attempts to wash their hands of responsibility for offenders with personality 414 K17373.indb 414 3/31/14 6:17 PM Dangerous and severe personality disorder (DSPD): The rise and fall of a concept disorder were anachronistic and doomed to failure DSPD developments may have been the starting point of a new approach to people with personality disorder, but it has become just one small part of a process that includes policy and attitude change, as in the NIHME (2003) document Personality Disorder: No Longer a Diagnosis of Exclusion, the development of Multi-Agency Public Protection Panels/ Panel Arrangements (MAPPPS/MAPPAs), development and demise of a National Patient Safety Agency and an overarching determination to develop safer services Standardised risk assessment and the Psychopathy Checklist We introduced this chapter with concerns about reliable and valid diagnosis of personality disorder; in particular, categorical diagnosis of antisocial personality disorder has been so confounded with criminality that it hardly discriminates between prisoners In the USA, for example, one study found 90% of prisoners had the diagnosis (Guze, 1976), while in England and Wales the rate was so high that the Office of National Statistics researchers took the decision to exclude it from most calculations (Singleton et al., 1998a) This unsatisfactory situation changed to some extent with the concept of the psychopathy, and development of the Psychopathy Checklist – Revised (PCL-R; Hare, 2003) It is not perfect, and there is plenty of room for argument about the nature of psychopathy, but the PCL-R satisfied the first precondition for research by allowing measurement and discrimination between groups Similar considerations apply to the management of risk; some of the claims for actuarial risk measures are overblown, and they are of limited use in individual risk prediction, but standardised measures have allowed systematic description and communication of risk, and lend themselves to population studies (see also chapter 22) It is fair to say that, without the improvements resulting from the use of standardised measures of personality disorder and risk, there could never have been a DSPD service An early vision of DSPD services was that all prisoners would be measured on a battery of scales and those with the ‘correct scores’ would go to the new service This approach oversimplifies the hazy boundaries between different types of deviance, and it risks repetition of old mistakes in medicalising criminality (Sim, 1990; Maden, 1993) We have also explored another historical problem in the treatment of personality disorder – how to measure change Clinicians accustomed to monitoring progress by the fading of symptoms such as hallucinations or delusions struggle with patients who often not present with sustained descriptions of subjective complaints in this kind of way, and it is easy to lose sight of treatment goals DSPD services were ahead of most UK forensic mental health services in exploring the use of structured dynamic measures to define goals and progress towards them We not yet know how well these proxy measures of change will correlate with behaviour in the community when patients move on Any attempt to measure such correlations is fraught with methodological problems – not least, the fact that only patients who appear to well on the proxy measure are likely to be exposed to the outside world One of the original concerns about the emphasis on the PCL-R and risk assessment tools in defining DSPD was that this would result in the locking away of ‘people who have not done anything’, but just happened to get a high score on an instrument about an abstract concept This worry has proved unfounded The main reason is that, for all the claims to statistical sophistication, violence risk assessment relies on the old adage that the past is the best guide to the future The risk threshold set for entry to DSPD services ensures that people must have done something in order to get over the bar In this context, strengths of the risk assessment tools recommended are that they rely largely on historical and verifiable fact and are transparent The Dutch TBS system The Dutch TBS system has been managing violent and sexual offenders in institutions and in the community since 1928 Under TBS legislation, offenders convicted of a serious sexual or violent offence and judged to present a high risk of re-offending are sentenced by the criminal court to a TBS order They serve a prison sentence appropriate to the offence and are transferred to a TBS facility for treatment at the end of that sentence They remain within the TBS system indefinitely (subject to regular review by a tribunal), first in a secure institution and, when safe, as conditionally discharged, supervised patients in the community Dutch courts rarely give a sentence of life imprisonment and the TBS order is in many ways a substitute Treatment within the TBS system is eclectic, but CBT is prominent, and there is also an emphasis on therapeutic community principles and on work; patients are expected to spend about half the week in paid employment Antilibidinal medication is widely used with sex offenders, and accounts for much of the medical input as most other treatments are delivered by psychologists or specially trained (non-medical) therapists The practical outcome of a TBS order – prison then indefinite detention in hospital – is the same as for many English prisoners transferred to hospital near the end of their sentence, but the Dutch system is more transparent The future is spelled out at the time of sentencing; planning can begin early The experience of staff in DSPD hospital units has been that they spend much time and energy mollifying patients who are understandably angry at being transferred to hospital just as they were expecting release to the community The nature of DSPD means that the information to support detention on grounds of risk was available at the time of sentencing, so it is reasonable 415 K17373.indb 415 3/31/14 6:17 PM Personality disorders to ask why, if an indeterminate order is appropriate, it was not considered so by the sentencing judge The problem was often compounded by the Mental Health Act (MHA) 1983, worded so as to encourage patients in a belief that refusal to co-operate would lead to their being deemed untreatable and, therefore, not detainable In fact mental health review tribunals rarely discharge patients on such grounds, and perhaps the removal of the language of ‘treatability’ by the MHA 2007 will help By contrast, people in the TBS system are always given the simple message that movement through the system depends on progress in treatment, so, where possible, everything works much more quickly Nevertheless, the TBS units also suffer from difficulties in discharging patients; after a minimum of years of treatment, about 20% of patients are judged unlikely ever to be discharged and plans are made for indefinite detention, subject to rights of appeal and regular review, with priority given to quality of life Hitherto, even high security hospitals in England have rarely had to contemplate indefinite stay for any patient, least of all those with personality disorder ( Jamieson and Taylor, 2002) A threat was that the DSPD initiative might have made English hospital units more like the Dutch TBS units in this less appealing way Sentencing within the ‘indefinite public protection’ (IPP) framework, however, went some way down this road, attracting a great deal of approprium as result (See chapter 2) Cognitive behavioural programmes for sexual and violent offenders DSPD may also be seen as a part of the backlash against the therapeutic nihilism that infected prisons in the 1970s and 1980s The ‘what works?’ movement of the 1990s (McGuire, 1995) sought to counter this pessimism and led to a rapid growth in CBT based programmes for sexual and violent offenders Canada can claim to be the birthplace of such offending behaviour programmes (OBPs), but they have now been developed in prisons in many countries, and some specialist mental health services are beginning to consider that versions of them might usefully be developed for patients too Inevitably, some offenders benefit more than others from OBPs, and there have been research reports claiming that people with high scores on the PCL-R are likely to worse than others in most respects: more likely to drop-out, to disrupt treatment or to re-offend after treatment There have even been claims in this last respect that such programmes make high PCL-R scorers worse, although a systematic review of the literature found that of the 24 studies of this identified, only three were of appropriate design for the research question, and none met the reviewers’ methodological standards (D’Silva et al., 2004) There may, in fact, be little case for the gloom about potential responsiveness Nevertheless, there is a problem with offending behaviour programmes which must be acknowledged They are designed to reach the maximum number of offenders at minimum cost so are, by nature, ‘one size fits all’, with little attempt to tailor the intervention to individual pathology One would not, therefore, expect outliers on any dimension to well Drop-outs are not of major concern so long as most people complete the course – indeed, drop-outs create a place for someone else when places on such courses are in high demand High PCL-R scorers were, thus, often excluded from standard programmes, so some more specialist versions have been developed through the DSPD initiative, for example the Chromis programme (Wallace and Newman, 2004) At present, only evidence relating to the generally available programmes, applied to less selected groups of offenders, is available, although there are no RCTs Most of the published trials have relied on matching Hanson et al (2002) reviewed 43 studies that included at least a matched, untreated group, yielding a total of 9,454 sexual offenders (5,078 treated and 4,376 untreated) Metaanalysis showed treated v untreated recidivism rates of 12.3% v 16.8% for sexual offending and 27.9% v 39.2% for all offending For both groups of offenders, these differences are statistically significant; when analysis is restricted to interventions explicitly meeting current standards for OBPs, the differences are more substantial: 9.9% v 17.4% for sexual recidivism, and 32% v 51% for all recidivism So, there is cautious optimism about such programmes, although Marshall and McGuire (2003) note we not know ‘with which types of offenders’ treatment is most likely to be effective (p.654) It is likely, however, that impact will be least on predatory offenders or those with ‘stranger’ victims and perhaps those with high psychopathy scores – in other words, those for whom DSPD services were designed (Maden, 2007) Brooks-Gordon and Bilby (2006) echo the note of caution, albeit principally for sex offenders, and draw attention to the ‘enormous political and institutional pressure to prove that treatment works’ Despite this uncertainty, cognitively based programmes remain at the heart of OBPs for DSPD, not least because of the advantage that staff in a prison can be maximally involved in delivering such programmes; training, and support in delivering the programme, is far less costly than a full clinical training, for whatever clinical discipline Then, too, explanations of behaviour couched in cognitive terms make sense to staff and offenders alike, and they help both to structure expectations and plan care pathways Explicit procedures and aims facilitate evaluation Even if more evidence is needed on effectiveness, they also provide for methods to achieve that The Violence Reduction Programme (Wong et al., 2007) at Saskatoon’s Regional Psychiatric Centre (RPC), a specialised unit of the Canadian correctional system, is an example of one of 416 K17373.indb 416 3/31/14 6:17 PM Personality disorder: Some conclusions these programmes Maden et al (2004) contrasts it with the DSPD programme, for which it served as a model There are two major differences: first, the Saskatoon unit is part of the prison system All programme participants are serving prisoners who have volunteered and can be sent back to ordinary prisons if they are violent within the unit, or if treatment is not progressing; second, the Canadian correctional system includes a ‘Supermax’ prison (see also chapter 25) that, effectively, provides backup in dealing with the most disruptive or violent behaviour By contrast, the English DSPD system is committed to providing two parallel and different services – the hospital stream and the prison stream The challenge for the high secure hospitals is daunting; if there is too much emphasis on control and security the CBT will not work, yet too much reliance on self-control may lead to indiscipline and the disruption of therapy The Future: Beyond DSPD The DSPD service was expensive, with a bed in a high secure hospital costing about £240,000 per annum This is a huge sum when it is anticipated that standard cases will require between and years of treatment and many patients will be there for much longer, although compared to some innovative treatments in physical medicine, the figure may pale into insignificance Whatever the ethical and scientific controversies about the service have been, to a large extent, economics have determined its future Study of the economics of treating personality disorder more generally is becoming ever more sophisticated (e.g Soeteman et al., 2010), and the full NICE guidelines on treatment of antisocial personality disorder and borderline personality disorder (NICE, 2009a,b) include financial information along these lines The true cost of untreated personality disorder in serious offenders, including recidivist child sex offenders is, however, incalculable Decommissioning of some of the DSPD pilot units will allow for funding of a ‘personality disorder pathway’, with access to psychologically informed planned environments (PIPES) in prisons and the community and extension of currently accredited programmes (Joseph and Benefield, 2012) Personality disorder: Some conclusions Personality disorder is a common problem – in one form or another far more common in the general population than schizophrenia – and yet its assessment and treatment has been peripheral in most general psychiatric services Forensic mental health services are beginning to respond, and some have specialist personality disorder services, with naturalistic outcome data that are promising Personality disorders are the cause of much misery for the primary sufferers and for their family and friends They have serious consequences in the associated mortality rates from suicide and accident, which are much higher than in the general population; some personality disorders have a strong association with repeated offending, sometimes serious offending The nature of disorders of personality is becoming clearer, but there is still much to learn to meet the substantial personal and population needs created by them With such improvements in knowledge about genetic loading and environmental hazards that may contribute in various mixes to causing them, personality disorders may, with benefit, be conceptualised as developmental disorders Improvements in assessments can and are being brought to bear on improving treatment, and there is growing, if far from good enough evidence that treatment, especially psychological treatments delivered within an appropriately multi-professional framework, can make a positive difference to health and social function Borderline and antisocial personality disorders are not the most common in the general population, but they tend to be the ones most frequently seen in specialist forensic services, whether based in health or criminal justice services Forensic mental health practitioners currently lead much of the good practice in working with people with such disorders It is important that the skills and the willingness to treat people with personality disorder are disseminated more widely throughout mental health services if such people are to be held on a recovery trajectory and, where the disorders are linked with serious offending, they, their families and the wider community are to be made safer 417 K17373.indb 417 3/31/14 6:17 PM ... approach 11 2 The scope and limits of this chapter 11 2 National, subnational and supranational legal structures 11 3 Controversial issues and shifts in public and professional opinions 11 4 3/ 31/ 14... Clinic of Forensic Psychiatry in Copenhagen 19 82–2 011 From 19 82, a member of the Danish Medico -Legal Council; from 19 92, vice-president and head of the Section of Forensic Psychiatry; 19 89–2 011 chairman,... Care and Rehabilitation) Act 2003 (13 4) Republic of Ireland Mental Health Act 20 01 (10 6, 10 7, 10 8, 11 0) Criminal Law (Insanity) Act 2006 (10 7, 10 8, 10 9, 11 0) South Africa Criminal Procedure Act 19 77