Introduction
1. The terms of reference of our Committee require us to compare practice, diagnosis and treatment with that elsewhere. It was therefore necessary for us to have a working knowledge of current practice in dealing with serious offenders if we were to make informed recommendations about developing their sentencing and management in Scotland.
2. There are many interesting projects developing in prison and health systems in the UK, some of which we were pleased to be able to visit. We were also anxious to be informed by practice and thinking further afield, and so undertook visits to the USA, Canada and The Netherlands, each of which takes a different set of approaches to our target group. The legislative basis of these approaches is described in the literature review commissioned by our Committee, which is summarised at Annex 3.
3. Because of the broad range of the facilities we wished to visit, our visiting programme was extensive, consisting of visits to 16 facilities in the UK and 14 facilities overseas.
4. We would like to register our gratitude to all those who helped with the organisation of these visits, without whom we would not have been able to gather a great deal of fundamental information about current practice at home and abroad. In particular, thanks go to those, at the Foreign and Commonwealth Office and elsewhere, who helped us to organise our overseas visits, amongst whom were Richard Homer, David Belgrove, Yvonne Rideout, Diane Foran, Olivia Moore, Dr Stephen Hart, Andre Batenburg, Roxanne Leib and several other very well-informed and helpful people. Without their help and advice it is doubtful that our visits would have been as smooth-running, informative and interesting as they were.
5. Our thanks also go to the people, too numerous to mention by name, who agreed to take the time to meet with us on our visits and with whom we had many valuable and wide-ranging discussions which greatly informed our thinking.
Part One: Domestic visits
6. Our visits to facilities in the UK were as follows:
Prisons:
HM Prison Durham (CSCs and Women's Wing)
HM Prison Grendon
HM Prison Peterhead (STOP Programme and Small Unit)
HM Prison Shotts (National Induction Centre and Small Unit)
Parole Board and Designated Life Tribunal:
Parole Board for Scotland
Designated Life Tribunal
Secure and medium-secure hospitals:
Ashworth Special Hospital, Merseyside
Broadmoor Special Hospital, Berkshire
Crozier Terrace Regional Secure Unit, London
State Hospital, Carstairs
Other health facilities, including those specialising in personality disorder:
Argyll and Bute Hospital, Lochgilpead
Cassel Hospital, Surrey
Douglas Inch Centre, Glasgow
Henderson Hospital, Surrey
Portman Clinic, London
Royal Cornhill Hospital, Aberdeen
Prisons
HM Prison Durham
Visited 29 0ctober 1999
7. Durham prison is a large prison of around 800 inmates which acts both as a local prison and a Category A prison, including for lifers at the beginning of their sentence.
8. Within the prison are two Close Supervision Centres (CSCs) (Wings I and G), which are part of a specialist national resource for those prisoners who are the most difficult to manage, alongside the other CSC at Woodhill prison, in Milton Keynes. The total CSC service accommodates, at present, 45 out of 68 000 prisoners in the English prison service (12 of whom are in Durham).
CSC: I Wing
9. I Wing is a small unit for prisoners who are difficult to manage, who may have a history of psychiatric or personality disturbance. The wing has a capacity to house nine prisoners, and was full at the time of visiting.
10. The wing has a high ratio of staff to prisoners (almost 1-1 on daytime shifts), and aims to have a high level of staff interaction with prisoners. The day is also fairly structured. The aim is to encourage prisoners to act responsibly and develop their ability to cope with other people.
11. The unit does not aim to address prisoners' offending behaviour outside prison, but manage and improve their behaviour within prison. For many of the inmates, the aim is long-term containment, and it is expected that many will spend several years on the Wing.
CSC: G Wing
12. G Wing opened in May 1999. At the time of visiting, it was still coming up to full complement and was holding three prisoners. Eventually, it will house up to nine prisoners, with a ratio of staff on duty to prisoners of almost 1-1.
13. Prisoners will have caused serious problems in the system. They will all have worked through all the levels at Woodhill. G Wing's brief is to help them develop interpersonal skills and learn to interact in an acceptable way with others.
14. Compared with I Wing, prisoners would have less of a psychiatric history, and the aim is for a fairly rapid reintegration in the prison system: normally between six months and a year.
Women's wing
15. The women's wing houses around 100 women prisoners serving from four years to life, including four Category A prisoners.
HM Prison Grendon
Visited 19 October 1999
16. Grendon is a Category B prison in Buckinghamshire. It is established on a therapeutic community model and has been running for around 35 years. The prisoners are long-term prisoners, nearly all with convictions for sexual or violent offences.
17. There are five wings with around 40 prisoners each, and an assessment wing with 20 prisoners. Each wing of the prison is a self-contained therapeutic community with around 14 prison officers and a psychologist, probation officer and therapist.
18. The regime at Grendon involves intensive group therapy and interaction as well as cognitive and psychodynamic programmes. The prisoners at Grendon have all volunteered to take part in the programme. The average length of stay is 14 months, although the hope is that people who will benefit from the regime will stay for at least two years.
19. Recent research against a control group of people who were selected as suitable for Grendon suggested a reduction in reconviction rate of 20 to 25%1.
HM Prison Peterhead
Visited 8 November 1999
Prison, including sex offender treatment (STOP) programme
20. The bulk of the prison population at Peterhead consists of sex offenders serving sentences of more than four years, up to and including life imprisonment. Although there has been resistance from some prisoners, most now participate in the group work done as part of the regime.
21. The STOP adopts a group-work-based approach to addressing offending behaviour and is delivered over a period of approximately one year.
Small Unit
22. The Small Unit accommodates a small number of offenders, all with a history of violence and some with borderline mental illness or low IQ. All are serving very long sentences. At the time of visiting, the Small Unit was housing seven prisoners; the maximum is ten. The seven prisoners had all volunteered to go to the Unit. No-one stays for more than three years and there was a waiting list to get in.
23. The regime is centred on regular meetings of staff and prisoners.
24. There is great emphasis on forensic psychology with a view to promoting behaviour changes.
25. At the time of visiting, members of our Committee were informed that a review of the prison estate was underway and the Small Unit at Peterhead was vulnerable to closure. We have since been given to understand that, following completion of the review, the operation of the Unit was suspended.
HM Prison Shotts
Visited on 17 September 1999
National Induction Centre (NIC)
26. The NIC opened at HM Prison Shotts in May 1995. The aims of the Unit are to provide a placement for adult male prisoners serving 10 years or more where they are sent at the time of or shortly after sentencing to come to terms with their imprisonment and where a long-term sentence plan can be developed.
27. There are 52 places in the Unit and, at the time of visiting, 50 prisoners. There are 32 staff.
28. Prisoners serve between six and twelve months in the NIC, before transferring, normally to mainstream settings (although a few have transferred to small units).
29. The NIC carries out Risk and Needs assessments on prisoners which inform the type of programme work and intervention that is required in the mainstream prisons. It also runs some short of induction programmes designed to assist prisoners to come to terms with their sentence.
Small Unit
30. Prisoners admitted to the Unit present serious management difficulties within mainstream prison settings. Admission is voluntary, and partly depends on a prisoner's acceptance that his behaviour must change. The Unit does not accept prisoners who are showing signs of psychosis or receiving psychotropic medication. Nor does it accept those designated as sex offenders.
31. The Unit is not specifically designed for inmates with severe antisocial personality disorder or psychopathy, although it will receive such prisoners from time to time. At the time of visiting, the Unit held ten prisoners, nearly all of whom were serving life or long sentences. Ages ranged from 29-45.
32. The Unit works on a community model. Prisoners undertake a variety of activities in and for the Unit, which are based on contracts agreed with members of staff. There is a deliberately closer working relationship between prisoners and staff than in other parts of the prison service (however, there are defined limits upon this).
Issues raised in prison visits
Exclusion from health services
33. The general comment was made that communication and joint working between health and prison services could sometimes be improved.
34. It was noted that the prison service operates under an obligation to accept whoever they are sent, whereas health services have scope to refuse to admit someone. There were concerns raised at prison visits that there is no overall authority which can say that a particular setting is the most appropriate available for the prisoner.
Female prisoners
35. Many of the women at Durham prison exhibit high degrees of self-harming behaviour (mutilation, serious cutting etc.), and it is generally difficult for the prison service to effect any positive change. The prison system is more geared to dealing with male violence and self-harm (e.g. more typically suicide by hanging than self-cutting). In particular, there is a lack of a resource, similar to I Wing at Durham, for women in a really chronic and chaotic state.
36. The point was made that much of the evidence about personality disorder suggests that borderline personality disorder (which is more common among women and more related to issues of self-harm than antisocial personality disorder) was more likely to be 'treatable', yet this group were receiving little or no concentrated input, compared with men in (for example) CSCs. Part of the explanation could be that the extra expenditure on men was felt to be justified because it is economic for the prison service to minimise the damage caused by such men.
Small Unit model
37. At Durham the CSCs were said to be greatly preferable to the segregation units, where prisoners have to be moved around frequently, and where it was impossible to have any kind of sentence planning.
38. The literature provided by Shotts Small Unit identified two possible unfulfilled service requirements: services for people who cannot cope with the challenges of a therapeutic community model and require a more structured regime with less personal responsibility, and services for other people who do not present as violent or extremely disruptive but need help to cope with exceptionally long sentences without foreseeable parole.
Therapeutic communities in prison
39. In Grendon prison it was clear that there is a delicate balance in maintaining the democratic structure of a therapeutic community in a secure prison environment. This can break down unless people who are manipulative or unwilling to engage are screened out or drop out.
Sex offending
40. The Shotts NIC does not take sex offenders, because of problems of integration (although it is likely that a number of the crimes will have had a sexual element which was not highlighted at the time of conviction). It was commented that the rigid separation of sex offenders may be an issue to be addressed at some point.
Psychological input
41. The importance of psychological input was highlighted during several visits, but some prisons were facing difficulties in ensuring access to psychological services. Some of this was linked to problems of recruitment and retention of trained psychologists.
Risk assessment
42. The Shotts NIC currently assesses risk only insofar as it relates to behaviour in the prison system. It makes no attempt to assess long-term 'dangerousness' or risk to the community. Because the current assessment is directed at prison issues rather than dangerousness, it could not be translated directly into a pre-sentencing assessment. However, it was felt by staff that such an assessment would be feasible and might be useful.
43. In general, the view from many prison staff with whom we talked was that an assessment of risk should be linked to decisions on release.
Information sharing
44. Frustrations were voiced by several people with whom we talked in the prison system about the difficulties in obtaining relevant information relating to previous offences and psychiatric histories.
45. In addition, it was commented that there were sometimes difficulties, in trying to address and affect a person's behaviour, if the offence for which a person had actually been tried and convicted did not include any sexual element of their crime.
Indeterminate sentences
46. Although indeterminate sentences were generally welcomed on public safety grounds, some people were concerned about the short tariffs attached to some indeterminate sentences, which did not seem to bear any relation to when the person could realistically expect to be released. It was said that this causes difficulties in sentence planning and unrealistic expectations by the prisoner.
47. It was commented by one group that it might be a good idea to relate the length of the sentence and the discharge decision to clear outcomes which the prisoner can understand and work towards.
48. The power to recall was seen as a benefit of discretionary life sentences. However, this could have unpredictable consequences for the size of the future prison population.
Release from prison
49. Post release, there can be considerable problems with accommodation. Even if it can be found, offenders who are not on licence sometimes disappear from the system.
50. At Grendon there was some anxiety that follow-up care was not always being provided when people moved on from the therapeutic community. The group who seem to have done best are those who have had a 'full dose' of treatment followed up by parole and aftercare.
Treatability of personality disorder
51. Many prisoners at Grendon have a label of personality disorder, but this term is not one that Grendon employs to distinguish between those who are amenable to treatment and those who are not. Instead, they look at elements of a prisoner's personality and behaviour which might be amenable to change.
Accreditation of programmes
52. Durham was beginning to develop accredited programmes. There was concern that pressure to deliver positive outcomes could mean that staff would feel that they had to put forward the 'best' prisoners for the programmes, not necessarily those in most need.
53. There have been some tensions in integrating the therapeutic community model at Grendon into the approach of accreditation of programmes. Grendon feel this is partly due to the density and complexity of the work undertaken within the institution. However, they feel that these difficulties are being overcome, and that promising results have been obtained when the cognitive programmes run by the prison service have been combined with the context of the therapeutic community.
Parole Board for Scotland and Designated Life Tribunal (DLT)
54. Members of our Committee undertook visits to a meeting of the Parole Board for Scotland, which considers questions of release on license and recall of adult prisoners serving determinate and mandatory life sentences, and to a meeting of the Parole Board sitting as a DLT, in which capacity it considers the cases of adult prisoners serving discretionary life sentences, and young offenders who are serving indeterminate sentences.
Parole Board for Scotland
Visited 20 July 1999
55. The Parole Board considers a dossier of reports on a prisoner's case. Prisoners are permitted to make representations. In the event that the information in the reports and the representations made by the prisoner are contradictory, it is for the Parole Board to decide how much weight to give to the different versions of events.
56. Questions of what weight it is appropriate to give to unsubstantiated allegations when considering questions of recall were raised at the visit.
57. There was a discussion of whether, in the case of certain recalled prisoners, public safety is better served by re-releasing them on strict licence conditions or keeping them in custody until their release date and then releasing them without licence supervision.
58. Information flow through the criminal justice system was a matter of great concern to the Board, and the view was taken that information flow between agencies was a key area to be improved.
Designated Life Tribunal
Visited 23 August 1999
59. In the relatively formal setting of the DLT the prisoner might be at a significant disadvantage without representation. At present only advice by way of representation (ABWOR) is available to prisoners before DLTs. There might be a case for the provision of full Legal Aid in all cases.
60. It was observed at the visit that although the DLT has no remit relating to the management of prisoners, its decision on release can be made more complex by service concerns. For example, a prisoner's lack of progress in the prison system might be more closely related to difficulties in finding programmes for him to undertake than to his own behaviour. However, there are clearly difficulties around making meaningful sentence planning provision for people undertaking very long sentences.
Secure and medium-secure hospitals
Broadmoor Special Hospital
Visited 4 November 1999
61. Broadmoor, in Berkshire, is one of three Special Hospitals in England, the other two being Ashworth (Merseyside) and Rampton (Nottinghamshire).
62. At the time of visiting, Broadmoor was caring for some 430 patients, 80 of whom were female. About 50 patients are admitted per year. There are generally around 30 patients from Broadmoor on 'trial leave' in lower security hospitals at any one time. The average stay at Broadmoor is around eight years, although there are some high-profile and/or elderly patients who are likely to remain in the hospital indefinitely.
63. Approximately two thirds of the patients at Broadmoor have mental illness; approximately one quarter of the patients have a sole diagnosis of personality disorder; and approximately one eighth of the patient population has dual diagnosis of mental illness and personality disorder.
64. Over half of the patients at Broadmoor are restricted patients, for the management of whom the Home Secretary has ultimate responsibility. Around one eighth of Broadmoor's patients are transferred to the hospital from prison on becoming mentally ill.
Ashworth Special Hospital
Visited 7 October 1999
65. As at publication of the 1998/99 Annual Report, the Mental Health Service at Ashworth Special Hospital had 264 patients and 565 staff. The Personality Disorder Service had 110 patients and 177 staff. The Women's Service (which was not visited) had 49 patients and 119 staff. There is also a separate rehabilitation service with 167 staff which services all three patient groups.
66. The Personality Disorder Service is not currently receiving new patients. The patients who are currently at the Ashworth Personality Disorder Service are a highly selected group, in the sense of being particularly disordered even compared with the other English Secure Hospitals. The people in this service are cared for in separate wards, which is a different model from Broadmoor and Rampton where people with personality disorders are, in the main, dispersed throughout the hospitals. The Personality Disorder Service has, in the last three years, reorganised around a containment model with psychological interventions, which draws heavily on the experience of Dutch TBS services. The treatment goal of the Service could be loosely described as helping the patients to manage themselves better in relation to the world.
67. The Sex Offender Treatment Programme is based on the prison 'SOTP' programme, with some adaptations - mainly that it is delivered at a slower pace. There are usually two sessions a week of 1.5 to 2 hours each.
Crozier Terrace Regional Secure Unit, Hackney, London
Visited 17 November 1999
68. Regional secure units (or medium secure units) accommodate mentally disordered offenders, whose level of risk is too high to maintain them in general psychiatric services, but who do not require to be placed in high security hospitals.
69. At the time of visiting, the total number of patients in the Crozier Terrace Unit was 48, but this was likely to increase to 100.
70. There is a multidisciplinary team, headed by consultant psychiatrists, with social workers, psychologists, nurses, occupational therapists and (on referral) creative therapists. There is also educational input.
71. Ninety per cent of the patients come through the courts and prisons, but admission to the service can come from both the lower and upper levels of security in psychiatric services, as well as from prisons, the police, and probation services.
72. There are four wards - an admission ward, an intensive care ward, and two ongoing assessment wards. There is currently no women's ward, but the Unit is developing a business case for 60 new beds, including a women's ward. The service is developing a 24-hour nursing care facility and rehabilitation wards with a lower level of security. The unit also has a flat with four beds, where staff can assess daily living skills such as managing cash for shopping etc.
The State Hospital, Carstairs
Visited 28 October 1999
73. The patient population of the State Hospital at the time of the visit was approximately 250 patients, 18 of whom were female. Seventy per cent of the patient population have schizophrenia. Only 5% have a sole diagnosis of personality disorder. There are also several patients with learning disabilities. The average stay in the Hospital is four and a half years (although it varies from around ten weeks to up to 25 or 30 years)
74. Patients arrived at the hospital's Admissions Ward from court, from other hospitals and from prisons. Approximately one third of the total population has been referred from court, one third transferred from prisons, and one third referred from general psychiatric hospitals.
75. Patients undergo an assessment process usually taking eight to ten weeks, after which they are either moved to an appropriate Ward or returned to court or the referring facility.
76. It is rare for a patient at the State Hospital to be discharged direct to the community. It is more usual for patients to be discharged to mainstream psychiatric hospitals.
Issues raised at secure and medium secure hospital visits
Relationships with prison system
77. At the secure hospitals, concerns were raised about patients who become mentally ill in prison and are transferred to secure hospital services. Such patients will be returned to prison on recovery from their mental illness. In practice, many of these patients spend many consecutive periods in prison and in hospital, on 'cycles' of mental illness and recovery.
78. In addition, the point was also raised that if prisoners are transferred to secure hospital accommodation and their sentence expires during that time, they are eventually discharged from in-patient care. It was suggested that there is a pressing need in such cases for the mental health and criminal justice systems to work more closely with each other, so as to avoid such individuals losing touch with the services which they may need.
79. Several clinicians took the view that better mental health facilities are required in prisons, in order to help prisoners avoid becoming mentally ill or to recover from mental illness if they do become ill. However, no consensus was reached on whether there should be a development of prison mental health services to the extent that they would be in a position to give, for example, compulsory medication (currently not lawful under the Mental Health Acts).
The care of ethnic minorities and other groups
80. Several comments were made at various visits relating to the apparently high level of compulsory detention of people from ethnic minorities, particularly young black men.
81. At Broadmoor some 30% of the patients are of non-white ethnic groups but the local population, from which much of the unqualified staff complement is drawn, is 99% white (although 9% of the qualified staff are of non-white ethic backgrounds). In order to address questions of culture, gender, sexual orientation etc, Broadmoor runs a therapy programme which is specifically aimed at women and patients from minority groups. The management at Broadmoor stresses the importance of understanding a patient's culture before addressing their mental illness.
Entrapment
82. At the English Special Hospitals we were given to understand that there is a major shortage of beds to which patients can be transferred on progression. Some long-term medium-secure units have closed, and those which are still open have tended not to wish to take patients who could be expected to remain in their care for much longer than two years. Some patients could in theory go from high security hospitals straight to lower levels of security, but the mainstream services are not keen to take them unless they have been through the intermediate medium-secure stage.
83. This was echoed at the Crozier Unit, where it was indicated that, because of pressure of beds, people currently in prison tend to be given priority over people being referred from high security hospitals (on the basis that the latter group are at least receiving some treatment). This can lead to entrapment in secure hospital accommodation.
Personality disorder - policy towards admission
84. On our visits we asked whether people with a primary diagnosis of personality disorder should be admitted to hospital. We were told that personality disorder can be a ground for admission to an English Special Hospital, but it was pointed out that individuals with this diagnosis tend to have certain characteristics - most have committed serious offences and score highly on measurements of personality disorder.
85. However, there appears to be an increasing reluctance by regional/medium-secure units to accept this group. At the Crozier it was seen as a bad, and very expensive, way of dealing with people with personality disorder. The expense is partly because the service is individually based, which may not be appropriate for personality disorder. There are some independent services springing up, but there was anxiety amongst some people we talked to about whether these services have the necessary skills to offer anything meaningful to this group of patients.
86. One view given to us at an English secure hospital was that many of the current patients could well be held in prison, but there was a group of what were termed 'inadequate psychopaths' who were appropriately admitted to hospital. It was also suggested that the difference between the personality disordered population and the mentally ill population in the English secure hospitals may be less marked than one would expect. Personality disorder was often a feature contributing to the offending behaviour of patients with episodes of mental illness.
87. At the State Hospital it was pointed out that many sexual offenders with personality disorder and some form of mental illness are sent to prison on conviction, but in the prison service there is relatively little in the way of therapy to help them recover from their illness and/or to address their offending behaviour and their personality disorder.
88. Many staff at the State Hospital took the view that, if a person is mentally ill, and required to be detained, they should be detained in hospital, whereas, if the person had a diagnosis of personality disorder only, they should be accommodated in prison or in some other type of service (whether located within the prison system or not).
'Treatability' of personality disorder
89. At Broadmoor it was suggested to us that prisons and hospitals should agree on assessment and therapy methods for people with personality disorder so that both systems were carrying out assessment procedures and therapy programmes which were consistent with and complementary to each other. In both environments, the aim would be to find aspects of the person's personality characteristics which can be tackled and improved in order to deal with a person's 'dangerousness'. Likewise, at the State Hospital, the clinical approach is that many patients may have personality difficulties and that these are targeted for specific clinical treatments. This approach is therefore concerned with risk management and minimisation of risk as well as the patient's own welfare.
90. At Ashworth, in the past, attempts were made to 'treat' personality disorder. Now the staff see themselves more as trying to reduce and minimise risk, and so look more than before at the index offences. It was accepted, though, that there is a group of people who are very hard to engage in any form of therapy, and who did not fit in well with a model based on progression. They are not a homogenous group, and only a few cause major management problems. For some, choosing to engage is a matter of timing, and their degree of motivation may change.
91. Most people to whom we talked indicated that a psychological input was key to the management or 'treatment' of personality disorders.
Risk assessment
92. It was continually stressed to us that assessment of risk must be multi-disciplinary, it must also take account of historical and collateral evidence (i.e. not simply rely on the word/testimony of the patients themselves), and should take place over a reasonable period of time.
93. The importance was also stressed of examining in a very broad way the evidence of what an individual's risk might be in different contexts - i.e. the risk when outside a secure hospital, the risk to whom, the risk if using which substances/materials/weapons etc.
94. However, the problem that many identified with actuarial risk assessment is that it can assess the risk to groups, but has less predictive value in relation to individual people.
Discharge and follow-up
95. The provision of secondary mental health services in the community was discussed. It was commented in England that mainstream adult mental health services would probably wish forensic services to follow people up for a period after release, but that there are resource issues in duplicating services already available through local mental health teams. At Ashworth it was also commented that there is a clear lack of available community forensic personality disorder services.
96. At several services it was considered to be unfortunate that a patient might be absolutely discharged after a couple of years, and lost to the system thereafter. It was suggested more than once that some type of conditional discharge should always be used if a person might still be dangerous or had a personality disorder.
97. There was also concern expressed that, in the community, there is a lack of services for the treatment of sex offenders. Community projects should be set up for those who need treatment but do not need to be kept in a custodial environment.
Hospital orders and hospital directions
98. Interim hospital orders were felt by the staff of the State Hospital to be useful, as they allow time for assessment of a person's mental disorder and for it to be treated. Many staff at the State Hospital had been pleased when the maximum length of an interim hospital order had been extended from six months to twelve months, because many individuals can successfully complete their treatment within the first twelve months after sentencing and then be transferred on to prison, if appropriate, to complete their sentence.
99. Hospital directions were also cautiously welcomed, particularly their use for people with both a treatable mental illness and a personality disorder. However, it was clearly the view that a hospital direction should not be used for someone whose mental illness was the sole cause of their offending behaviour.
Other health facilities
Argyll and Bute Hospital, Lochgilphead
Visited 5 October 1999
100. Our Committee visited a programme where dialectical behavioural therapy (DBT) is in use for people with borderline personality disorder.
101. There are 10 people on the DBT team at Argyll and Bute Hospital, from a variety of disciplines.
102. There are at present nine out-patients undertaking the programme. There had previously been an intensive four-week course in operation, but funding constraints and a perceived lack of support from the hospital had led to it being shelved indefinitely.
103. The DBT programme involves the application of learned skills to give a person with borderline personality disorder the ability to cope with various situations. A particularly important part of this is 'mindfulness', which is a skill that can be applied in crisis situations. It involves paying close attention to the immediate environment and regulating the impact of impulsiveness, affective instability and suicidal behaviour.
Cassel Hospital, Richmond, Surrey
Visited 14 October 1999
104. Cassel Hospital has three units: the family unit (31 beds); the adult unit (17 beds) and the adolescent unit (12 beds).
105. Of the patients in the adult unit 90% have a personality disorder and 70% have a diagnosis of borderline personality disorder. Not many of this group have had contact with the criminal justice system and most are referred from general psychiatry services. The adolescent unit contains youngsters from similar sources as the adult patients. Very few have any contact with the criminal justice system.
106. Adult patients undergo an outpatient consultation, the main purpose of which is to assess the patient's understanding of his/her condition and motivation for treatment. There is also an assessment of risk to others: the unit is anxious to avoid violent patients or those with any psychosis.
107. Adult patients remain in the unit for between six and 12 months and families for 21 months. This is a fairly strictly applied time span. Discharge is likely to be by return to the referring agency. Unacceptable behaviour is dealt with by discharging patients to their referring source.
108. The inpatient programme consists mainly of psychodynamic and psychoanalytical therapies.
Douglas Inch Centre, Glasgow
Visited 2 November 1999
109. The Douglas Inch Centre is a multi-disciplinary forensic mental health service, serving Greater Glasgow. It has been running since the 1960s. Historically, the service was outpatient based, but there are now also allocated beds at Woodilee and Leverndale, as well as nine learning disability beds at Lennox Castle.
110. Half of the Centre's referrals come from the courts, and they do many court reports. Half come from the NHS and other services (e.g. social work).
111. The inpatient population is mostly mentally ill, but the outpatient population has many people with related problems such as substance abuse or personality disorder.
112. The psychology service has a full-time equivalent of 2.3 psychologists (six people). They have a long waiting list for the service (around eight months).
Henderson Hospital, Surrey
Visited 14 October 1999
113. This hospital works on a therapeutic community model. At the time of meeting with staff the patient mix was as follows: 50% had convictions, 10% had set fires and 10% of the population were on probation. With the latter exception all patients were informal.
114. The maximum length of stay is one year, at which point patients are discharged. No detention is used under the Mental Health Act 1983. They very rarely deal with known sex offenders though sometimes a history of sex offending is revealed during treatment.
115. Selection for admission is by a group of staff and patients, by a democratic process.
116. There are no individual-focused treatment approaches. All treatment is via the therapeutic community. Non-compliance or breaches of rules may lead to patients being 'voted out' of the unit before to the end of their 12-month stay.
Portman Clinic, London
Visited 17 November 1999
117. The Portman Clinic is an NHS outpatient clinic offering assessment, treatment and management for children, adolescents and adults who engage in criminal or violent behaviour or have sexual 'perversions'. It is unique in the UK.
118. People from a variety of disciplines work at the Clinic, all of whom have training as psychoanalysts or child psychotherapists. There are 15 senior staff and five honorary consultants.
119. The Clinic works on a psycho-analytical developmental model, and places considerable emphasis on the early years of life. It typically works with people over several years.
120. The average adult patient received by the Clinic will be guilty of a number of offences. Typically, the defence solicitor will ask for a report on suitability for psychotherapy. The Clinic would not normally accept actively psychotic adults, although it does treat people with high levels of neurosis such as depression and anxiety.
121. The Clinic also offers a range of outreach and consultancy services.
Royal Cornhill Hospital, Aberdeen
Visited 1 November 1999
122. The day therapeutic community at the Royal Cornhill Hospital had been operating for a few months at the time of visiting and had been established following the closure of the former Social Learning Unit.
123. The day unit had eight or nine clients in two small groups when visited. The planned maximum was 20 clients in two groups. Treatment was envisaged as lasting for around 12 to 15 months with extensive follow-up.
124. Patients attend five days per week. There are group meetings which have various tasks including meetings of the community. The therapy offered includes thrice weekly analytic groups, plus art therapy and psychodrama, which are offered once weekly.
125. The client group does not include people with severe personality disorder who have offended but does deal with people who have 'serious disturbances' (described as various personality disorders including borderline).
Issues raised in visits to non-secure hospital facilities
Personality disorder and treatability
126. What was notable from many of these visits was the optimism shown by some, for example the Henderson, Argyll and Bute and Cassell Hospitals, about the treatability of personality disorder generally, especially borderline personality disorder, and their contrasting pessimism about the treatment of those with severe antisocial personality disorder. At Argyll and Bute we were informed that DBT cannot be used to treat predatory/psychopathic people, because for the therapy to work the person must be suffering distress as a result of their personality disorder, which such people tend not to manifest.
127. In addition, these facilities tended to take people on a voluntary basis only (except the Douglas Inch Centre) which would tend to 'deselect' those who are not amenable to the types of treatments they provide.
Treatment in a prison setting
128. We asked about whether the treatments for personality disorder provided by these services could be imported in any way into a prison setting. On the whole the response was in favour of the use of a therapeutic community model of some type in a prison setting, although clearly such a model is based upon a voluntary commitment to it and so cannot be used for many recalcitrant prisoners. Many people that we spoke to referred to HM Prison Grendon as a positive role model for future services in prisons.
Information sharing
129. Frustrations were again voiced by some regarding access to information. The experience of several people to whom we talked was that there were widely variable practices regarding allowing access to records and sharing information.
Research needs
130. At the Portman it was commented that psychotherapy has been bedevilled by the lack of randomised control trials.
131. It was also commented that further research was needed into what services might be of use to people with severe antisocial personality disorder.