Professional Documents
Culture Documents
Personality Disorder
Abstract
Background: The dangerous and severe personality disorder programme was instigated on
the basis of law and order situation, constructed on the false premises. Aim: To critically
explore the effectiveness and benefits of the DSPD programme. Methodology: Qualitative
approach has been implemented to explore the effectiveness of the DSPD programme. A
systematic review approach has been further applied to extract studies. 10 studies have been
included on the basis of search strategy process. These studies were selected to provide indepth significance regarding the DSPD programme. Results: The instigation of the DSPD
programme has been effective throughout the treatment of personality disorder individuals.
The higher costs of the DSPD programme have restricted to complete the treatment among
participants. Incentives are explored from the DSPD programme in order to identify the BPD
and ASPD behaviours. Conclusion: The presence of personality disorders have been
emerged from the difficult problems of dangerousness. Several different units have been
established to provide treatment to personality disordered individuals.
Keywords: Criminal, Dangerous, Offenders, Personality Disorder, Severe
Personality Disorder
CHAPTER 1: INTRODUCTION
1.1 Background of the Study
The dangerous and severe personality disorder (DSPD) pilot scheme was a
government initiative introduced in 1999 by the Home Office and Department of Health. It
was designed to provide a solution to the dilemma presented by those individuals diagnosed
as having a personality disorder (PD). A high risk was deemed under the Mental Health Act
(2007) and was nearby the end of or had no custodial tariff. Under the Mental Health Act
(1983), these individuals were classified as untreatable despite presenting as high risk they
would be released back into the community. The Mental Health Act (1983) treatability clause
stated that detention within a hospital setting could only be achieved if the individual was
treatable (Tyrer et al 2010; Vollm and Konappa, 2012).
The tragic incidents like the Michel Stone case which was believed by many to be the
final straw in governmental frustration with the psychiatric community perceived to be
avoiding a difficult patient group (Maden 2007). Michael Stone a known psychopath attacked
and killed Lin Russell and her 6 year old daughter as they walked home. The eldest daughter
who was 9 was also battered and left for dead but she survived, the familys pet dog was also
killed. The Michael Stone case contributed to the development of the Dangerous and Severe
Personality Disorder (DSPD) program combined with the amendment of the Mental Health
Act and the development of four specialist units. Two of the units were developed within the
existing frameworks of the prison system at Frankland and Whitemoor. The other two were
developed within the National Health Service at Rampton and Broadmoor (Tyrer et al 2010).
The DSPD program at the Peak offered 12 therapies where Dialectical Behavioural
Therapy aimed to reduce violent behaviour and self-harm (Linehan 1993). Cognitive
Analytical Therapy was revealed for the development of problem-solving skills and insight
(Ryle 1997). Other existing therapies were also accessible for targeting criminogenic needs
Personality Disorder
such as sex offender program and substance misuse program (Hogue et al., 2007). By each
unit having the ability to function autonomously, therapies have been designed and developed
to treat Personality Disorder. Duggan et al (2007) identified over ten different therapies and
interventions from the analysis of 27 random controlled trials. Most commonly utilised
therapies were Cognitive Analytical Therapy, Dialectical Behavioural Therapy and
psychoanalytical based therapies. These were often used alongside pharmacological
interventions.
Individuals diagnosed with Borderline Personality Disorder responded better to
Dialectical Behaviour Therapy. Individuals diagnosed with Antisocial Personality Disorder
responded better to Cognitive Behavioural Therapy. Individuals diagnosed with Avoidant
Personality Disorder or Mixed Personality Disorders responded better to psychodynamic
based therapies (Vollm and Konappa 2012).
1.2 Problem Statement
The extent of personality disorder has been accounted around 78% among male
remand and 64% among male sentenced prisoners in the prison population of United
Kingdom. In western countries, the prevalence rate of personality disorder is reported to be
65% of the entire offenders in prisons having mental disorders. However, the functional
association between offending behaviour and personality disorder is not apparently observed
throughout the course (Scott, 2014). A complex pattern of ingrained psychological traits is
constructed within the personality. Personality is recognized to be in the disordered state
when traits causing significant harm persistently illustrating inflexible and maladaptive
symptoms. The international classification of diseases 10 (ICD-10) and the diagnostic and
statistical manual of mental disorders IV-TR (DSM-IV-TR) are the major diagnostic
evaluation systems, identifying the extent of personality disorders (Kohut, 2013).
Personality Disorder
programme
To explore alternative initiatives and programmes for personality disorder
What are the benefits of the DSPD programme for individuals experiencing
personality disorders?
Personality Disorder
What are the challenges of the DSPD programme in therapeutic and forensic services?
What are the initiatives and alternative programmes for personality disorder?
Personality Disorder
services of mental health practitioners for the therapeutic regime and public protection
(Vllm and Konappa, 2012).
Personality Disorder
Personality Disorder
Personality Disorder
10
for the evaluation of Massachusetts treatment centre among violent sex offenders. It has been
examined that monetary incentives are deemed essential for the improvement of sex
offenders. Another study implemented cognitive behavioural treatment programme for
paedophiles within Australian prisons (Yu, Geddes and Fazel, 2012). The findings of the
study have been evident in illustrating the cost-effectiveness of the intervention programme.
The potential costs and incentives of the DSPD programme have been evaluated through a
Markov decision model. The model has revealed that anticipated costs of the programme
progressively augment as compared to the monetary value of the anticipated incentives
(Young et al., 2012).
Personality Disorder
11
Personality Disorder
12
Cochrane meta-analysis have been poorly evident due to methodological restriction whereas
the political and institutional pressure was significantly emphasized to ensure the instigation
of DSPD programme. It is likely to assume that the cognitive-behavioural treatment might be
effective in the accomplishment of DSPD programme but further consequences are presumed
(OLoughlin, 2014; Bowen, 2013).
2.4 Challenges in the DSPD Programme
The existence of DPSD programme was specifically recognised as the alternative
approach to deal with the cluster of individuals who were found to be at the restriction among
the criminal and health justice systems. The initiatives of the DSPD programme was
determined to undertake the significant risks of personality disorder individuals and to adhere
the functional link between risks and disordered symptoms (Tyrer, 2013). Theoretical
approaches have been broadly existed to comprehend the causes of personality disorder
encompassing probable theories. According to the study, it has been observed that the
structured assessments are essential for both offending behaviour and personality disorder
components of DSPD. These structured assessments are required to conceal cognitive,
affective, interpersonal, self-regulatory and behavioural dimensions (Bowen, 2013).
The paucity of theories and anticipations throughout the planning and implementation
have been witnessed from the initiative of the DSPD programme. Non-completion and lowengagement in therapeutic programmes are the essential dilemmas occurred in the
rehabilitation and treatment of the offenders (Howard, 2015). The probable outcomes of the
low engagement entails poor institutional support, poor treatment outcomes and eradicated
staff morale. Low responsivity, resistance and low motivation are often utilized to express the
low engagement of the theoretical attempts (Gilbert et al., 2015). However, these terms
constructed problems for the therapeutic programmes and; therefore, the concepts are
incorporated under the term treatment readiness. It has been suggested from the clinical
Personality Disorder
13
evidence that personality disorder offenders are usually unready for treatment due to their
internal and external characteristics. Thereby, it allows the structured assessment to be
followed from the alterations of readiness in the services of individuals with DSPD (Draycott,
Kirkpatrick and Askari, 2012).
Planning and monitoring, understanding patient perception and the point of referral
are the key aspects on which the clinical evaluation of readiness relied. Self-harm, sexually
abusive behaviour and aggression are the major issues that confront the cohesive and
optimistic therapeutic environment. The accomplishment of therapeutic objectives can be
disturbed from the behaviours of personality disorder individuals (Cloninger and Svrakic,
2016). The fear of victimization can restrict patients to attend programmes and therapeutic
activities. The distraction of patients towards the treatment tasks is observed from the tense
and hostile therapeutic environment as well as to corrode confidence, optimism and
persistence of staff regarding therapeutic activities. A sense of predictability regarding the
environment has been experienced by patients in DSPD units whereas participation is
required to strengthen the therapeutic programmes. Therefore, staff morale and positive
therapeutic environment should be sustained in order to preserve cohesive and optimistic
therapeutic environment (Vllm, and Konappa, 2012).
Tyrer et al (2010) document an extensive list of failings and negative aspects. Many
criticisms were raised including a lack of professional input into the terminology of
admission criteria, the use of the DSPD label as a diagnosis, and no clear definitions of
dangerousness. It was alleged that the DSPD units were used only for warehousing with
little treatment to offer. Howells et al (2011) discussed inaccuracies and misconceptions
discovered in the paper. It is claimed that the DSPD label was used as a diagnosis; therefore,
no evidence was found. Individuals admitted to the DSPD Program did pose a higher risk and
displayed more severe Personality Disorder traits when compared to the non-DSPD groups
Personality Disorder
14
(Kirkpatrick, Draycott, Freestone et al 2010). The issue regarding lack of treatment is that
none of the four DSPD units reached full capacity until 2009, so due to the lack of trained
staff and full quota of patients being admitted, treatment pathways did not run as planned in
the beginning (Howells, et al 2011).
The treatment pathways required a high level of therapeutic input. In this case at least
25 hours of therapeutic activities and interventions was necessary from all of the multidisciplinary team. Interventions and treatment pathways were different in all four units as
autonomy was allowed to each unit to select their own therapies and treatment pathways. This
resulted in a diverse range of therapies available when comparing the four units (Vollm and
Konappa 2012). At Rampton hospital, the Peaks Unit uses a complex individualised treatment
pathway to target specific factors relevant to each patient that requires treatment in a high
secure environment (Hogue et al., 2007). This approach using a principle can be tailored
through the combination of functional analysis and formal risk assessment (Howells et al.,
2007).
2.5 Therapeutic Interventions of DSPD Programme
The differences between the diagnoses and responses to therapeutic interventions
were minimal (Weinberg et al., 2006; Davidson et al., 2006). Therefore, no clear answer was
to be found in recommending certain therapies to certain diagnoses. This might be explained
by Personality Disorder symptoms not remaining stable as originally thought before. The
pathological features of Personality Disorder are less stable and more developmentally
heterogeneous than previously believed (Ready and Robinson 2008; Roberts, Caspi and
Moffit 2003; Hopwood, Baker & Morey, 2008). This does support the age-related decline of
pathological traits in Personality Disorders. Over a ten-year period, the Personality Disorder
traits were quite stable; however, the Personality Disorder symptoms fluctuated according to
the environment, which further highlighted the level of heterogeneity in the population.
Personality Disorder
15
Randomised Controlled Trials are considered to be the gold standard in the evaluation
of treatment efficacy. They evaluate the impact of treatment but having an untreated control
group could be considered unethical as a group meeting criteria for a DSPD program being
left untreated could pose serious risk problems to self and others (Draycott, Kirkpatrick and
Askari 2012). The HCR- 20 (Webster et al., 1997) risk measure has been used in studies to
demonstrate change over time in patients meeting criteria for Personality Disorder and
Dangerous and Severe Personality Disorder (Morrissey, Beeley and Milton 2014). The study
demonstrated changes as a result of the treatment so this could be used to demonstrate
treatment efficacy. Vollm and Konappa (2012) conducted a literature review of papers
relating to the DSPD Program regarding treatment efficacy. Results showed a dearth of
evaluative studies, 29 empirical research papers and three extensive research papers. There
were no high quality studies that found treatment pathways or environmental impact. There
remains little evidence for the evaluation of the treatment efficacy of the DSPD programme.
The DSPD pilot is being phased out and it is a question of assessing whether the
DSPD units have been a cost effective investment. Unfortunately there is a lack of evaluative
research drawing a definitive and complex conclusion. This is perhaps due to the relatively
young age of the pilot and the lengthy process of publishing work; however, the distinct lack
of information raises concern (Vollm and Konappa 2012). Traditionally a difficult and
stigmatized population has enabled the exploration of different treatments for personality
disorders (Tyrer et al 2010). The National Institute for Health and Clinical Excellence have
made recommendations for personality disorder services to be available throughout the UK.
A number of new treatments have been developed with a strong evidence foundation, leading
to a positive effect on staff morale with this difficult client group (Bowers, Carr-Walker and
Paton, 2005). The admission criteria for DSPD was not based on strong evidence, however, in
Personality Disorder
16
the upcoming ICD 11 personality disorder classifications is similar to those used to assess
severity and avoid excessive co morbid traits (Tyrer 2013).
The DSPD population statistically presents as a higher risk than other populations;
however, the severity of their personality disorder is no greater than other individuals with
personality disorder. Initially the majority of referrals to DSPD units were prisoners nearby
the end of their sentences, which claims that the units were simply a place for individuals
classed as a high risk and release back into the community (Howells et al., 2011). The
observed reductions in risk and improvements in mental health have been minimal.
Aggressive behaviour and self-harming was observed to increase in detainees although this
may be due to problems with the management of the detention system. The study highlighted
inefficiencies during admission and assessments leading to substantial delays as there was no
clear pathways to progress was accessible. Furthermore, there was limited time spent in
therapy considering the number of staff available (Draycott, Kirkpatrick and Askari, 2012).
2.6 DSPD Pilot Schemes
The reasons for devising the DSPD pilot schemes remain unclear but the relevant
facts are the large financial investments and apparent fallings of the pilot schemes. However,
consideration must be given to the future of the detained population (Kirkpatrick et al 2010).
The study suggests focusing on the initial roots of the pilot that would be more beneficial to
the detained population and also reduce the required financial investment. Originally the pilot
scheme was supposed to be based on the Dutch ter beschikking stelling (TBS) system.
However, the development and implementation of the system was completely deviated
throughout its instigation. Therefore, the TBS system treated a similar population for
approximately half of the cost of the DSPD pilots and for a longer period of time.
DSPD units often struggle with clear goals for progression through the system
whereas the TBS developed a clear integrated pathway at all levels considering the high
Personality Disorder
17
secure care and support for the community. Noticeably, maintaining a strong rehabilitation
ethos, focussing on paid work, regular leave and responsibilities involved in independent
living enabled this progression (Volm and Konappa 2012). The focus of the system would be
shifts to enhance the quality of life instead of treatment in case there is no progression
observed. This is facilitated by focusing on the objectives and apparently eradicating the costs
down to support community. The TBS program still has the problem of identifying the
effective treatment and to prevent the higher expenditure incurred by the DSPD pilot, which
perhaps qualify this system as a future alternative.
The DSPD Programme has been subjected to controversy and contradiction since it
was introduced and continues; however, this program is now decommissioned from the
government. The service was deemed a failure by many institutes because it was classified as
a costly program with limited evidence demonstrating success. This review of papers
available has questioned whether achievements have been acknowledged and failure is a fair
description. Contradiction and debate continues regarding the initial aims for the DSPD
Program. The expected detention time, the suitability of the assessment process, public
protection, effective treatment and reduced risks are the major concerns in the contradiction
and arguments for the DSPD program. In relation to research, there is no argument as to
whether the available studies have been beneficial to the DSPD Programme but initial
proposals highlighted the need for knowledge as to why people develop DSPD and how it
can be prevented and; therefore, information in this area is limited. Staff working in DSPD
units should be studied as participants experienced a high dropout rate. It would be
interesting to explore whether this would still occur that the service is no longer under
scrutiny due to the fear of repercussion.
Personality Disorder
18
CHAPTER 3: METHODOLOGY
3.1 Research Design
Qualitative research approach has been implemented in the study to examine the
effects of dangerous severe personality disorder programme on the individuals experiencing
with these complexities. A systematic literature review has been applied for extracting the
studies regarding the DSPD programme. Systematic review is regarded as the specific
qualitative approach used to recognize and construct the factual information within the
research. As the research setting is based on the mental health units and hospitals; therefore,
the main agenda was to extract studies addressing the implementation of DSPD programme
for the treatment of personality disorder individuals. The data collection, inclusion and
exclusion procedure for the studies were specifically built on the basis of systematic review
approach. The main determination of applying systematic review in qualitative studies was to
diminish biasness and provide readers to evaluate the assumptions of research. This approach
also facilitated other individuals to address the systematic review by incorporating latest
evidence.
3.2 Inclusion and Exclusion Criteria
The studies were selected in the systematic review approach on the basis of inclusion
and exclusion criteria. The inclusion criteria for the study have selected studies with clinical
or semi-structured interviews using explicit criteria to diagnose personality disorders.
Furthermore, case-control and cohort studies were also included in the study determining the
issues of personality disorders behaviours among offenders as compared to control groups.
The inclusion criteria of the study was based upon the full-scale articles addressing the
effectiveness of the DSPD programme, challenges in the DSPD programme and therapies and
Personality Disorder
19
Personality Disorder
20
Personality Disorder
21
Personality Disorder
Table 1: Systematic Literature Review
Authors
Barrett and Byford
(2012)
Title
Costs and outcomes of an
intervention programme for
offenders with personality
disorders.
Method
The incremental cost of
the DSPD programme has
been determined by using
a Markov decision model.
The purpose was to
determine cost
effectiveness on the basis
of monetary incentives.
Bateman et al (2016)
To investigate the
mentalization-based
treatment for alleviating
symptoms of anti-social
personality disorder, a
randomized controlled
trial has been used to
recruit offenders for the
treatment.
Results
The results have
revealed that costs were
highly consistent with
the intervention
programme. It was
anticipated that cost per
serious offence was
approximately over 2
million. Costeffectiveness
interventions have been
developed from the
prior evidences that
lead to the adjustments
of the programme.
The incentives have
been reported from
mentalization-based
treatment to recognize
the behaviours of
patients along with
ASPD and comorbid
BPD. These incentives
encompasses
enhancement of
psychiatric symptoms,
social adjustment,
Conclusion
Personality disorders
programme was supported
from the cost-effectiveness
of the intervention
programme. It is deemed
that the costs of the
programme are higher as
compared to the incentives
for personality disorder
offenders.
22
Personality Disorder
Bennett (2015)
Bruce et al (2014)
A cross-sectional cohort
study design has been
utilized to examine the
consequences of 107 high
risk offenders associated
with personality disorder.
interpersonal issues,
negative mood, extent
of suicide attempts,
self-harm, hostility,
minimization of anger
and paranoia.
It has been reported
that treatment dropout
has been comparatively
related with the
diagnosis of narcissistic
personality disorder.
However, PCL-R
scores were not
comparatively
associated with
treatment dropout. The
patterns have been
indicated that observes
the diagnosis of
antisocial personality
disorder as related to
augmented treatment
dropout.
The total sample was
relatively lower as
compared to mean
offender group
reconviction scores
identified (51%). The
23
Personality Disorder
Participants were
recruited from the
outpatient department of
housing groups. The
samples were described
through criminal justice,
self-reported and
collateral data.
Howard et al (2012)
The psychopathy
checklist-revised (PCLR) was used to detain 38
male prisoners in DSPD
units and 62 male
offenders from
conventional medium
hospital units.
Kouyoumdjian et al
(2015)
A systematic review of
randomized controlled trials of
interventions to improve the
health of persons during
imprisonment and in the year
results of multivariate
analysis have stated
that offenders with
increased support with
housing groups were
potential to reoffend
than the other groups.
Five male offenders
reoffended violently
even though there was
no difference among
groups.
High scores have been
reported on PCL-R
among the DSPD
group. Furthermore,
greater severity and
more convictions have
been indicated in the
DSPD groups.
Interpersonal and
affective features of
psychopathy have been
reflected from the
regression analysis.
There was direct
association of
dialectical behaviour
therapy with clientcentred therapy and
24
Personality Disorder
after release.
Patel (2015)
Rampling et al (2016)
Non-pharmacological
interventions for reducing
aggression and violence in
serious mental illness: A
systematic review and
narrative synthesis.
borderline personality
disorder. MEDLINE,
EMBASE, BIOSIS and
PsycINFO have been
used to extract the data.
transference-focused
therapy with schemafocused therapy. A
moderate statistical
significance has been
found from the effects
of non-comprehensive
intervention
programmes.
A qualitative
The results of the
methodology has been
thematic analysis have
included in the study to
shown that violent
explore violent thoughts
thoughts and fantasies
and fantasies among
were fundamental
mentally disordered
constituent in the
offenders. These
concepts and function
participants were
to sustain the needs of
recruited from the units of individuals. Functional
high secure hospital.
analysis has showed
assorted functions of
VTF including dealing
with provocation and
emotional regulation.
A systematic review and
23 practical
narrative synthesis for
interventions and
non-pharmacological
diverse psychological
interventions have been
intervention studies
intended to diagnosis
were selected including
personality disorder.
randomized controlled
Seven relevant journals
design. High risk of
25
Personality Disorder
along with five online
databases were used to
extract the data.
Sampson et al (2013)
Stoffers et al (2012)
experimental biasness
has been found from
the dialectical
behaviour therapy.
Cognitive behavioural
therapy and modified
reasoning and
rehabilitation have
been found among the
mentally disordered
offenders.
A medium secure hospital 78% costs have been
personality disorder has
highly incurred among
been selected to acquire
non-completers as
the data. A Markov cohort compared to
simulation was used
completers.
along with a probabilistic Furthermore, the results
decision-analytic model.
have indicated that
The anticipated costs
non-completers incur
were examined from the
52000 to the NHS and
potentiality of cost
criminal justice system
differential over the time as compared to
horizon.
treatment completers.
Treatment completion
rates in personality
disorder units might
provide cost savings for
NHS services and
criminal justice system.
A systematic review
The studies extracted
activities. A stronger
evidence base is required to
develop quality RCTs and
long-term consequences.
26
Personality Disorder
people with borderline
personality disorder.
randomized controlled
trials have been used to
enhance the health of
prisoners in captivity.
Social science and
biomedical databases
have been searched for
the extraction of 95
studies.
implementation of effective
interventions have been
recognized from the studies
in order to enhance the
health of offenders.
27
Personality Disorder
28
4.2 Discussion
Numerous studies have explored the informed treatment dropouts by observing the
attitudes and tolerance towards the personality disorder diagnosis. These studies have been
fairly supported to comprehend the significance of personality disorders and maintained
involvement of clinicians and offenders towards treatment (Howard et al., 2012;
Kouyoumdjian et al., 2015). The exclusion of treatment dropout from the psychotherapy
treatment programme emphasizes the personality disorders of antisocial personality and
narcissistic personality disorders. It has been explored that attributes of personality disorders
are not associated to the PCL-R scores in order to acquire assorted range of confronting
personality disorder traits. Antisocial personality disorders have been deemed essential for the
personality disorders to be found associated with treatment dropouts. Therefore, the
personality concept of psychopathy is challenged from the particular set of traits (Patel,
2015).
Barrett and Byford, (2012) have examined the cost-effectiveness of the DSPD
programme by approaching decision modelling to consider its effectiveness on the practicable
treatment of personally disordered individuals. The findings have evaluated that there was no
positive and direct link from the cost-effectiveness of the DSPD programme on the
personality disorders offenders. The major cause behind the failure of cost-effectiveness
programme might be linked to the interest that reveals to reduce the serious offence. On the
contrary, anticipated costs have illustrated greater for the costs of the programme as
compared to the monetary value of anticipated incentives (Rampling et al., 2016). It has been
observed that the DSPD programme was effectively executed in the high secure prisons and
hospitals to identify the costs of the programme. Furthermore, greater incentives from the
cost-effective model might be yielded by executing the programme within lower prison areas
(Barrett and Byford, 2012). The seriousness of committed offences by offenders has been
Personality Disorder
29
revealed from the cost-offset model. Prior researches have argued that incentives can be
greater than costs when low-cost prison is preferred to execute the DSPD programme. The
past evidences have supported the argument, recording the phases of offences with the
association of personality disorders committed on discharge (Stoffers et al., 2012; Sampson et
al., 2013).
The evidence has indicated that the cost-benefit of specialist treatment for personality
disorder offenders have been associated with the findings showing effective implementation
of economic models in several different criminal justice systems. However, eradications in
the costs of intervention groups did not assumed from the intensive and lengthy and
interventions. Thereby, there is a need of establishing cost-effective intervention programme
to investigate the personality disorders in the mainstream prison areas. Bateman et al (2016)
have implemented a randomized control design to evaluate the clinical management of the
patients with borderline personality disorder and antisocial personality disorder. The study
has evaluated the effects of eradicated symptoms associated to patients social behaviour
along with ASPD and BPD. These symptoms have been compared with the outpatient
structured protocol of equivalent magnitude excluding mentalizing constituents.
The information extracted from the randomized control design has indicated that
mentalization-based treatment provides effective treatment for the individuals with ASPD and
comorbid BPD. Results have indicated that symptoms of hostility, anger and paranoia are
significantly observed among patients with structured clinical management cluster.
Furthermore, impulse control-related issues and extent of suicide occurrences have been
adhered at the end of intervention programme. However, significantly lower occurrences
have been observed among patients with personality disorders from symptoms of self-harm
episodes. The aggressive activities of offenders have been identified from the measures of
Personality Disorder
30
depressing mood as showing vulnerability to the hallmark of ASPD and BPD (Bateman,
Bolton and Fonagy, 2013).
Significant enhancement and better adjustment have been showed from the
occurrence of personality disorders among mentalization-based treatment. At the end of
treatment, social adjustment, interpersonal issues, and poor general functioning have been
included in the enhanced MBT intervention programme. Sampson et al (2013) have explored
the cost-effective program for non-completion treatment in forensic personality disorder
service. The results of the study have provided in-depth significance regarding the clinical
information extracted from the forensic personality disorder service. It has been observed that
there was slight decrease in the treatment completion extent as compared to the completion
time found in prior studies. 23% personality disorder offenders have been attributed in the
severe or very severe personality disorder cluster. Furthermore, the average cost for
completing the treatment was found to be 499,759 whereas 551,473 was found among noncompleters. Thus, it has been examined that there is potential chances to incur low costs
among completers than the non-completers over 10 years (Cloninger and Svrakic, 2016).
It has been observed in the deterministic results that there is augmentation in the
cumulative costs for both groups; however, this augmentation is revealed at an eradicating
extent. The anticipated difference in costs of DSPD treatment among completers and noncompleters were identified by approaching the decision-analytic modelling methods. The
study has also revealed the outcomes of treatment completion from the modelling techniques
used for personality disorder offenders (Draycott, Kirkpatrick and Askari, 2012). The
probability of the anticipated cost difference is found to be higher among costs of initial
treatment for completers. Therefore, it is assumed that the offenders spent more time with
community and less in hospitals and prisons that complete their treatment as compared to
non-completers. Furthermore, the frequency of non-completers has been augmented since
Personality Disorder
31
following years in one of the three hospital states. However, there was no causal relationship
found between post-discharge costs and treatment completion. The complete treatment of the
individuals has been revealed from the incentives offered from the services of forensic
personality disorder (Gask, Evans and Kessler, 2013).
Despite having cost-effectiveness and incentives of DSPD programme, there are
several challenges posed in the complex situation in prisons and hospitals. Furthermore,
significantly enhanced treatment is found from the arousal and behavioural dimensions of
anger and paranoia within the treatment group as compared to control groups (Hopwood,
Baker & Morey, 2008). The contemporary issues of anger and behavioural dimensions have
been revealed among personality disorder individuals along with severe mental illness.
Thereby, Stoffers et al (2012) have implemented ADHD intervention programme to address
the problems associated with the personality disorder behaviours of offenders. The findings
have suggested that ADHD is effective in exploring the drop-out treatment of the intervention
program. It is deemed that short-term cognitive skills are more accepted among patients with
personality disorders.
Personality Disorder
32
CHAPTER 5: CONCLUSIONS
The murderous attack on Mrs Russell and her daughters and public outcry over the
attack have become the cause to construct the DSPD programme. A cynical misuse has been
examined from the services of mental health to improvise public safety agenda from the
initial phases of the development of the DSPD programme. The commitment was supported
from the establishment of the DSPD programme to provide effective and appropriate services
to enhance mental health consequences and to ensure positive progress for this specific
cluster. The DSPD programme is essential in representing the mental health services for the
dangerous and harmful individuals.
The core focus of the dangerous severe personality disorder initiative has been
specifically approached to the concepts of those experiencing mental health services and
criminal justice. Furthermore, the approaches are sustained to conflict the demands of
satisfying public safety and services of mental distress. It has been concluded that the
initiative of DSPD lies in the achievement of both services and public safety. Violent
behaviour is the major concern examined to influence on the outcomes of the DSPD
programme. Thereby, the DSPD initiatives are diverted from the required health needs of
deprived and marginalized cluster.
The complex issues of dangerousness are associated to the mental health in the form
of personality disorders. The instigation of DSPD programme is recognized to be the
effective implementation to focus and resolve these issues. The opportunities have been
developed by the effective treatment services of the DSPD programme for those individuals
who formerly acquired very less attention towards mental health care personality disorder
issues. In the United Kingdom, several different health care units have been constructed
specifically for the treatment of personality disorders individuals. The intervention
Personality Disorder
33
Personality Disorder
34
References
Baer, R.A., Peters, J.R., Eisenlohr-Moul, T.A., Geiger, P.J. and Sauer, S.E. (2012). Emotionrelated cognitive processes in borderline personality disorder: a review of the
empirical literature. Clinical psychology review, 32(5), pp.359-369.
Barrett, B. and Byford, S. (2012). Costs and outcomes of an intervention programme for
offenders with personality disorders. The British Journal of Psychiatry, 200(4), pp.
336-341.
Bateman, A., Bolton, R. and Fonagy, P. (2013). Antisocial personality disorder: A mentalizing
framework. Focus, 11(2), pp.178-186.
Bateman, A., OConnell, J., Lorenzini, N., Gardner, T. and Fonagy, P., 2016. A randomised
controlled trial of mentalization-based treatment versus structured clinical
management for patients with comorbid borderline personality disorder and antisocial
personality disorder. BMC psychiatry, 16(1), p.304.
Bennett, A. and Hunter, M. (2016). Implementing evidence-based psychological substance
misuse interventions in a high secure prison based personality disorder treatment
service. Advances in Dual Diagnosis, 9(2/3), pp.108-116.
Bennett, A.L., 2015. Personality factors related to treatment discontinuation in a high secure
personality disorder treatment service. Journal of Criminological Research, Policy and
Practice, 1(1), pp.29-36.
Bowen, M. (2013). Borderline personality disorder: clinicians accounts of good
practice. Journal of psychiatric and mental health nursing, 20(6), pp.491-498.
Bowers, L., Carr-Walker, P., Paton, J. (2005). Changes in attitudes to personality disorder on
a DSPD unit. Criminal Behaviour and mental health. 15:171-183.
Personality Disorder
35
Bruce, M., Crowley, S., Jeffcote, N. and Coulston, B., (2014). Community DSPD pilot
services in South London: Rates of reconviction and impact of supported housing on
reducing recidivism. Criminal Behaviour and Mental Health, 24(2), pp.129-140.
Clark, D. (2014). Emerging Severe Personality Disorderin Childhood: The reification and
rhetorical functions of a proposed developmental disorder.
Cloninger, C.R. and Svrakic, D.M. (2016). Personality disorders. In The medical basis of
psychiatry (pp. 537-550). Springer New York.
Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Teta, P., Murray, H., & Palmer, S. (2006). The
effectiveness of cognitive behaviour therapy for borderline personality disorder study
of cognitive therapy (B0SCOT) trial. Journal of personality disorders.20 (5), 450
465.
Draycott, S., Kirkpatrick, T. and Askari, R. (2012). An ideographic examination of patient
progress in the treatment of dangerous and server personality disorder: A reliable
change index approach. The Journal of Forensic Psychiatry & Psychology, 23(1), 108124.
Freestone, M., Howard, R., Coid, J.W. and Ullrich, S. (2013). Adult antisocial syndrome co
morbid with borderline personality disorder is associated with severe conduct
disorder, substance dependence and violent antisociality. Personality and Mental
Health, 7(1), pp.11-21.
Gask, L., Evans, M. and Kessler, D. (2013). Personality disorder. BMJ: British Medical
Journal, 347(7924).
Gilbert, F., Daffern, M., Talevski, D. and Ogloff, J.R. (2015). Understanding the personality
disorder and aggression relationship: an investigation using contemporary aggression
theory. Journal of personality disorders, 29(1), p.100.
Personality Disorder
36
Hogue, T.E., Jones, L., Talkes, K., & Tennant, A. (2007). The Peaks: clinical service for those
with dangerous and severe personality disorder. Psychology, crime and law. 18, 57
68.
Hopwood, C.J., Baker, K.L., & Morey, L.C. (2008). Extra test validity of selected personality
assessment inventory scales and indicators in an impatient substance abuse treatment
setting. Journal of personality assessment. 90, 574 577.
Howard, R., Khalifa, N., Duggan, C. and Lumsden, J. (2012). Are patients deemed
dangerous and severely personality disordereddifferent from other personality
disordered patients detained in forensic settings?. Criminal behaviour and mental
health, 22(1), pp.65-78.
Howard, R.C. (2015). Antisocial personality comorbid with borderline personality disorder:
A pathological expression of androgyny?. Personality and mental health, 9(1), pp.6672.
Howells. K. et al (2007). Challenges in the treatment of dangerous and severe personality
disorder. Advances in Psychiatric Treatment, 13, 325-332.
Howells. K. et al (2011). The baby, the bathwater and the bath itself: A response to Tyrer et
als review of the successes and failures of dangerous and severe personality disorder.
Medicine, Science and Law, 51(3), 129-133.
Kirkpatrick. T. et al (2010). A descriptive evaluation of patients and prisoners assessed for
dangerous and severe personality disorder. Journal of Forensic Psychiatry and
Psychology, 21(2), 264-282.
Kohut, H. (2013). The analysis of the self: A systematic approach to the psychoanalytic
treatment of narcissistic personality disorders. University of Chicago Press.
Kouyoumdjian, F.G., McIsaac, K.E., Liauw, J., Green, S., Karachiwalla, F., Siu, W.,
Burkholder, K., Binswanger, I., Kiefer, L., Kinner, S.A. and Korchinski, M., (2015). A
Personality Disorder
37
Personality Disorder
38
Personality Disorder
Weinberg, I., Gunderson, J.G., Hennen, J., & Cutter, C.J. (2006). Manual assisted cognitive
treatment for deliberate self-harm in borderline personality disordered patients.
Journal of Personality Disorders. 20 (5), 482 492.
Young, S., Hopkin, G., Perkins, D., Farr, C., Doidge, A. and Gudjonsson, G. (2012). A
controlled trial of a cognitive skills program for personality-disordered
offenders. Journal of attention disorders, p.1087054711430333.
Yu, R., Geddes, J.R. and Fazel, S. (2012). Personality disorders, violence, and antisocial
behavior: a systematic review and meta-regression analysis. Journal of personality
disorders, 26(5), p.775.
39