10.1 Our terms of reference require us 'to compare practice, diagnosis and treatment with that elsewhere, to build on current expertise and research to inform the development of a medical protocol to respond to the needs of personality disordered offenders'.
10.2 The remit therefore carries the implication that the presence of a personality disorder is a potentially important component in those who commit serious violent or sexual offences. We do not think this implication should be over-stated. Our approach to the problem of serious violent and sexual offenders has consistently been governed by the identification and management of the risk they present to society rather than by the presence or absence of any particular psychological or medical condition. Nonetheless, our remit clearly requires us to address the issue of personality disorder. In this chapter we set out our understanding of the term, discuss its relevance to serious violent and sexual offending in Scotland and make some observations concerning treatment.
What is Personality Disorder?
10.3 The category of mental disorders known as 'personality disorder' is probably the most contentious in psychiatry and associated disciplines. Personality disorders that are manifested by antisocial behaviour patterns (discussed further below) are the chief concern in this chapter. In antisocial types of personality disorder there is, at present, inadequate evidence of a generalised abnormality in the brain, or elsewhere in the central nervous system or in any other body structure. Science has not, so far, found a widely accepted explanation of what abnormality causes the antisocial behaviour in those with this type of personality disorder. Therefore to some extent the personality disorder is defined by antisocial behaviour and the behaviour is explained by the disorder. Not surprisingly, this type of definition has been criticised for being somewhat circular.
10.4 There is a further problem in grading the seriousness or severity of antisocial types of personality disorder. Some workers in this field do not clearly distinguish between a moderate degree of personality disorder and the most severe form of the condition. The latter is sometimes referred to as 'psychopathy' but we think that term may have unwelcome implications and we therefore avoid it. We do however emphasise that our concern is with severe degrees of antisocial types of personality disorder.
10.5 Finally, there are related issues that generate what can only be described as unanswerable questions. For example, if the abnormal behaviour disappears, has the mental condition remitted? Can a person with a personality disorder exercise control over his/her behaviour? Is a person with a personality disorder legally responsible for his/her actions? Is the condition simply a way of describing one extreme in the range of human behaviour? These are all huge questions and their discussion is largely beyond the remit of the Committee. We do however emphasise that although the subject is contentious, there continues to be a slow accumulation of knowledge based on properly conducted scientific research.
10.6 There are definitions of personality disorder, and its various sub-types, in the standard classifications of mental disorder, namely the ICD-10 Classification of Mental and Behavioural Disorders (World Health Organisation, 1992) and the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition - DSM IV (American Psychiatric Association, 1994). In essence there are four components in the definition of a personality disorder. These are:
i. a pattern of behaviour or emotional response or perception
ii. that is evident in early life, persistent, pervasive and a deviation from the person's cultural norm
iii. that leads to distress to the person or to others or to society and
iv. is not attributable to any other psychiatric or physical disorder.
10.7 A personality disorder is thus characterised by a pattern of qualities that is lifelong, that leads to distress or dysfunction and is not due to other conditions. The ICD-10 contains eight categories of personality disorder within Section F60, while the DSM IV lists ten within three different clusters in Section 301. It cannot however be over emphasised that the various categories of personality disorder are not mutually exclusive, and that overlap between them is common. Indeed it is relatively unusual to find 'pure forms' of any particular type of personality disorder.
Personality disorder in Scotland
10.8 There are no figures available for the prevalence of personality disorder in the Scottish population. Community surveys from elsewhere suggest that up to 11% of the adult population may suffer from any type of personality disorder17 but the great majority are not related to an increased likelihood of offending. We know that the prevalence of personality disorder is substantially higher in those people who have medical complaints and who consult general practitioners or are admitted to hospitals.
10.9 Personality disorder is thus common, probably five times more common than a serious mental illness such as schizophrenia. Extrapolating from the figures above we can estimate that between 200 000 and 300 000 adults in Scotland have a personality disorder. In striking contrast is the rarity of psychiatric hospital admission for people with a primary diagnosis of personality disorder. Less than one in 300 people with a personality disorder is likely to be admitted to a psychiatric unit in any year. In 1998 personality disorder accounted for only 2% of the 32 000 psychiatric admissions in Scotland18 there is likely to be an under-recording of the diagnostic category of personality disorders in the statistical returns from which these data are derived. Data are not available for the frequency with which people with a personality disorder come to the attention of medical services or social work agencies.
Antisocial personality disorder
10.10 In relation to offenders, there has been particular interest in the type of personality disorder described as dissocial in ICD-10 and as antisocial in DSM IV. Historically other words have been used such as psychopathic and sociopathic to describe this type of personality disorder. Unfortunately each new term quickly acquires pejorative overtones that affect its application and have damaging implications. For the purpose of this report we will use the term antisocial personality disorder as this seems to be most widely used in current scientific literature. Our concern is with the disorder in its severe form.
10.11 ICD-10 lists the following six characteristics:
i. Callous unconcern for the feelings of others.
ii. Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations.
iii. Incapacity to maintain enduring relationships, though having no difficulty in establishing them.
iv. Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.
v. Incapacity to experience guilt or to profit from experience, particularly punishment.
vi. Marked proneness to blame others, or to offer plausible rationalisations, for the behaviour that has brought the patient into conflict with society.
10.12 DSM IV lists some similar features but also requires that the person is aged at least 18 years before the diagnosis is made, and that there is evidence of disordered conduct with its onset before the age of 15 years.
10.13 There is evidence that antisocial personality disorder is associated with:
1. Increased risk of physical illness.
2. Frequent use of healthcare services.
3. Other psychiatric disorders, e.g. substance misuse and depression.
4. High rates of mortality, particularly by suicide and by accidents.
Prevalence of antisocial personality disorder in Scotland
10.14 Having provided a brief outline of the definition of antisocial personality disorder, we now turn to the more important questions of the prevalence of the condition among those who commit serious or violent sexual offences in Scotland. Our knowledge is incomplete. Psychiatric or psychological assessments are only carried out on selected offenders and therefore the characteristics of all serious and violent sexual offenders are not known. We do however have some data in relation to sentenced prisoners. In a study of men serving sentences in Scotland, Cooke19 using a research instrument known as the Psychopathy Check List - Revised version (or PCL-R) - found that approximately 6-8% could be diagnosed as having a severe antisocial personality disorder and 52% had a less severe form of antisocial personality disorder. Research in England and Wales (using a different measuring instrument) found 63% of sentenced men, and 31% of all women in prison had an antisocial personality disorder, but the research did not seek to identify severity of the disorder20.
10.15 There are limited data available concerning people with a personality disorder who are compulsorily detained in hospital and who have a mental disorder manifested only by abnormally aggressive or seriously irresponsible conduct - often considered the Scottish equivalent of the category psychopathic disorder in the Mental Health Act 1983 for England and Wales. In 1998 there were more than 4000 compulsory admissions to psychiatric hospitals in Scotland. These include approximately 3700 non-offenders (i.e. ordinary patients who have not broken the law) admitted under the civil provisions of the Mental Health (Scotland) Act 1984, and approximately 500 offender patients admitted either under the Criminal Procedure (Scotland) Act 1995 or Part VI of the Mental Health (Scotland) Act 1984. These compulsory admissions are in the legal categories of mental illness or mental handicap. Information kindly provided for us by the Mental Welfare Commission for Scotland confirms that in less than 20 cases was detention in hospital applied by reason of a mental illness manifested only by abnormally aggressive or seriously irresponsible conduct. These were all under civil provisions and there were no such detentions ordered by the court in respect of offender patients.
10.16 At the State Hospital, a survey conducted by Thomson et al.21 found only 13 patients (5.4% of the resident population) in whom the principal diagnosis was a personality disorder. However a further 51 patients had the disorder in combination with other conditions. Indeed an unpublished survey referred to in the Report of the Inquiry into the Care and Treatment of Noel Ruddle (Mental Welfare Commission for Scotland, 2000) suggests that up to 75% of the State Hospital population may have a personality disorder of one type or another.
10.17 Summarising these points we can conclude as follows:
1. It is not known how many serious violent or sexual offenders have a personality disorder.
2. Personality disorder alone is very rarely the diagnostic criterion for compulsory admission either under civil or criminal mental health legislation.
3. Approximately 50% of male sentenced prisoners in Scotland have an antisocial personality disorder, and this is severe in up to 8% as measured by current research instruments.
4. In 1997 there were 13 patients at the State Hospital with a principal clinical diagnosis of personality disorder.
Personality disorder and other conditions
10.18 While personality disorder is in itself an unlikely reason for compulsory detention in hospital, abnormal personality traits are commonly found in patients who are detained under mental health legislation. The figures for personality disorder in combination with other disorders given in paragraph 10.16 (above) are broadly similar to those reported from the English special hospitals22. In these populations the psychiatric conditions that are most likely to co-exist with personality disorder include schizophrenia, other types of paranoid psychoses, substance misuse and learning disability.
10.19 Personality disorder may be present in some people who commit serious sexual crimes. In general however sex offenders are a heterogeneous group with few uniform psychiatric features. Thus they may or may not have a personality disorder, they may or may not be sexually deviant and they may or may not have a recognized psychosexual disorder. The presence or absence of a personality disorder in itself is not a reliable indicator of any propensity for committing sexual offences.
10.20 The discussion outlined in paragraphs 10.1-10.17 indicates why we consider that personality disorder is an inappropriate 'starting point' from which to consider the problem of sentencing serious or violent sexual offenders. In short, it is not sufficiently specific to include the wide range of people who may commit serious violent or sexual offences. Many serious offenders do not have an antisocial personality disorder. We are aware that the UK government has proposed for England and Wales various measures in relation to a condition it has referred to as 'dangerous severe personality disorder'. For reasons stated earlier, we have considered that the more appropriate approach in Scotland is to consider risk assessment and risk management, rather than focus solely on personality disorder.
Treatment for personality disordered offenders
10.21 Although offenders with personality disorder are only part of our terms of reference we have been asked to comment in particular on issues of practice, diagnosis and treatment in relation to this group. The way in which services should deal with offenders with personality disorder is considered in Chapter 11, but it may be helpful to address the general question of treatment before setting out our detailed recommendations.
10.22 The evidence of the effectiveness of various treatment approaches was exhaustively studied by Coid and Dolan in 1993, in a work commissioned by the Reed Working Party23. More recent analyses have been carried out by Loesels and Blackburn.24
10.23 We also received submissions from a number of organisations and individuals about treatment and 'treatability'.
10.24 Although there was some anecdotal evidence of promising treatments, such as dialectical behaviour therapy and therapeutic communities, the majority of psychiatric responses reflected current 'therapeutic nihilism', and the lack of convincing research evidence to support any particular treatments. However, a number of respondents disputed the perception that personality disorder was 'untreatable'. The National Schizophrenia Fellowship Scotland pointed out that such a view was likely to be a self-fulfilling prophecy - if treatment is assumed to be hopeless, then no treatment will be tried and evaluated.
10.25 The Psychotherapy Section of the Royal College of Psychiatrists said that there was clear evidence that effective treatments (particularly psychosocial interventions such as cognitive and dialectical behaviour therapy and psychodynamically orientated day patient treatment) exist to alleviate the symptoms of personality disorder.
10.26 The consensus view, which we share, is that it is unduly pessimistic to conclude that 'nothing works'. However, we are still some way from being able to say exactly what does work, and for whom. Furthermore, it is generally agreed that interventions are more likely to have a beneficial effect with those who are willing to engage with treatment, and with those who are less severely disordered. Indeed, in relation to severely personality disordered offenders, there is some evidence that recidivism increases after treatment.
10.27 All currently accepted treatments for personality disorder require the co-operation of the person with the disorder. Treatment cannot be successfully imposed against the will of that person. Not only is the research literature on treatment approaches unconvincing but it derives principally from settings where voluntary patients undergo treatment in conditions in which they are not compulsorily detained. The applicability of these treatments for compulsorily detained people in custodial settings has not been established.
10.28 It is also extremely difficult to measure treatment success clinically, since any evaluation of the individual's psychological state depends largely on self reporting. Nor can it be assumed that treatment which may alleviate some of the symptoms of personality disorder will necessarily reduce the risk of serious violent or sexual offending, since the connection between the disorder and risk is often complex.
10.29 It is important, therefore, that any attempt to reduce the risk to society created by offenders with personality disorder is not predicated on the idea that compelling people to receive treatment will necessarily achieve this aim.
10.30 Personality disorder is a mental disorder, but it by no means follows that treatment must only be delivered in a health care setting. Several responses to our consultation from psychiatrists and NHS services contended that psychiatry was not best placed to meet the needs of offenders with personality disorders, and that, insofar as treatment was appropriate, it was principally social and psychological treatments that were indicated. Other responses from social work and prisons suggested that forensic psychiatry did have a role, but in partnership with clinical psychology, social work and others.
10.31 There is no clinical tradition in Scotland for detaining large numbers of serious violent or sexual offenders with personality disorders in secure or other hospitals. Any change in current practice can only be driven by clinical developments and not by a policy decision that lacks a sound theoretical footing. We have not been able to identify any major clinical development in the treatment of personality disorder that would justify a change in Scottish practice. We therefore expect that serious violent or sexual offenders who have a personality disorder will, on conviction, continue to serve sentences in prison. We recognise that the burden of responsibility for providing safe custody and for addressing the problems that gave rise to offending will remain with the SPS. This is a heavy burden and responsibility but we do not think it can be carried out by any public body other than the SPS.
10.32 We have noted the discussion in the Home Office consultation paper25 on what has been called the 'third way' between hospitals and prisons for personality disordered offenders. Such institutions do not currently exist and the difficulties in establishing them in Scotland would be immense. They would require appropriate location, staffing, policies and regimens. At present we do not consider that the establishment in Scotland of a third way type of institution is either feasible or advantageous. Instead we think that an imaginative approach is necessary within the SPS. Regimens are needed that are driven by risk assessment and its continued management throughout the term of imprisonment and, with the assistance of other agencies, in the community. We discuss these measures further in Section Two.
10.33 There are some other general issues regarding treatment. Any change in personality disorder takes place over long periods of time. This presents problems in evaluating treatment since it is hard to know whether any beneficial change is the result of treatment or is simply the amelioration of violent behaviour due to the ageing process. More importantly, for our purposes, it means that short 'blasts' of treatment are highly unlikely to be effective. Personality disorder is a 'lifetime condition' and therapeutic interventions may require to be delivered over lengthy periods. Thus a consistent and co-ordinated approach is necessary between agencies and in different service settings. The British Association of Social Workers commented that there are many people who do not 'fit' either the mental health or criminal justice system. A complex package of care and intervention is often required, which in turn necessitates a flexible range of disposals.
10.34 Many experts are sceptical about the extent to which underlying personality can be changed, once a pattern of dysfunctional behaviour has been established. Treatment, if it works at all, will probably help the person better to adjust his/her situational responses to societal norms, rather than "cure" the disorder. When working with personality disordered offenders, the most important aim is to reduce the risk of their committing further antisocial acts. Treatment, therefore, should be seen not as a time-limited intervention but as part of an overall strategy for the management and reduction of risk.
Preventive detention
10.35 We gave careful thought to the matter of the identification of people with personality disorder currently at liberty but who, at some time in the future, might commit a crime of a serious violent or sexual nature. The implication of such identification is that it might be followed by some form of preventive detention, whether or not the personality disorder is a condition for which medical treatment is available, feasible or beneficial. The implications of this type of measure are profound. We did not learn of any jurisdiction where it is currently in practice. In the UK it is possible under existing mental health law for civil detention in hospital to be on the basis of personality disorder that meets appropriate criteria but the disorder must be one for which treatment is appropriate; and there must be a prospect of benefit from treatment. In other words this legislation may not be applied simply to achieve preventive detention.
10.36 No witnesses from whom we heard supported a move towards preventive detention of this type. We did not hear any professional body or agency say they considered it an appropriate task for their particular profession or agency. Practitioners had little confidence in their ability to identify cases; providing, staffing and running an appropriate place of detention would pose difficulties that would probably prove insurmountable; and above all the deprivation of freedom for those detained would not be balanced by a sufficiently measurable gain in terms of public safety. For all these reasons we firmly rejected the proposition of pre-offence preventive detention.
Prevention
10.37 Finally, within the modern national health service it is recognised that health policy should be directed not solely towards treatment but also at prevention. The prevention of personality disorder is not a matter within our remit. However, we noted with interest the comments of the Royal College of Psychiatrists in its report on offenders with personality disorder - 'the preventive approach appears to offer more hope and a stronger basis for the investment of scarce resources and treatment interventions'26. In England and Wales, the Home Office and DoH document on managing people with dangerous severe personality disorder contains a section on prevention strategies, focusing particularly on intervention in childhood and adolescence. We commend such an approach to the Scottish Executive.
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RECOMMENDATION 47 The Scottish Executive should consider measures that might be taken to include the prevention of personality disorder within its broader strategies, including those on education, social inclusion, public health and substance misuse. |