Introduction
11.1 We have emphasised that the identification and sentencing of high risk offenders should be based on the development of improved methods of risk assessment and management, rather than the identification of a particular type of psychiatric condition or personality disorder. Nonetheless, our terms of reference require us to specify the services required by serious violent or sexual offenders with personality disorder. In our considerations of this complex matter we have heard evidence from experts and practitioners in the field and have visited services within the UK and abroad.
11.2 In this chapter we review the types of service that currently exist both within Scotland and elsewhere, identify the problems inherent in such services, and finally make some recommendations which are intended to help create the basis for developments in treatment and management.
What is currently available?
11.3 Our Committee was unable to identify any service in Scotland with a sole and specific remit for the care or treatment or supervision of offenders with personality disorder. Within certain local authority, penal and health services there are some limited facilities within the general provision for a wider group of clients, prisoners or patients. We visited some of these, and met staff from others (see Annex 4), and were impressed by the dedication of professionals in dealing with a difficult group of people, often with little support.
11.4 Within local authority criminal justice services, we heard evidence that the designation of an offender as 'personality disordered' was regarded as unhelpful, for various reasons. First, it had a discriminatory effect serving to exclude the offender from services because of an implied risk inherent in the designation. Indeed it was even suggested that the term was used by staff in psychiatric services as a means of rejecting the offender from service provision. Second, it carries the implication of untreatability or incorrigibility and makes the offender an unattractive prospect to agencies that are more keen to work with clients who are seen as likely to benefit from the particular intervention.
11.5 The SPS does not have a resource specifically for offenders with personality disorder. There are small units at Shotts and Peterhead prisons for particularly difficult prisoners, many of whom would probably attract a diagnosis of personality disorder. (The unit at Peterhead has since been suspended from operational use). We were impressed by the success that the staff have had in coping with a very difficult group of prisoners. However, even in these units it was clear that there were substantial problems in coping with a small number of highly antisocial prisoners. The aim of these units is primarily to manage difficult prisoners, rather than to offer treatment for personality disorder, and in this task it seemed successful.
State Hospital and other health facilities
11.6 As indicated above (paragraph 10.14) the State Hospital contains mentally disordered offenders of whom a small number have a sole diagnosis of personality disorder but a larger number have such a disorder in combination with other psychiatric conditions. There is considerable expertise at the State Hospital but it was not suggested to us by staff that the hospital currently had a particular focus of interest in, or treatment for, personality disorder.
11.7 The special hospitals in England (broadly equivalent to the State Hospital in Scotland) accommodate a much higher proportion of patients with a primary diagnosis of personality disorder than does the State Hospital. This reflects both differences in mental health law (the Mental Health Act 1983 in England has a specific category of psychopathic disorder) and a different tradition within the English special hospitals. The evidence base for the effectiveness of the special hospitals in managing personality disorder is limited. The Ashworth inquiry27 found that the decision as to whether a serious offender with personality disorder was sent to prison or to hospital was (in their words) 'a lottery'.
11.8 We found no other in-patient services specifically for personality disordered offenders in Scotland. The situation regarding community NHS facilities was little different. Some day hospitals or community-based services attempted to deal with personality disordered offenders but there were no designated services for such people. We were advised that even specialist services for offenders, such as that at the Douglas Inch Centre in Glasgow which deals with many offenders who would be categorised as personality disordered, lack appropriate staffing to offer comprehensive psychologically based programmes designed to address offending behaviour for this group.
Why is the service base low?
11.9 A comprehensive evidence base for the successful management of personality disordered offenders within the criminal justice system does not exist. In its absence it is not surprising that specific services for personality disordered offenders have not developed. This is an area where failure is common and may sometimes have grave consequences. Professional staff naturally wish to be associated with success rather than failure, and there have been few initiatives. We are not surprised. There are also well recognised pitfalls in the provision, functioning and management of any such service and these too are likely to be powerful deterrents.
11.10 Striking a balance between treatment and control of serious offenders with personality disorder is a challenging task given the behavioural manifestations of the disorder and the vagueness of definition in certain treatment approaches. A recurring theme apparent from the visits to the facilities and services, and from presentations made to our Committee, was the difficulty arising from failures to manage the relationship between the offender with personality disorder, whether or not in combination with any other psychiatric condition, and the service in question. Many of the facilities visited had experienced problems at some time arising from a breakdown in the boundaries between staff and patients/prisoners; these had often led to situations of potential or actual danger.
11.11 Key features of personality disorder are the behavioural and interpersonal manifestations of the individual's personality traits. These present particular challenges in treatment and can easily lead to the 'splitting' of staff. That is, staff members, individually or collectively, become the focus of the patient/prisoner's distorted relationships and behaviour; some staff are 'favoured' by the client while others are not. Generally such 'favour' comes at a price for the staff member unless he/she is aware of it, and is able to receive proper professional supervision to deal with it. Indeed for all staff working with such personality disordered people the importance of proper supervision is essential for maintaining appropriate professional boundaries.
11.12 Our Committee recognised that the legislative framework, the treatment goals of the service and the possible outcomes for the prisoner/patient must be integrated in a way that is clear to staff and their clients. Where services had a less clear framework there appeared to be a danger that containment and treatment issues could become confused. Such confusion provides opportunities for the manipulation of the rules and regulations of the service concerned, and possibly of the actual treatment programmes.
11.13 It was clear to our Committee that mental health models of care with the modern emphasis on patients' rights and user empowerment can sit uneasily in a service dealing with serious offenders with personality disorder. People with severe personality disorder can be very challenging and litigious; they can identify and exploit 'fault lines' in the organisation of any treatment setting. Services should have clear philosophies of treatment and management; these should protect the clients' rights but also provide an organisationally robust environment that supports consistent treatment interventions to promote positive change in clients.
11.14 We found a variety of approaches in the services visited. Some placed a greater emphasis on containment with specific treatment interventions, others provided a living environment (or milieu) that in itself was seen as the major part of the therapy, as in therapeutic communities. Other facilities combined features common to both these approaches within a structured therapeutic environment. Many of the facilities visited provide a range of environments allowing for movement between differing levels of security. These arrangements reflect the fact that any service must allow for change and progression in its client group.
11.15 Our Committee is not in a position to identify the 'best' approach but we think it important to recognise some of the key features that we, and others, consider essential in the provision of services for serious offenders with personality disorder, whether such services are in a prison, health service, local authority or other facility. Some of these key features are in accordance with evidence submitted to the Ashworth Inquiry28. These include:
11.16 There exists a serious shortage of properly qualified and experienced practitioners with the appropriate expertise to initiate and maintain services with the features we have outlined above. We discuss below the possibility of piloting new services. We emphasise that there are unlikely to be any such developments until there is a sufficiency of skilled professionals to offer specialist input and provide appropriate leadership.
A medical protocol for personality disordered offenders
11.17 Included in our terms of reference is a requirement for 'the development of a medical protocol to respond to the needs of personality disordered offenders" based on "current expertise and research'. We therefore gave the task much consideration.
11.18 In this context, a medical protocol usually refers to a set of guidelines providing a basis for good medical care. The Scottish Intercollegiate Guidelines Network (SIGN) has published more than 40 clinical guidelines covering a range of medical disorders, all based on current evidence. To date, only two SIGN publications deal with mental disorders, namely management interventions in dementia (February 1998) and psychosocial interventions in the management of schizophrenia (October 1998). The other conditions covered by SIGN are physical conditions such as coronary artery disease, asthma and epilepsy.
11.19 We do not think that the problem of personality disordered offenders lends itself to the development of guidelines or a medical protocol of this type. The term, personality disordered offenders, does not describe a medical condition. The great majority of personality disordered offenders will not routinely have contact with doctors or with other medical agencies, though they might consult them with various health problems. The starting point for any medical protocol must be a clearly defined medical condition or medical symptom, rather than a group of offenders within the criminal justice system.
11.20 Further, the majority of people with personality disorders do not break the law, and only a small number commit serious violent or sexual offences. We do not think that a medical protocol for personality disordered offenders can usefully be developed. We think there may be a case for an organisation such as SIGN to address the more general issue of personality disorder with a view to establishing national clinical guidelines on the basis of current evidence.
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RECOMMENDATION 48 The Scottish Executive should consider whether or not the condition of personality disorder generally should be referred to SIGN with a view to the development of national clinical guidelines. |
New Services
11.21 We have concluded above that the service base in Scotland for serious offenders with personality disorder is minimal. We have also emphasised that little evidence exists that any specific treatment approach has a measurable effect on recidivism in this group of offenders. Our Committee is thus faced with a dilemma in considering recommendations for new services. An apparent need for services is not matched by proven benefit of any particular type of service, yet to make no recommendation implies that no attempt should be made to improve the current situation.
11.22 It is our view that there is no single treatment approach which, were it to be adopted, would solve the problem of serious offenders with personality disorders. Over the years, there have been many false dawns. Therefore our recommendations focus on the more general task of long-term management rather than on a time-limited delivery of treatment. We think the aim of the task is the better protection of the public.
11.23 We found little support for the notion that a new specialist service for serious offenders with personality disorders should be developed outwith existing agencies. Our Committee agrees that such a service is not appropriate for Scotland for a number of reasons. First, no professional group from which we heard considered it had the knowledge, skills or professional enthusiasm to take on such a task. Second, there is no clear definition of the appropriate clients for such a service, nor of the treatment approach it might reasonably adopt. Third, we think that a new service, even if it were feasible, would serve to increase rather than diminish organisational boundaries.
11.24 It therefore seems clear that the needs of serious offenders with personality disorders, and those of society, must be met by the efforts of existing agencies. We recognise that at present serious offenders with personality disorders are an issue for many agencies but may easily become the responsibility of none. There is also an understandable tendency to avoid responsibility for such offenders because of the criticism that is directed at staff if there is serious re-offending (see paragraph 2.17).
11.25 Given the lack of demonstrable benefit from any single treatment approach, we think there is scope to develop and improve the task of long-term management of these offenders in the context of a risk management strategy. We think professional staff of all disciplines would feel more confident, and less vulnerable to public criticism, if the supervision and surveillance of these offenders, in institutions and in the community, was determined by an approach based on sound risk management. We have described in Section One the elements of modern risk assessment based on methods of structured clinical judgement. We would like to see a similar approach govern the management of personality disordered offenders whether in custody or in the community. Risk management is a multi-professional task and we expect that the Risk Management Authority would be a crucial source of guidance on the type and quality of management to be applied.
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RECOMMENDATION 49 Services for serious offenders with a personality disorder should focus on long-term risk management according to standards promulgated by the Risk Management Authority. |
11.26 In respect of treatment interventions we think these will be necessary particularly to deal with co-morbid conditions, such as alcohol or substance misuse. They will also be required to assist the offender to make necessary adjustments in his/her social functioning and behaviour. Although we are unable to recommend the wholesale introduction of a new treatment approach, we strongly support properly planned pilot developments that can be evaluated for their benefits. Since the numbers in any pilot services in Scotland are likely to be small, we also support arrangements to share experience with those elsewhere in the UK and beyond.
11.27 We do not consider that we are in a position to recommend specific types of pilot services. We anticipate that these are likely to be based on currently accepted psychotherapies, including cognitive and psychodynamic models, and therapeutic community approaches. Of equal importance as an agreed treatment philosophy is the need for any service to be co-ordinated between relevant agencies, including those in the community. We hope that the Risk Management Authority could play a useful role in gathering and disseminating evidence of useful treatment approaches, and in supporting trials of new methods. We also anticipate that much can be gained by sharing experience with England and Wales. Although our remit is distinct from the work of the Home Office in relation to 'dangerous severely personality disordered' individuals, and our recommendations differ from their approach, it would appear that there are likely to be new service developments in England and Wales from which Scotland can learn.
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RECOMMENDATION 50 Pilot services should be developed, with the support of the Risk Management Authority, in relation to the long-term management and, where appropriate, treatment of personality disordered offenders. These should be co-ordinated between relevant agencies, draw on the experience of similar pilot projects elsewhere, and should be subject to rigorous evaluation over a period of years. |