DSPD: ‘No longer a diagnosis Of exclusion’?
by Melody Wimhurst
What Contribution can social work make to the treatment of men with a diagnosis of severe and dangerous personality disorder in a forensic setting?
Firstly, I would like to express my deepest appreciation to my supervisor Dr David Orr, for his support, advice, wisdom and encouragement over the time I have been working on this project. A heartfelt thank you also goes to Judith Shaw for her help and support over many months. I would particularly like to thank Dr Gwen Adshead for kindly providing many useful papers. Finally, thanks to my mum and dad and Lydia and Matthew Lintern for their help with proof reading and formatting and to everyone who has helped me in any way during the process; there are too many names to mention.
In 1999 the UK government introduced a programme to treat individuals, with Dangerous and Severe Personality Disorder (DSPD), who were considered to be high-risk, violent offenders. This literature review critically examines the significant contribution that social work could make in relation to the treatment of men with a diagnosis of DSPD. The highly controversial DSPD diagnosis is explored and an examination of how the lived experiences of men with a DSPD diagnosis are represented within the literature is undertaken, with a focus on ‘voice’. The treatment options available to men with a DSPD diagnosis are discussed. The paper concludes by arguing that, in line with Hyslop’s emancipatory model (2011), social work has a significant contribution to make in regard to future policy developments concerning the treatment of personality disorder in a forensic setting and that social workers with AMPH status should be deployed in prisons in England and Wales.
Chapter 1: Introduction Page 6
Chapter 2: Methodology And Ethical Considerations Page 12
Chapter 3: What is a diagnosis of DSPD? Page 20
Chapter 4: How are the lived experiences of men with Page 34 a diagnosis of DSPD reflected in the literature?
Chapter 5: What treatment options are available for men Page 44 with dangerous and severe personality disorder
in a forensic setting?
Chapter 6: What contribution can social work make in Page 50 relation to the treatment of men with a diagnosis
of DSPD in a forensic setting?
Chapter 7: Conclusion Page 58
Bibliography Page 61
Appendix 1: Searching Table Page 70
“. . . there is, however, a group of dangerous and severely personality disordered individuals from whom the public at present are not properly protected. . . there should be new legislative powers for the indeterminate, but renewable detention of dangerously personality disordered individuals. These powers will apply whether or not someone was before the courts for an offence.”
The Home Secretary, Jack Straw, House of Commons, February 1999 (Feeney 2003, p.349).
The statement above is deeply disturbing since it raises concerns about threats topublic safety from dangerous and mentally unwell members of society. However, without an investigation of research evidence this‘lock ‘em up and throw away the key’ declarationis a means of politically labelling the mentally unwell and sanctioning stigma under the guise of public protection. No statistics or figures are given and no research evidence is offered to support this inflammatory rhetoric. It is important to look both at the research evidence and the political context in which these comments were made.
The murders of Lin and Megan Russell on 9th July 1996 ‘gave rise to instant and justifiable national horror’ (Mental health enquiry report 2006, p. 4, see also: The Mirror 1997, p.6). This resulted in a furious public outcry that alleged that a loophole in the mental health law had effectively allowed the man subsequently convicted for the murder, Michael Stone, to remain at liberty when he was clearly a danger (Chittenden and Sheehan 1998).In the light of his conviction the Labour government suggested a plan to reform the MHA 1983 (HC Deb 26th October 2000).
Shortly after this speech was made, in July 1999 the UK Home Office and the Department of Health published the document: ‘Managing Dangerous People With Severe Personality Disorder’.In 2000 the DSPD programme was launched. This initiative aimed to identify those with “dangerous” severe personality disorder in the forensic population (prison or psychiatric hospital), who posed a high risk of committing violent or sexual offences if released back into the community, in order to provide effective treatment which would reduce the risk (Buchanan and Leese 2001, p.1955, see also: Feeney 2003; Maden 2007; DSPD programme 2005).
The former Home Secretary’s statement also suggested preventative detention, which raises serious ethical questions around the deprivation of liberty under the European Convention of Human Rights Article 5 (Gledhill 2010, p.440, see also Corbett and Westwood 2005).Whilst this was not enacted by parliament, considerable debate ensued about the treatment of severe personality disorder, in a political climate of public protection, which will be explored within this literature review.
Throughout the literature there is consensus that there is an over-representation of people with mental health problems in the prison population. It is estimated that between 4% and 11% of the UK population has a personality disorder (PD), whilst for people in prison, studies have estimated this figure is between 60% and 70% (Ministry of Justice (MJ) 2011, i). Approximately two-thirds of prisoners meet the criteria for at least one type of PD and a high proportion of cases are managed by the National Offender Management Service (NOMS) (Department of Health (DH)/NOMS 2011, p.9). Antisocial personality disorder (ASPD) is especially common in prison settings in the UK prison population (DH/NOMS 2011, p.9), with the prevalence of people with ASPD identified in one study as 63% in male remand
prisoners, 49% in male sentenced prisoners and 31% in female prisoners (Gibbon et al. 2010, p.2). A model is given below:
Figure 1: Estimated number of people with personality disorder
Based on an analysis of 11,636 cases in OASYS assessed as presenting a high or very high-risk of serious harm to others sentenced between 2005 and 2009.(DH 2011).
For those diagnosed with PD,access to services in prison and in the community are often denied, because they are stigmatised and regarded as a more difficult group with whom to work (DH2011). This failure to focus appropriately on issues relating to PD is a barrier to the National Health Service (NHS) and NOMS meeting their respective objectives of health improvement and public protection. Furthermore, rights to treatment in prison have been enshrined in the European Prison Rules (EPR; Council of Europe, Recommendation Rec, 2006), Article 10(3) of which stipulates: ‘The penitentiary system shall comprise treatment of
prisoners the essential aim of which shall be their reformation and social rehabilitation…’ (McRae 2009, p.172).
The NHS has been operating in prisons since 1990. From April 2006, prison health, which included mental health services, was transferred to the NHS (DH2003, cited in McRae 2009, p. 172). However, set against the somewhat utopian ideal which the European Prison rules propose is the current reality within England and Wales:
The degree of overcrowding and pressure of facilities in the local prisons…is at a level which militates against the promotion of health-care, both physical and mental (McRae 2009, p. 173).
Although written in 2009, there is no evidence for the situation having changed. A study at Whitemoor Prison, although somewhat limited in its generalisability, surveyed men assessed for the DSPD programme. Only 25% of prisoners interviewed (n=40) on the Red Spur DSPD assessment unit had been in contact with mental health services in the past, with the vast majority commenting that they had had no help in dealing with their problems while in the prison system (Tyrer et al. 2007, p. 52).
This literature review attempts to examine the ‘highly controversial’ DSPD initiative (Duggan et al. 2007, p.96, see also Rutherford 2010, pp. 49- 52).This was a pilot project to establish whether specialist services for men deemed as having this diagnosis were viable (Hogue et al. 2007). It has also been described as the ‘DSPD experiment’ (Völlm and Konappa 2012, p.165). The initiative commenced in 2002 and initially took place in two high security prisons, Whitemoor and Frankland, and two maximum security psychiatric units, Broadmoor and Rampton.
From the outset, it should be noted that there is a ‘dearth’ of literature on the DSPD programme as a whole (Völlm and Konappa2012, p. 174), thus this review relies on a limited evidence base. Firstly,it discusses the DSPD diagnosis, ten years from its inception, now the programme is being disbanded. The annual operating costs for the programme as reported in 2011, within the NHS and CJS are estimated at from £69m. The total cost is reported to be nearly half a billion pounds (Rutherford 2010). There is a proposal to use the money spent on the programme to treat a wider range of people, particularly targeting those in high and medium security prisons (DH/NOMS 2011).
Secondly, the discussion will address the treatment options available for men with a diagnosis of DSPD and some of the complexities surrounding the diagnosis of PDare explored. The concept of ‘male dangerousness’ will then be examined, referring to studies which consider the validity of the risk prediction tools used to define ‘dangerousness’.
Thirdly, the lived experiences of those undertaking the programme are discussed and the linked issue of why there is a lack of qualitative research literature is explored. The issue of whether the voices of those who have been silenced by society should be heard is considered. Narrative discourse will be used to explorethe courtroom drama through which the societal construct of the ‘monster’ is created, whose voice is heard during a trial and then is effectively silenced after the verdict is delivered. The ‘untellable narrative’ hypothesis proposed by Burr (2003, p.145)will be used in relation to this analysis.
Fourthly, the implications for social work are examined. The model of social work as a Practice of Freedom (Hyslop 2011) will be offered as a viable proposal in a context of social
justice.In line with Hyslop’s (2011) emancipatory model, this paper proposes that social workers should be based in forensic settings, endorsed by the policy document issued in response to the DH consultation paper (2011). This literature review highlights the importance of multi-disciplinary teams working with PD in such settings. The Scottish prison service model is offered as a viable option for the future, as social workers are employed within prisons in Scotland. A further recommendation is for obligatory screening for mental health conditions to be a legal requirement during imprisonment (see McRae 1990, p. 175).
This paper argues that social work could have an integral role to play at a macro level within a discourse of social justice and should therefore be located within the CJS in England and Wales. Social workers are able to work in an anti-oppressive manner with offenders who have severe mental health issues and to advocate for a highly stigmatised group of individuals, thus creating the possibility of making an invaluable contribution to the Public Protection agenda.
This literature review is founded upon the ideological premise that social work should involve itself with both the formulation and implementation of social policy on a national level. The National Association of Social Workers (NASW) (2008) Code of Ethics requires:
Social workers should monitor and evaluate policies, the implementation of programs, [sic] and practice interventions” and should promote and facilitate evaluation and research to contribute to the development of knowledge (Dodd and Epstein 2012, p.3).
Methodology and Ethical Considerations
Defining the research question
Research around the efficacy of therapeutic communities with regard to the treatment of PD was an initial focus. During my first placement in a high security adult prison, my interest began to shift towards treatment for PD in a forensic context. A conversation with a client, Paul, highlighted the difficulties faced by men with mental health problems in prison. Paul had been detained and diagnosed with PD in a specialist psychiatric hospital, which had been a traumatic experience. Paul did not understand the implications of the diagnosis and had no previous engagement with mental health services in the community. This raised concerns that I wanted to investigate further.
I started by compiling a mind map, highlighting areas of interest. Initial searches on Google and Google Scholar were conducted around prions and the treatment of PD. The results indicated much relevant material.
The research question evolved as the literature search was undertaken. Whilst searching for ‘personality disorder in prisons’. From this general reading, the acronym ‘DSPD’ came to light. Searching became focussed on the epistemology of the term and the methodology behind the treatment programme which had been devised for this client group. Further searches highlighted current government thinking with regard to the treatment of offenders with PD. The website for PD provided useful video material with regard to the National Institute for Clinical Excellence (NICE) guidelines on the treatment of ASPD and Borderline
PD (also known as Emotional Intensity Disorder). This is based on ICD-10 criteria (NICE Clinical Guidelines 78). For the purposes of this discussion, the term BPD will be employed.
The acronym ‘DSPD’ is employed within the title of this review since, being far removed linguistically from any clinical meaning, it conveys the stigmatising nature of the diagnosis: ‘In psychiatry it is all too easy for people with problems to become a something, something which is less than human’ (Rutherford 2010, p.51). This is juxtaposed against the phrase ‘Personality Disorder: No longer a diagnosis of Exclusion,’ (the National Institute for Mental Health for England) (NIMHE) (2003) to create a rhetorical question, which reflects the dissonance inherent in this juxtaposition.
I am aware that this is a highly controversial topic. The men about whom this paper is written have been proven guilty of crimes which have caused immense suffering to the victims and the victims’ families. However, I have attempted to write in a non-judgemental way which acknowledges the humanity of these men, who have been given a diagnosis of DSPD; I believe that everyone has the capacity to change. I have attempted to use language in a descriptive way. The term ‘patient’ is used throughout the review for the individuals selected for the DSPD programme who have been detained in psychiatric hospitals and in prison, since the programme is intrinsically a form of treatment. This is not universally seen as a preferable term (see for example Mcguire-Snieckus 2003, McLaughlin 2009, Simmons et al. 2010). When referring to particular studies I have adhered to the language which the authors themselves have utilised, in order to remain true to the integrity of their reporting, and commented where appropriate.
I wondered whether a specific role existed for social work in this context. I located one article about Forensic Social Work, which exists primarily in female prisons and Young Offender Institutions (Carson 2011) and the question arose as to what kind of social work practice (if any) was being undertaken with men in a forensic setting. The role of social work appeared to be sporadic within the prison systemin England and Wales, and yet from personal experience this role was highly relevant with regard to the Community Programme Approach (CPA) (Social Care Institute for Excellence) (SCIE), for men returning to the community. This anomaly underpinned my research. This initial reading alsohighlighted the work of leading experts within the field. ASSIA was then utilised and a hand search undertaken for references written by experts, in order to signpost other articles.
A revision of theresearch questionsgave the searching process a specific focus. I devised a table and recorded searches(Appendix 1).The ASSIA search engine was utilised, using the phrase: Personality Disorder, initially without using inverted commas, in order to give an overview of available literature.This searching strategy again indicated key researchers in this area and gave a useful overview with regard to the current political context.The operator‘AND’ was utilised, in order to narrow the search and obtain fewer results.
Inclusion and exclusion criteria were adopted, in order to incorporate both prison and psychiatric hospitals within the review.Various words were selected to describe men living in a forensic setting and used to search. Articles chosen were written in English and published after 1999 until 2012. The date selected reflected the aim of the review, which was to look at the contemporary situation with regard to treatment, not to do a historical study. This date also incorporated a key piece of legislation regarding policy directives with regard to DSPD.
One of the inclusion criteria was that articles chosen were published in the United Kingdom (UK), although the author might represent an international institution. The rationale underlying this was to gain a perspective on relevant material pertaining to the UK, whilst retaining the integrity of the study. Howeverthrough hand searching, I discovered that some of the leading British experts on PD had published in American journals. This led to a revision of the exclusion criteria in order to include their work.
The DSPD initiative relates solely toEngland and Wales, however sincethe forensic social work role exists in the Scottish prison system a report on this was used within the study. One further paper came to light which did not fit the inclusion criteria; a comparative study of offenders with DSPD with high-risk offenders in other countries, which was reported in an international journal; this was included because it was a qualitative study specifically focussing upon the characteristics of the DSPD population.
Wallace and Wray (2006) have devised a useful and simple categorisation system to classify literature which was employed:
Hierarchy of Evidence
There has been considerable debate over the nature and quality of robust social work research (Smith 2009, p.17).Aveyard maintains that there is a general consensus regarding the hierarchy of evidence and that some forms of evidence are stronger than others in addressing
different types of research questions (2010, p.61). Systematic reviews and meta-analyses are considered to be the pinnacle of current research, in terms of rigour, followed by Randomised
Controlled Trials (RCTs) (Sackett et al., cited in Aveyard2010, p.66). It is argued by many that with regard to evaluating the effectiveness of a treatment or intervention, whichis considered the ‘gold standard’, RCTs are: ‘A form of clinical trial, or scientific procedure used to determine the effectiveness of a treatment or medicine.’(Aveyard 2010, p.48).
Aveyard proposes there should be a symbiotic relationship between the nature of the research and the type of question employed within the review. As this review proposes to examine current treatment options and the lived experiences of men who are receiving treatment, it was decided to utilise a combination of quantitative and qualitative literature. Articles were selected according to thisaetiological paradigm.
With regard to addressing the lived experience of men with a diagnosis of PD in a forensic setting, the guidance produced by the Social Care Institute for Excellence (SCIE) was followed. This recommends that empirical evidence, bothqualitative and quantitative literature, provides the best evidence foreffectiveness of specific interventions. Searches were undertaken for studies incorporating service user and carer testimony (in the forensic context staff are the carers undertaking this role). Testimony should arguably be central to the systematic review (Braye and Preston-Shoot, cited in Orme and Shemmings 2010,p.22), thereforesome studies highlighting the attitudes of staff towards the men in their care were selected, since this may be a significant factor with regard to the iatrogenic effects of treatment.
The concept of robustnessis contentious in evaluating any study. McDonald, cited in Orme and Shemmings (2010, p.23),claims that robustness must address questions of validity.Coren and Fisher, cited in Orme and Shemmings(2010, p.23), purport that knowledge is valid only if subjected to user and carer testimony. This ‘emancipatory’ approach, which transforms the relationship between service research and the lives and voices of service users, could be viewed as a ‘liberating force’ (Smith 2009, p.75). I therefore attempted search for articles which incorporated the testimony of service users or the people who care for them.
Due to the nature of this review, much of the literature selected was taken from the fields of forensic psychology and criminology, however I attempted to counterbalance this with relevant articles from the field of social science or social work. The theoretical stance proposed by Coren and Fisher, cited in Orme and Shemmings (2010, p.23) and Smith (2009, p.75), outlined above, regarding validity, remained a frame of reference during the searching process. I attempted to use the recommendations offered by Shaw and Norton (2007), which state that stake-holdercommunities should apply judgement ‘selectively but not self-servingly’ (cited in Orme and Shemmings2010, p.23).
Critically appraising the literature
Three assessments were considered:
- Is this literature relevant to my review?
- Have I identified literature at the top of my hierarchy of evidence?
- Is this literature of high enough quality to include in my review?
The literature was scrutinised and two articles discarded since they were published outside the United Kingdom. Aveyard states that:
as a novice researcher, you are advised to include everything that is relevant to your review, but to acknowledge the limitations of the literature and hence the weight or impact that the literature has in addressing your research question (2011, p.91).
This guidance provided the framework for the next stage of the review. A critical appraisal tool devised by Wooliams et al. (2009), cited in Aveyard (2011, p.97),was selected and a table designed in order to report on each piece of literature selected. A system of colour coding was used to identify specific themes which emerged.
It is acknowledged that there arelimitations to this study. The method of ‘systematic searching’ posed a considerable challenge to a novice researcher who has a learning difficulty which impacts upon structure and organisation. This was addressed by optimising the support structures available within the university. A discussion during the searching process highlighted that research undertaken in the United States of America (USA) is considered to be at the forefront of the psychiatric field and the exclusion of such research is acknowledged as a limitation.A further limitation is that due to both time and financial constraints, it was not possible to access all articles listed in the searching paper. Three of the reported themes in a key qualitative study by Maltman, Stacey and Hamilton (2010) are not in the public domain. The author of this review received no response when requesting the paper, so is unable to fully report on the findings. All decisions regarding the selection of papers have been taken by the author, thus there is an element of subjectivity with regard to the selection process.
The review was conducted in line with the ethical guidelines outlined by the University of Sussex. Formal approval by the supervisor was granted for the research proposal.A statement was signed by the author that no empirical research would be undertaken.
The work of DrG. Adshead, Consultant Psychotherapist at BroadmoorHospital ,who is well known,featured in several of the searches. However, ethical concerns exist regarding Dr Adshead’s practice as she was brought before the General Medical Council because a patient denied having given consent to publish confidential information.After careful consideration, and due to Dr Adshead being found fit to continue in practice, it was decided to include articles written by Dr Adshead which state that consent, whether verbal or written, has been obtained.Dr Adshead alsomade several relevant papers available for this literature review.In order to retain the integrity of the study I feel it is important to declare that I have attempted not to let this sense of obligation affect my judgement when evaluating her work.
What is a diagnosis of DSPD?
(P4) ‘I was expecting to be around some really disturbed
people . . . I was shitting myself . . . you hear that many
stories of people like Hannibal Lecter . . .’
(Maltman et al. 2008, p.10).
The issue of ‘treatability is fundamental to any discussion around the DSPD diagnosis. Under the original Mental Health Act 1983 (MHA), the ‘treatablitytest’ stipulated that patients who pose ‘a significant risk of serious harm to others as a result of a mental disorder’
could only be detained if doing so is likely to alleviate or prevent further deterioration in the patient’s condition(DH 2000, p.9, see also Gledhill 2000). In response to cases such as that of Michael Stone the government wanted to allow those diagnosed with mental health conditions with a tendency towards violence, or sexual offending, to be detained against their will without having actually committed a crime (Adshead 2001).
Although preventative detention was not enforced, the MHA reforms which were enacted in 2007 changed the “treatability test” into an “appropriate medical treatment test”, whereby patients can be detained against their wishes as long as there is a medical treatment available to them that can alleviate or prevent the worsening of the disorder or one or more of its symptoms. The treatment must be appropriate, and readily available to the patient (DH 2007). The Criminal Justice Act (2003) was also transformed with the introduction in April 2005 of public protection sentences whereby indeterminate detention can be imposed on the basis of convictions for serious violent or sexual offences, with release after the tariff period
has been served, this being dependent on the parole board being satisfied that the risk has been reduced (Tyrer2007, s1).
Origins of the DSPD diagnosis and treatment programme
Amongst the literature, there is a great deal of commentary on the highly controversial DSPD diagnosis from scientific, legal, socio-political and ethical perspectives, with most tending towards a rejection of DSPD as a valid medical diagnosis.The literature is heavily charged with opinion, however the contributors to the debate are professionally credible and their viewpoint is supported by evidence.One review article looks at the successes and failures of the DSPD programme. The article describes the‘proto-diagnosis’ of DSPD which is a ‘new concept in forensic psychiatric practice’ This article argues that the diagnosis is ‘suspect’, stating that it was created with limited contributions from experts in the field, mostly from a single psychologist, Dr David Thornton. (Tyrer et al. 2010, p.95).
In a commentary on ‘“Dangerousness” and dangerous Law’ in a leading medical journal, Farnham and James echo Tyrer’s concerns, commenting that ‘DSPD is a neologism, that has no legal or medical status’ (2001, p.1926). One editorial in a peer-reviewed journal argues that the diagnosis was ‘generated by politicians’ (Gunn 2000, p. 75). A similar comment is made in another editorial in a leading psychiatric journal, which describes the DSPD diagnosis as an example of ‘political theatre’ (Maden 2007, s.8, see also Corbett and Westwood 2005).The term ‘DSPD’ has also been deemed ‘a political invention’ by social commentators (Batty 2002;Goldacre 2002). This newspaper article claims that many doctors hold such an opinion. No mention of which doctors ascribe to this view is given, which reduces the validity of the statement, howeverit does highlight the high public profile which the diagnosis gained.
A rigorous qualitative study which is useful in relation to the DSPD diagnosis examined the referral and socio-demographic characteristics of the 202 male patients admitted, with 174 consenting to participate in research (Burns et al.2011). Fully informed written consent was obtained and ethical approval was outlined. The patients had an average median age of 38 years. Most were white and born in the UK. Most patients (75%) are reported to have met full DSPD criteria as suffering from severe personality disorder that caused them to be dangerous. Whilst the findings in this study confirmed that DSPD units contained dangerous offenders with no evidence of preventative incarceration, there is a persuasive argument regarding whether people should be treated for a spurious medical condition:
Dangerous and Severe Personality Disorder is an administrative category, not a medical diagnosis, and whether individuals so labelled should be managed within high secure hospitals or prisons remains a subject for debate (Sinclair et al. 2012, p.252, see also Burns et al. 2011, p.1).
It should be noted that the study by Burns et al. (2011) is an international comparative study, therefore only aspects of the discussion are useful in relation to this review.
One quantitative study sought to establish whether, after ten years of specialist service provision, patients deemed DSPD were different from other personality disordered patients detained in forensic settings. Thirty-eight men who were detained in high-security units were compared with sixty-two men detained in conventional medium-security or high-security hospital units using the Psychopathy checklist-Revised (PCL-R) and other standard clinical, personality disordered and offending measures. The drawbacks of this paper are that ethical approval was not outlined and the sample size was relatively small. The authors outlined the limitations of the study. The paper concludes that there is no justification for treating personality disordered offenders with core personality features of psychopathy differently from other personality disordered offenders (Howard et al. 2012).
A systematic review of empirical research highly relevant to the discussion around the nature of the DSPD diagnosis was undertaken byVöllm and Konappa (2012). This is highly relevant to a discussion around the DSPD diagnosis in that it examines literature from 1999-2011, with 29 empirical research papers identified and three comprehensive research reports. No ethical approval is outlined, although the limitations of the study are discussed. Most studies surveyed were concerned with describing the DSPD population and confirmed that the projects targeted high-risk personality-disordered offenders (Völlm and Konappa 2012).
Apilot programme was established in 2001,with the establishment of four high-security units, as discussed previously. A quantitative report sheds light on the first cohort of prisoners that completed treatment in the Fens DSPD unit at HMP Whitemoor:
These men were those with a diagnosis of severe personality disorder whose offending was linked to their psychopathology. These men were particularly likely to commit interpersonal offences, including serious sexual and physical violence, manslaughter and murder (Saradjian, Murphy and Casey2010, p.45).
The authors explain that the treatment programme was rigorously scrutinised and agreed by an international group of experts in this field, subject to similar analysis to accredited prison programmes. There are several weaknesses in this review. The sample size is very small (n=18). No limitations are outlined and no ethical approval is reported. Furthermore, the study was not located in a peer-reviewed journal.
The units in which those selected for the DSPD programme were housed became known as ‘the Dangerous and Severe Personality Disorder or DSPD units’ (Saradjian et al. 2010). The DSPD projects included high-security prison units at Whitemoor, Frankland and Low Newton (for women); high- security hospital units at Broadmoor and Rampton. DSPD thus refers to both the patients and the units within which they were placed.
DSPD and male ‘dangerousness’
It is noteworthy that whilst theDSPD diagnosis is not gender specific, women are only mentioned within the review literature once: by Völlm and Konappa(2012, p.167), who report that there were 12 DSPD places provided by the Primrose Project at HMP Low Newton. The picture given by the literature is somewhat confusing because the Primrose Project is not mentioned in any of the other papers. There is a general consensus that the DSPD project was specifically for men (Sinclair et al. 2012, p.25,Burns et al. 2011, p.131).
The language used for the title of the pilot units for the male participants contrasts starkly with the flower metaphor used for the women’s unit: ‘The Peaks’ (RamptonHospital), (Hogue et al.2007, p.57), ‘The Fens’(Whitemoor Prison), (Saradjian, Murphy and Casey, 2010), ‘Red Spur, Blue Spur, Green Spur’(Whitemoor Prison), (Farrington and Joliffe 2002, p.9) are more suggestive of rugged, mysterious mountain ranges rather than a soft, traditionally feminine flower. The linguistic context of the units for the male participants is dark and foreboding, which could arguably be seen as a metaphor for the ‘dangerous masculinity’ of the men selected for the programme. For the purposes of this discussion, it is not possible to examine this issue in any further detail; however, it is nonetheless worthy of mention.
The focus of the literature is thus largely on male offenders, with a capacity for 300 men over the four pilot sites (Völlm and Konappa 2012). Saradjian et al. (2007,p.45), state that the aims of the DSPD units were: ‘to protect the public from some of the most dangerous people in society’, although the epithet ‘people’ is, in this case, a euphemism for ‘men’. The use of the generic ‘he’ is also used synonymously with the phrase ‘an inmate’ in a paper by Morris, Gibbon and Duggan (2007, p.74).
The classification of risk
“The operational definitions of risk and severe PD being used in the pilot project were arrived at somewhat pragmatically as no such definitions existed especially in the recognised clinical literature…Unfortunately many of the risk assessment tools do not give the specificity we would have hoped for…”
(Farrington and Joliffe, 2002, p.8).
At this juncture, it would be useful to examine in more detail the concept of ‘dangerousness’which is synonymous with risk. The epithet ‘dangerousness’ is discussed in the reviewed literature both in terms of the risk prediction rating scales (Howard et al. 2002; Tyrer et al. 2007)and in a socio-political context (Corbett and Westwood 2005; Deacon 2010).
An influential feasibility study commissioned by the Home Office, exploring the possibility of using an RCT to evaluate the DSPD pilots at Whitemoor, was undertaken by Farrington and Joliffe (2002). The operational definition of DSPD based on ‘Dangerousness’ was developed by Thornton and Hogue (2001) namely: ‘A significant risk of committing a serious violent or sexual offence after release (within the next 15 years) (Farrington and Joliffe 2002, p.7). Five risk assessment tools used to predict this were utilised. The authors point out that there is some repetition of the items in these instruments and they are likely to be highly intercorrelated. This was being investigated at the time of writing by the DSPD assessment. The risk must be greater than 50 on at least two of the assessments for the individual to be considered dangerous. The conclusion was that efforts should continue to create the conditions to support the “gold standard” RCT design (Farrington and Joliffe 2002, p. 4).
Following this recommendation, an RCT study took place at two pilot sites in the DSPD programme (HMP Whitemoor and HMP Frankland), using an RCT design. The study looked at the effects of early and late assessment(Tyreret. al. 2007). This trial is unique in the literature because the prison system generally does not support the RCT method of randomisation (Farrington and Joliffe 2002). Seventy-five prisoners took part in this trial, with thirty-three randomised for early assessment and thirty-eight for late assessment with one hundred per cent data collection over the course of the trial, which is almost unknown in a trial of this nature. The results showed that taking all the IMPALOX risk and personality measures together; one in three of these prisoners did not satisfy the stated minimum requirements for DSPD. It should be noted that prisoners referred in the early part of the DSPD programme were volunteers and later ‘recruits’ were often coerced into ‘volunteering’ for treatment (Tyrer et al. 2007, p.6).
The public focus on ‘male dangerousness’ is echoed in the IDEA (Inclusion for DSPD Evaluating Assessment and Treatment) study mentioned above, which outlines that only male patients were accepted for the DSPD units(Burns et al. 2011). This point is echoed by Saradjian et al (2007), who state that the men assessed and treated within the units were: ‘Deemed to be at a high risk of reoffending in a form that would cause significant harm, both physical and psychological, to another person’. (Saradjian et al. 2007, p.45).
Scholarly debate exists as to whether many of the men assessed did not meet the selection criteria for the DSPD programme. One study discusses the problems inherent in the selection process: ‘many were included in the assessment programme despite having little in the way of severe personality disorder’(Tyrer et al. 2009, p.152). This is perhaps unsurprising given that a leading expert argues that within the field of psychiatry there is no universally accepted definition of severe PD (McMurran 2002, p.3). The Royal College of Psychiatrists (1999) suggests that severe PD should be characterised by:
gross societal disturbance along with gross severity of personality disorder within the flamboyant group and a personality disorder in at least one other cluster also (McMurran 2002, p.3).
Results indicated that compared with their counterparts in non-specialist services, the ‘DSPD group’ had higher scores on PCL-R psychopathy, which raises questions regarding the functional outcomes of the DSPD programme, since:
there is currently no evidence that core personality features of psychopathy are amenable to treatment, there is little justification for treating high-psychopathy forensic patients differently from those with other disorders of personality
(Howard et al. 2012, pp. 65-66).
This study questionsthe concept of ‘dangerousness’,reporting that other than their higher PCL ratings, the men who agreed to take part in the survey bore a striking resemblance in terms of their personality and offending to men who had ‘not attracted the DSPD label’ (Howard et al. 2012,pp.73-75).The authors argue that unsurprisingly, the high PCL score, which was a crucial factor in the criteria for severe PD, as identified within the government
DSPD programme (2004), was found to significantly predict membership of the DSPD cohort. However, the prediction of ‘dangerousness’ is contestable:
It appears paradoxical that DSPD patients, supposedly admitted on account of their alleged dangerousness, showed personality features that according to the results of the Yang et al. (2010) meta-analysis are not associated with increased risk of violence in men (Howard et al. 2012, p.75).
It is somewhat ironic to note the ‘lucid’ comments of some of the patient interviewees at Whitemoor Prison regarding the ‘cognitive deficiencies’ of the assessment process (Tyrer et al. 2007, p. 54). For example, it was very difficult for prisoners who had previously been assessed as high PCL scorers to appear to demonstrate an acceptable interpersonal style (Factor 1 criteria), since attempts to do so tended to be interpreted as ‘evidence of greater psychopathic deviance’ (Tyrer et al. 2007, pp. 54-5). This highlights the problematic nature of labelling under the guise of assessment.Lindqvist and Skipworth (2000) also express concern that predictor variables of recidivism are often regarded as largely immutable, which set against a rehabilitation model creates tension.
An earlier study by Buchanan and Leese (2001) also casts serious doubt as to the prediction of ‘dangerousness’ intrinsic to the DSPD programme. Published reports were reviewed in which the accuracy of a clinical judgement or a statistically derived rating of dangerousness was validated by its use to predict the violent behaviour of adults within the community. The sensitivity and specificity of procedures used by every study were calculated and these procedural measures were then applied to the purported base rates of violence for people with DSPD. The twenty one studies which afforded suitable analytic criteria gave the following results: ‘Using the average positive predictive power of these procedures, six violent people would need to be detained to prevent one violent act’ (Buchanan and Leese 2001, p.1926).
Making predictions over shorter time-scales did not improve their accuracy. However, it should be noted that several of the studies within the review cited above were undertaken outside the United Kingdom. Furthermore, since no demographic data is given and thestudies were all undertaken pre-2000, there is limited generalizability in regard to this discussion.
These findings were replicated in a similar study by Ullrich, Yang and Coid (2010). A stratified sample of high and low risk prisoners were identified. The sample who agreed to take part included 1396 male prisoners serving sentences of more than 2 years for a sexual or violent principal offence. The study followed the participants for up to two years following release. A cohort of 43 prisoners still remained in prison at the end of the follow-up period. Ethical approval was given and written informed consent obtained from all participants. The interviews were conducted by research assistants who were closely supervised, although their professional background was not provided. A UK Home Office algorithm tool was used to predict ‘”dangerousness”’. (Ullrich, Yang and Coid 2010, p. 85).
Their findings indicated that five DSPD offenders would need to be treated (or detained) to prevent one violent offence after release into the community. However if this number is differentiated into major and minor violence, the study suggests that 26 DSPD offenders would need to be treated to prevent one major act of violence (Ullrich, Yang and Coid2010, p.87). The study demonstrates support for the DSPD programme because based on the estimate of attributable risk, if there had been an effective intervention for those identified as
DSPD within the group surveyed, this would have resulted in a reduction of 71% of violent recidivism within this group.
The studies above question the usefulness of the risk assessments with regard to ‘dangerousness’. This position is counteracted by an investigation which examined the sociodemographic characteristics of the men selected for the DSPD programme. The authors found that the majority (75%) of patients met full DSPD criteria ‘as suffering from severe PDthat caused them to be dangerous’, with many patients having an extensive psychiatric and offending history, with a median offending age of 12.6 years before the index offence(Burns et al. 2011, p.130). It should be noted that 174 of the 202 patients approached agreed to participate in the study, which was 14% of the target population. The risk assessment measures taken from the clinical notes were not formally tested with regard to reliability. No information is given with regard to the professional background of the two research assistants located in each of the units and administering the interviews. Whilst the authors claim that the findings of this study are ‘broadly reassuring’ with regard to the patients meeting the specified criteria for inclusion in the DSPD programme, it does nonetheless highlight that a quarter ‘did not have recorded evidence of meeting the criteria’, with the most common reason being the absence of a causal link between PD and offending (Burns et al. 2011, p.134). Furthermore, although three-quarters of the men who took part in the study met the rigorous criteria at intake, the report states that‘more than halfhad this clearly recorded in their notes’ (Burns et al. 2011, 134). The quarter of the men who did not meet the intake criteria, which is not discussed in the study,is nonetheless a significant number (43 according to a calculation by the author of this paper). The shortfall in recording procedures is significant in that it has implications for future parole. This will be discussed later in this literature review.
A major issue in regard to the DSPD diagnosis was compulsory assessment for DSPD:‘in particular, prisoners may be even more likely to tell lies in an attempt to avoid the consequences of being labelled as DSPD’ (Farrington and Joliffe 2002, p.9). Research is needed to devise key risk measures that correlate with serious violent and sexual offending and also the validity of self-reporting by DSPD prisoners (Farrington and Joliffe 2002, p.21).
Recently, significant inroads have been made with regard to the developmental trajectory of PD (Fonagy 2007). Several major cohort longitudinal studies have been conducted which have yielded somewhat surprising data with regard to symptomatic remissions(Fonagy2007), which are reported within the American literature and therefore lie outside the scope of this study, yet are nonetheless worthy of mention. This raises the question as to whether, if symptomatic remission occurs over time, ‘risk of dangerousness’ also remits over time. It is therefore questionable as to whether it is ethical permanently to attribute a label of ‘dangerousness’ to an individual via a diagnosis.
Implications for release
Trebilcock and Weaver (2010) undertook a study which is unique amongst the literature. This study involving three linked investigations aimed to identify the legal characteristics of DSPD patients and prisoners, record their Parole Board (PB) and Mental Health Review Tribunals (MHRT) during the period of the study, and explore PB and MHRT members’ views about the decision-making in relation to DSPD patients and prisoners.A case record database was established, describing the legal characteristics of 172 DSPD patients and prisoners. Data collection was on going between January 2007 and June 2008. A qualitative interview study was also conducted with 9 DSPD clinical staff, 13 PB and 12 MHRT members. The study limitations are outlined. Ethical approval is not recorded.
Since admission to DSPD services and before 31 Dec 2007, 86 of 172 patients had 118 PB/MHRT. Documents submitted to PB/MHRT meetings were collected in 80 cases (68%) and decision letters in 111 (94%). The data surveyed thus provided a useful snapshot of the trajectory of many of the DSPD participants; however an important factor which should be noted is that the study does not account for the amendments to the MHA (2007), which came into effect in November 2008, which included the removal of the category of psychopathic disorder. Thus the study is limited to patients reviewed under the terms of the MHA(1983).
The results show that no DSPD prisoner was recommended for a transfer to open conditions or release to the community by the PB. The report highlights a difference in outcomes for those reviewed by the MHRT. Whilst the report states that the majority of DSPD patients (no number is given) received no recommendation from the MHRT, one patient was recommended for discharge to the community, one for return to prison, seven for transfer to medium secure services and one for reclassification of his mental disorder. This is significant in that it shows that a possible difference in thinking between the two decision making agencies and also indicates a positive outcome for an albeitsmall number of the DSPD cohort.
Results from the qualitative survey indicate that the majority of DSPD prisoners were originally given an indeterminate prison sentence, whilst most DSPD patients were given a determinate sentence. Both sets of results suggest that the outcomes for hospital patients in terms of implications for release appear to be more positive than for prisoners, however the research evidence is limited to the findings from one study therefore is not generalizable. The report was not published in a peer-reviewed journal and one of the researchers undertook the study as part of a PhD studentship.
The proposal to disband the DSPD programme after ten years was mooted in a recent consultation document (DH 2011).The report recommended that the specialist DSPD units at Broadmoor and Rampton would be closed, with prisoners moved to personality disorder directorates in
the same hospitals (at similar costs as the DSPD programme), medium secure NHS hospitals or back to the prison system.Only those prisoners who meet the requirements of the MHA would be treated in hospital, but the number of referrals may increase as a result of the absence of provision in prisons. It remains to be seen what the long-term outcomes will be for those who took part in the programme.
How are the lived experiences of men with a diagnosis of DSPD reflected in the literature?
“12 months ago I’d have said to anyone, don’t go there. My world view has been turned around, full turn. I’d advise people now to come here. Because it’s all about you, it’s not about the system, there’s no skulduggery…” (Tyrer et al. 2009, p.53).
Literature examining the lived experiences of men were specifically selected for the DSPD programme is somewhat scarce, with only six papers identified: Tyrer et al. (2009); Sinclair et al. (2012) andVöllm and Konappa (2012), whose systematic review includes three further qualitative studies, chosen from a total of 29 empirical peer-reviewed research papers. The qualitative papers identified in this systematic review were: Ryan et al.(2002), which was not specifically focussed on DSPD patients;Maltman, Stacey and Hamilton, (2008), which examined the views of individuals in a DSPD setting and Burns et al. (2011 c), which investigates the characteristics of DSPD patients, in comparison with other high risk offenders. The drawback here is that the latter study offers an international comparison, although it is useful regarding demographic data of the 174 DSPD patients who took part in the study. The latter two papers will be discussed at a later stage.
One study involved in-depth interviews with 60 participants purposely sampled across four pilot DSPD units from a total sample of 168. Reassurance was provided to participants about confidentiality. Ethical approval is not discussed.No information is provided regarding whether the same researcher or interviewer was used to conduct all the interviews and no detail is given with regard to their professional training. It was disappointing that despite the
author pointing out the importance of using qualitative methods to evaluate novel initiatives, only one direct quotation was used in this paper (Sinclair et al. 2012),
One of the findings was that transfer to the DSPD programme resulted in considerable uncertainty about progressing through the system in both prison and hospital units. A further unanticipated finding was that some of the participants had little choice or warning about coming to the programme. A large proportion of the hospital patients (44%) compared with only 7% in the prison units, spoke of how they perceived procedural security as restricting access to activities and curtailing their autonomy. This paper is highly relevant in that the large sample is broadly representable.(Sinclair et al. 2012).
A robust study by Tyrer et al. (2007) was very useful in regard to understanding the experience of participants, both staff and prisoners, in the assessment phase of the DSPD programme. This evaluation of the assessment procedure was conducted using purposive sampling, on Red Spur; the DSPD unit at Whitemoor Prison, over four years, from early 2001 until 31 March 2004, and 40 prisoners participated. Informed signed consent was obtained from the prisoners who took part.Staffwere also interviewed, however all staff withdrew from the study from approximately late 2002. This was due to clinical and managerial staff feeling unable to express their concerns about the difficulties faced in implementing the assessment. This in itself tells a story regarding levels of anxiety about conducting the assessment process.
While the picture of the assessment programme as a whole is somewhat negative, particularly in terms of assessment procedural difficulties, reports of prisoner experience during the assessment process do show positive outcomes. For example, one prisoner commented:
‘I’ve never,evernot been violent: trying or learning to control it is a major step for me. For 9 months I’ve not attacked anyone’ (Tyrer et al. p.53).
This qualitative study demonstrated that most prisoners found their time on the Red Spur Assessment Unit beneficial, that they had some opportunity for better self-awareness and, in some instances, improved quality of life (Tyrer et al. p.58). One significant factor which renderedthis study remarkable was that it gave voice to many prisoners by directly quoting them.It is important to note that the assessment process is not synonymous with the DSPD treatment programme; some of those assessed were not ultimately considered suitable for this.
A further qualitative studywas useful in giving voice to patient perspectives on DSPD assessment Maltman, Stacey and Hamilton (2008). The study was conducted in Rampton Hospital (The Peaks Unit), which admitted male patients for assessment and treatment from March 2004. All patients were detained under the Mental Health Act(MHA) 1983. A pertinent aspect of this research is that it emphasises the importance of allowing patients the opportunity to be involved in their own healthcare. Thiscuts across the ethos of the DSPD programme in which no service user involvement was permitted. There are clear benefits to examining patient perspectives, for example,mental health patients can provide detailed and constructive service evaluation, despite their fragile mental health.
Although this study paid attention to ethical and procedural considerations, such as having a second interviewer to manage the informed consent process in an attempt to avoid coercion, since the lead researcher was an active clinician there were significant weaknesses which will
be further discussed. It is also noteworthy that whilst the interview sample was relatively small, several direct quotes are mentioned within the paper.
Many of the themes which emerged from the 12 interviews conducted echoed the findings from the Red Spur assessment unit. Although, as the authors rightly point out, it is tenuous to directly compare the two, since the sample at Red Spur volunteered themselves within markedly different political, legislative and cultural frameworks. Nonetheless, for the purposes of this discussion, some of the overlapping themes paint a picture with regard to common factors in the DSPD initiative.The themes listed are headed as: ‘Fear, Shock, Offering Hope, the ‘DSPD’ Label, Information and Coping withBoredom,’(Maltman, Stacey and Hamilton 2008, p.10). One noteworthy aspect in regard to the findings is that only the first three themes listed above are reported ‘in the interests of a concise paper’ and as holding ‘most relevance to a wider audience’ (Maltman, Stacey and Hamilton 2008, p.10). One wonders at the reasons underlying this because none of the other quantitative or qualitative papers identified in this review withhold findings in an effort to be concise. It is interesting that one needs to correspond with the author directly to obtain information regarding the DSPD label. This is arguably an example of ‘silencing’ the voice of the DSPD population in regard to their label and will be examined later in the paper.
One of the findings from this study was that personal safety fears were a predominant feature, with the DSPD unit having a bad reputation with both staff and patients in other areas of the
hospital (P11) ‘People had said that it was called the ‘Dark Side’ (Maltman, Stacey and Hamilton 2008, p.10). The paper outlines that ‘the Dark Side’ had become a popular Rampton Hospital metaphor for ‘the Peaks’, however hospital staff have since been encouraged to use the latter more neutral title.
A significant aspect of the DSPD programme is that the literature gives very little information regarding prisoners of ethnic minority status. It would appear that the majority of participants in the programme across the four sites were white males. It is difficult to comment on this aspect of the programme.
On apositive note, hope in the programme was expressed by participants in the Whitemoor Prison study, for example ‘increasing optimism and personal insight.’ One patient commented (P10) ‘…I believe in the Community Meetings…there’d be a lot more trouble on the ward’ (Maltman, Stacey and Hamilton 2008, p.12). Although false hope was perceived by some of the participants, especially regarding length of stay (Maltman, Stacey and Hamilton 2008, p.12).
A literature review detailing the views of service users in a forensic setting was somewhat useful,however pre-1999 data was used and many of the studies involved mixed gender samples, thus the generalisability was limited (Coffey, 2006). Adshead (2012) provided a unique focus with regard to the lived experience of ‘offender patients’ in a high security hospital, which, although not specifically focussing on men within the DSPD programme, was nonetheless highly relevant.
One unusual qualitative study explores ‘accounts of recovery and redemption’ from the perspective of offenders with a mental disorder who have committed homicide (Ferrito et al.
2012, p.1). Semi-structured interviews were conducted with seven men who were residing in a high-secure hospital. The interviews were analysed using interpretative phenomenological analysis. Patient consent was ethically obtained. Whilst the study offers a unique perspective in relation to ‘recovery’, no DSPD patients were mentioned and only two of the men interviewed had a diagnosis of PD, thus it is of limited use in regard to this discussion. The various papers identified were therefore of varying relevance to the research questions. The lack of qualitative literature with regard to the DSPD initiative is significant and will be explored later in the review.
Two further qualitative papers examined the attitudes of staff towards the people with PD within their care (Bowers et al. 2005, Carr-Walker et al. 2004). The study by Bowers et al. (2005) is of particular interest in that it explores changes in attitudes to personality disorder on a DSPD unit. Data was drawn from a longitudinal study of prison officers, with measures at baseline, eight and 16 months, but relying on the eight and 16-month interviews. Semi-structured interviews using a staff Attitude to Follow-up Interview tool developed for the study. Interviews were conducted with prison officers working in the assessment and intervention units at Whitemoor Prison. Ethical approval was granted.A total of 96 interviews were conducted with 66 officers. Data analysis was conducted in two stages. The findings indicate that a clear, unified direction and treatment regime is regarded as creating and maintaining positive attitudes to PD. The findings also showed a development of greater understanding of personality disorder and prisoners as individuals. Although only a small-scale study using a specifically designed measurement instrument which had not been
previously tested, this shows that the DSPD programme made a positive impact upon staff’s attitudes towards the men in their care.The scarcity of qualitative data regarding the ‘voice’ of the DSPD participants warrants further discussion and will now be explored.
There are disproportionately more quantitative papers than qualitative articles available. Why so little articulation has been given to the people at the heart of a process which has lasted ten years needs to be addressed. A plausible explanation may be found within the literature on narrative. A Consultant Psychotherapist at Broadmoor maximum secure psychiatric hospital offers an insightful theoretical commentary on this issue (Adshead 2011). Forensic psychiatric narrative is discussed within the setting of the courtroom and the psychiatric report is likened to a tragic narrative. The index offence is the ‘crisis point in the narrative which fixes the identity of the defendant’ (Adshead2011,p.365). The significance of narrative for the construction of personal identity is explored by Adshead (2011), who purports that the construction of offender identity is a key process in the drama of the criminal court. We are reminded that the defendant whose mental illness ‘causes’ his offence is: ‘a tragic figure, whose mistaken and damaged mind has brought about his own downfall, as well as creating terror and suffering for others’. This ‘offender’ identity may then be combined with a ‘patient’ identity, namely; one who suffers. The Greek word ‘pathos’ means suffering and is the root of the word, ‘patient’. ‘As an expert in mental disorders and their relationship with violence, the forensic psychiatrist gives voice to this ‘patient’ identity.’(Adshead2011, p.365).
However it is equally possible that the forensic psychiatric expert’s narrative can cast doubt on this identity:
These experts ‘create’ monsters with their narrative: classic monsters of story who threaten the community. But if the prosecution depict the defendant as a monster who threatens the community, the defence will try and portray him or her as a person who lost their way in life’s dark wood; who, on a quest, made mistakes and metaphorically, lost ‘sight’ of what was happening or the true import of what they did
Adshead (2011) argues that the use of concepts such as narrative does not undermine attention to professional ethics in terms of objectivity, honesty and veracity. If both sides are creating stories, there is no significant concern about ethics as long as both sides are afforded the opportunity to recount their tale. The concerning factor is when only one story is told or where the story teller ‘fails to communicate their “voice” ’ (Adshead 2011, p.).
This struggle for ‘identity definition’ within the courtroom may be viewed as a microcosm of a societal conflict between ‘tellable’ and ‘untellable’ narratives (Burr 2003, p.145, see also Turner 2012). It could be argued that the Frankenstein type ‘monster’ represented by the ‘Dangerous and Severe Personality Disordered’ manoffers a ‘tellable’, therefore socially acceptable explanation for the ‘untellable’ ‘mental illness narrative’ of men such as Michael Stone. This ‘tellable’ narrative is perhaps the reason for the language utilised by the tabloid press in relation to murder, for example, the editorial comment: ‘This monster must be caught and put away for the rest of his life’ (The Mirror 1997,p.6).
Once the ‘tellable’ narrative has been articulated, often loudly, through media reporting, the tale is told, the identity of the ‘monster’ is established and the individual in question is incarcerated and effectively silenced. There is no redress with regard to the ‘offender identity’ which has now effectively been legally established within the adversarial courtroom. As Albert comments regarding his perception of stigmatisation:
“You’ve done something violent and you are now seen as Mr. Violent. Someone is making a judgement and you can only judge people on their actions”.
(Ferrito, Vetere, et al. 2012,p.12).
This perception of male violence is explored in a television documentary entitled Frankenstein: A Modern Myth (2012). It is interesting that the voices of those who are incarcerated at Broadmoor Hospital may be acceptably ‘heard’ within such a programme, which explores the mythology of the monstrous. Adshead comments during the programme:
“I think there’s something about this very childish wish that we can see monstrousness. It’s for real, it’s clear and we’ll know it when we see it and yet. . . we keep constantly being surprised by it – ‘buthe didn’t seem like that’ – well, what did you think he was going to be like?”
It is also noteworthy that the Parole Board Amendment Rules (2009) have removed the right to an oral hearing for prisoners serving an indeterminate sentence. Thus many such men who have participated in the DSPD programme truly do not have a voice (Trebilcock and Weaver 2010, p.16).
Perhaps whilst society may not be able to ‘contain’ such a dialogue of cruelty and violence at a macro level, it may be safely contained within a forensic setting where patients’ voices may be both articulated and listened to. It may well be the role of the forensic psychotherapist and indeed forensic social worker to offer an alternative ‘tellable’ and socially acceptable narrative, as in the aforementioned Frankenstein: A Modern Myth (2012), in which Adshead comments: “80% of our people have experienced abuse or neglect, which is about 4 or 5 times the national average…”
There is however, an alternative discourse: a narrative of transformation, which separates the identity of the narrator from their offences. This discourse contrasts markedly with much of the language employed in the literature and is therefore worthy of discussion. The use of a narrative approach in group psychotherapy with offenders is discussed in two papers. Adshead (2011) argues that identity is created in narratives and that psychodynamic therapies allow people to change their narratives of themselves. The term‘redemption narrative’ is used to describe this transformation. The offender identity is altered insofar as it is understood in greater depth. ‘The possibilities for a future self can also be explored’ (Adshead 2011, p.184). A similar theme of ‘recovery and redemption’ of offender patients is explored in Ferrito et al. 2012. Although not specific to the DSPD programme, both papers explore recent psychotherapeutic work with patients in a high security setting.
Just as Adshead (2011) challenges identity definition, Hollway (2010) challenges the nature of the research relationship that is assumed in most qualitative methods. This is purported to be misguided and to affect the character of the evidence that can be produced. A theoretical outline and two case examples are used to support the argument. An alternative theory of a psycho-social subject is explored, drawing on psycho-analytic concepts that emphasise unconscious conflict, defences against anxiety and the centrality of unconscious intersubjective dynamics in the research relationship. A qualitative method called the free association narrative interview is offered. This paper purports that qualitative research must build upon such evidence. This paper proposes a paradigm which could be useful for future forensic research proposals.
What treatment options are available for men with dangerous and severe personality disorder in a forensic setting?
‘It would appear that –The key question regarding what treatments are effective for high-risk personality disordered offenders – remains unanswered’ (Völlm and Konappa 2012, p.165).
The term ‘DSPD experiment’ is frequently used in the literature (Tyrer et al. 2010; Völlm and Konappa 2012) and it would appear that the DSPD programme offered the possibility of conducting an RCT under controlled condition. This initially appeared hopeful however the findings highlight the difficulties involved in conducting research in a forensic setting, concluding that an RCT would not be appropriate in a forensic context.A critique of the assessment phase of the DSPD programme was conducted by Tyrer et al. (2009). This rigorous quantitative and qualitative study distances itself from the Home Office report conducted by Farrington and Joliffe (2002) commenting that governmental reports differ from publications in a learned journal which are subject to peer-review.
An intrinsic problemwhich the literature reviewed demonstrates in regard to treatment options is the problematic and complex nature of the DSPD diagnosis itself, as discussed previously.Treatment is inextricably linked with assessment and diagnosis; it is impossible to offer effective treatment based on inaccurate assessment.The assessment process is discussed in the investigation conducted by Völlm and Konappa (2012, p.172), who point out that the IMPALOX study conducted by Tyrer et al. (2007 and 2009), using an RCT approach allocating prisoners to undergo the DSPD assessment either within 2 months of randomisation or after a waiting period of 6 months, had a number of protocol violations which meant that few conclusions could be drawn. The standard assessments of PD diagnosis are recognised to be especially defective in regard to identifying more complex PDs (Tyrer et al. 2009). Tyrer et al. (2009) demonstrate that there was an over-reliance on the PCL-R measure which was only moderately reliable in this group. Furthermore, it should be noted that ‘obligatory screening for mental health conditions is not a legal requirement during imprisonment’ (McRae 2009, p. 175) meaning that many prisoners may have undiagnosed mental health issues which remain untreated during their time of incarceration.
Burns et al. (2011) undertook a studywhich examined the significantly differing treatments within the four DSPD units using a modified Delphi process. The treatments were allocated to eleven mutually exclusive categories. No ethical considerations were discussed. This study states that it is important to recognise that the distinction between what is considered as a ‘psychological treatment’ and what constitutes ‘care’ is far from straightforward (Burns et al. 2011, p.2). Pharmacological treatments were not considered.
The clinical judgement of ‘importance’ was used which was based on three factors agreed with the units across the sites. Findings highlighted that only two different treatment categories were provided in all the units. Ten per cent of patients had no treatment in each year and specified psychological treatment programmes comprised an average of less than 2 hours a week. Detailed collection of the patients’ timetables demonstrated in contrast to the expectation of staff at the onset of the study that structured activities occupied considerably more scheduled time (9 hours per week), as compared with the two hours per week spent in treatments.
This rigorous study highlighted that a rationalisation of the treatments is required in order to offer an evaluation of their effectiveness. This reflected the ‘free hand given to the units in designing their treatment regimes’ (Burns et al. 2011, p.13). It was thought that such treatment variations between the four units would ‘constitute a natural experiment and indicate promising developments’ (Burns et al. 2011, 13).The study concludes that the treatments are very expensive, in terms of public finances and time invested by staff and patients (Burns et al. 2010, p.13). However there are obvious limitations to the findings namely the rating of ‘importance’ (Burns et al. 2011, p.12), which may change over time as staff become more experienced. This also demonstrates the artificial construct of treatment outcomes.
It is also worthy to note from this study that the reasons for the ten per cent of patients who did not receive treatment in each year and the more than twenty five per cent of patients who received no treatment at Frankland is not explored. This non-compliance from patients is said to reflect a long pattern of non-engagement. For some patients (no number is specified) it
Was a conscious decision not to take part in treatment in order to ‘prove’ that they were not treatable. Some insisted that they were doing so on the advice of their solicitor (Burns 2011, p.11).
This study highlights the arbitrary and disparate nature of the DSPD programme. It is worthwhile considering thatmoving men to the units against their will may have undermined the treatment process itself. No literature was found which looked specifically at issues of non-compliance.
Völlm and Konappa’s (2012) systematic literature review again highlightsthe scarcity of rigorous empirical research in relation to the DSPD pilot programme. This investigation shows the lack of high-quality trials carried out concerning specific treatments or service environments. The authors conclude that sadly after ten years of service delivery, there is no consensus on how to treat those with DSPD (Völlm and Konappa 2012, p.176).
Since the DSPD programme was a novel initiative, information on the treatment options available prior to the programme’s inception can only be ascertained by looking at literature pertaining to the treatment of PD.This is however outside the scope of this review, although it is worthwhile of brief attention. The literature echoes the comments cited above that there is no consensus on how to treat those with PD, either through psychological or pharmacological approaches (Duggan et al.2007), (Duggan 2009). These papers will now be discussed.
Duggan et al. (2007) undertook a systematic review of RCTs for the use of psychological treatments for people with PD, building upon an earlier review undertaken in 2006. The findings from the earlier review conducted in 2002 were included. The report did not include findings from other RCTs that were excluded for methodological reasons. This excluded the criminological literature and the substantial substance misuse literature. Due to the rigorous nature of the RCT protocol, only 27 RCTs were identified and only two of the studies examined ASPD. Whilst many of the studies reviewed here are pre-1999, the study is not of great value regarding the DSPD treatment programme; however it nonetheless indicates a limited evidence base for treatment and most importantly, the problematic nature intrinsic in forensic research.
A further paper on this theme, an editorial in a peer-reviewed journal, examines evidence from RCTs in the mental health literature in specific relation to ASPD as defined by DSM-IV criteria (Duggan 2009). Only five of the trials reviewed satisfied stringent Cochrane criteria. Duggan persuasively argues that it is difficult to develop a scientific basis in forensic mental health, due to its multi-disciplinary purpose. The author argues that various forensic mental health agencies all have differing views and agendas, thus it.The paper concludes that treatment is based on moderate quality RCTs, with no pharmacological evidence for treatment of adult ASPD. Therefore it is difficult to agree to a consensus on fundamentals, which is the hallmark of a science. Since ASPD,is highly represented amongst the forensic population in the UK, the findings are highly relevant to the treatment options available for those with DSPD.
Gibbon et al. (2010) drew the same conclusion regarding the sparse nature of research concerning ASPD. This robust review undertaken by the Cochrane Collaboration investigated psychological interventions for ASPD and found only three relevant investigations in the UK. Of the 48 studies identified only 11 fully met the inclusion criteria for anti and dissocial PD. No randomised trials have been published assessing the efficacy of dynamic psychotherapies specifically for ASPD; there are only a small number of trials which examine the efficacy of psychoanalytic therapies for PD in general. There is limited evidence for the efficacy of psychodynamic psychotherapy. Whilst the study is of limited generalizability as only three of the studies were conducted in the UK, it shows the lack of rigorous scientific studies pertaining to treatment. No firm conclusions were drawn from the evidence available.The results suggested that there is insufficient trial evidence to justify using any psychological interventions with ASPD.
As mentioned above the discussion in the study by Duggan et al. (2007) is nonetheless very helpful in relation to the treatment of DSPD because itoutlines the complexities of attempting to conduct empirical research. A Systematic Review aspires to be rigorous, however certain assumptions are made, for example which trials included or excluded, which outcome measures are relevant etc. Thus a certain amount of arbitrariness, for example the decision not to involve criminological literature.
Of particular interest here is that the authors found that excessive outcome measures used in the studies reviewed makes cross-comparison difficult (Duggan et al. 2007). It is somewhat unsurprising thatsimilar conclusions in relation to the treatments offered in the DSPD programme are reported(Burns et al.2011). Numerous treatment options were given across the four units, with three sites listing 24 potential treatments each and one had 43. Some appeared to be the same treatments, but with different names and others appeared quite similar although using different names. (Burns et al. 2011, p.3).
The analysis offered by Duggan et al. (2007) regarding the quality of research papers is worth considering, particularly in the light of the numerous treatments offered by the four units in the DSPD programme. The authors suggest firstly that researchers need to have a pre-agreed ‘standard’ measure that provides an indication of overall functioning and allows cross-study comparison. Secondly, there is a clear need for mental health research and PD research in particular to undergo a process of rationalization.The primary recommendation is to define a limited number of standard outcome measures specific to and related to the core difficulty for each PD. Finally, adequate reporting is essential in clinical trials.
Following on from this, the quality of prison research is discussed in an editorial in a peer-reviewed journal by Maden (2003). This is in response to a DH report written in 1999 encouraging a programme of research to support the prison development agenda. The paper argues that the priority should be for the CJS to study interventions and to adopt randomization in treatment trials. The paper argues that research is increasingly politically driven and that government departments are abandoning responsive funding, with research proposals being increasingly written by civil servants. The author challenges the proliferation of psychological interventions applied to offending, as distinct from the treatment of mental disorder.(Maden2003, p.248). It is interesting to consider the DSPD treatment programme in the light of these comments.
What contribution can social work make in relation to the treatment of men with a diagnosis of DSPD in a forensic setting?
There was little among the quantitative or qualitative data which offered a perspective on this subject, due primarily to social work being scarcely mentioned within the literature under discussion, since many papers focussed upon assessment and diagnostic issues (see Appendix 1). Social work is disparate within the CJS in England and Wales, with forensic social workers primarily working within secure psychiatric hospitals, rather than in penal settings, whereas within the Scottish system social workers are based in prisons (Social Work Inspection Agency, 2011). It is therefore difficult to reach any firm conclusion from the literature.
One keynote paper written by a leading mental health charity was located which discusses the convergence of mental health and criminal justice policy, legislation, systems and practice. The DSPD programme is examined. The findings show that there is ‘patchy resettlement planning and support’ (Rutherford 2010, p.77). It is clear that there is a gap in effective aftercare provision and that there is a potential role for social work involvement
Hyslop’s poignant discussion on ‘Social Work as a practice of freedom’ has a significant contribution to make with regard to the discourse of social justice and offers a useful paradigm as to the role of social work within the context of incarceration.
The two-faced identity of social work has several incarnations, including what
Bourdieu et al. (1999…) identify as ‘. . . a certain prophetic militancy or
inspired benevolence’. Social work is, at least in part, concerned with differentiating, and thereby humanizing, its subjects: re-enfranchisement and repatriation as opposed to exclusion and punishment.
Although Hyslop’s argument is compelling, it would appear that social work is unable to stand in splendid isolation within a forensic setting. Deacon (2004) suggests there should be a symbiotic relationship between social work and its environment. This article was the only contribution by a British social worker, within the review literature, to explore the context of working within a forensic setting.Hyslop’s(2011) analysis paves the way for a radical approach to working in a criminal justice context and demonstrates that social work does indeed have a role to play in criminal justice discourse for the future.
Bion’s theory of containment, as discussed by Hollway (2010), is especially useful in regard to the DSPD programme. The starting point of Bion’s hypothesis is ‘unconscious intersubjectivity, where emotions are continually passed between people’(Hollway2010, p.17).Bion posits that when a feeling becomes too painful to bear because of its associated feeling, the defence of projection is employed by putting it onto someone else. That person experiences the feeling via empathy. If it is also too painful for the other person to contain, the person throws it out quickly, or denies its painfulness, perhaps by reassurance.
If, on the other hand, the other person can contain the pain, it can be returned ‘detoxified’ and faced as an aspect of reality (Hollway2010, p.17).
However, the difficulty of containing someone else’s pain can take its toll upon a professional team. Smith (2010)discusses the impact of a client with PD upon a social work team and the difficulties which this man created for professionals, and Rizq (2012) explores the impact upon counsellors in primary care of working with clients with BPD.
Bronfenbrenner’snested model is useful here in that the CJS could be argued to represent the societal mechanism or Exosystemfor containing those who cannot contain themselves,(Wilson 2011, p.290). The struggle for containment is demonstrated in the case of Michael Stone, whose case was instrumental in the formation of the DSPD initiative.Containment may also be seen operating at a macro level with the incarceration of those who cannot contain their own pain or behaviour and is offered both through both the physical and therapeutic environment. An example of this isDr Adshead speaking on a national radio programme,describing Broadmoor residents as ‘our people’ (Desert Island Discs,2010).Dr Adsheadis arguably an example of the positive adult attachment figure discussed in one of her papers, who is able to safely contain the severe distress of the men with whom she works (Adshead 2002). Social workers could also operate in this way within the forensic environment, allowing both dialogue with and voice for those whom society has silenced, thus offering the possibility ofHyslop’s (2011) model to be realised.
However, whilst Hyslop’s (2011) rhetoric is persuasive as an emancipatory model, once containment has been implemented this needs to be juxtaposed with the problems faced by staff, such as social workers working in a high-security forensic setting. Deacon (2010) discusses the social context of physical and relational containment in a maximum security psychiatric hospital (Ashworth). Deacon forcefully argues thatthe task of high security hospitals (and arguably prisons) may be regarded as ‘uniquely challenging’ (2004, p. 93).This is represented by:
the confinement of individuals within a social context at once both sceptical about and unrealistic in their expectations of professional abilities to protect the public from harm. Such patients suffer mental disorders and have demonstrated extremes of dangerous behaviour.
(Deacon 2004, p.93).
Whilst the DSPD initiative did not take place in Ashworth Hospital, the patients described are similar to the DSPD population, and the challenges faced by staff are thus highly relevant to those faced by forensic staff working within the DSPD programme. Deacon argues that the tension with regard to the physical hospital boundary represents the toxicity which should be contained within.She proposes that processes need to be in place to develop ‘potentially containing policy frameworks’ (2004, p. 94).The DSPD initiativecould be viewed as just such a policy framework. The analysis offered by Deacon (2004) demonstrates the role that social work can have in relation to working with men with a diagnosis of DSPD in a forensic setting. Social work is both able to offer the containment that such men in distress require and therapeutic containment via support to fellow colleagues, such as prison officers, offering a psycho-social rather than criminogenic perspective.Duggan (2009) reflects that perhaps more than any other mentally disordered group, those with ASPD have contact with multiple agencies such as housing and social services and therefore a mechanism linking these differing agencies together is vital to optimise effective service delivery to this group of people.
Leading on from this, it would seem that social workers should be based in forensic settings as a matter of course; to include both psychiatric hospitals and penal establishments. A recent document written in response to a consultation process,acknowledges the role of social workers as ‘frontline staff’ in working with personality disordered offenders (DH NOMS 2011, p.14). However the emphasis for leading the pathway planning initiative lies with the CJS and NHS which favour a criminogenic/bio-medical rehabilitative model rather than a psycho-social approach. Social workers with Approved Mental Health Practitioner (AMPH) status could play a valuable role in contributing to the development of forensic services.
Many social workers are social supervisors in the community and this role could also be developed within a forensic prison context, thus adequate preparation could be made for people who are due to be released back into the wider community.
A dearth of literature exists regarding the role of the forensic social worker,with only one small scale study identified examining a social work team in St Andrew’s healthcare (Henson, Whitall and Pattinson 2011). Although the findings are far too small to be generalisable, the varied tasks which forensic social workers perform are explored. The paper argues that many aspects of the work undertaken are often away from the patient and somewhat hidden (Henson, Whitall and Pattinson 2011, p.25).The lack of literature with regard to forensic social work highlights that the role, where it does exist, is almost invisible.
There is also a lack of social work involvement for those in the criminal justice system:
the availability of effective social care support for people in the criminal justice system is poor,services are patchy or non-existent, both in the community and in custody. The main barrier to progress is lack of clarity regarding which agency is responsible for providing social care in the various criminal justicesystem settings(DH 2009, p.49).
Social work should be recognised as able to offer a significant contribution towards the policy debatein this context and not be seen as a ‘poor relation’. A recent policy document: The Offender Personality Disorder Pathway Implementation Plan (DH, MJ 2011) states that there is a need to reach an agreement on the responsibility for the delivery of social care services, based on national protocols, based on the specific service need and a nationally agreed interpretation of responsible authority. A proposed model designed by the author to illustrate this point is given below:
Figure 2: Interface of social work with the Ministry of Justice and Department of Health.
|The Offender Personality Disorder Pathway Implementation Plan (DH, MJ 2011)|
Figure 2: Proposed model
The role of the social supervisor as outlined above commences after discharge and is an integral support service with regard to effective rehabilitation. It would therefore be beneficial for social workers to be based in a multi-disciplinary forensic team, in both the prison estate and forensic mental health units, in order to ensure a smooth transition back to the wider community.
The research examined in this review highlights the weakness of the assumption that the severity of personality disorder is causally linked to violence and that treatment would reduce this risk (Duggan 2011, p. 432). The element of accurate risk prediction integral to the DSPD programme has also been shown to have a wide margin of error (Duggan 2011, p.432). The complexity of risk prediction is expounded by Tyrer, who reminds us that we are a long way from the film Minority Report in which’the exact nature and timing of violent offences was identified by ‘precogs’ with advance knowledge. . .’(Tyrer2007, s.2).
There is a danger in pursuing the route of actuarial risk assessment to determine a patient’s risk of recidivism (Lindqvist and Skipworth 2000). Farnham and James predict where such paths may lead:
. . . one has only to look across the Atlantic to the USA. With more than 2 million people in prisons, and dangerousness used as a criterion for execution, as well as preventative detention, society is no safer and liberty dies a little (2001, p.1926).
The attempt to use quantitative studies to ascertain how to treat men with a complex condition has demonstrated that treatment outcomes are very difficult to measure. It is somewhat disappointing that such an enormous amount of public money was invested and there has been little to show for it. Perhaps the answer lies in a different direction.
Fortunately, there appears to have been a shift in thinking from the initial public protection focus in the Labour Party’s manifesto in 2001 to a more treatment centred perspective.(Duggan 2011).This is in both senses of the word: the bio-medical model of treatmentand also the importance of a positive therapeutic environment, with multi-disciplinary teams
supporting effective practice with a challenging client group. Although initially, the language used regarding the DSPD programme was pathologising,Duggan (2011) rightly points out that the needs of a group hitherto largely ignored by psychiatrists became centre stage in the agenda ofpolicy makers. This has resulted in a move towards acknowledging that treatment for PD is needed for a large majority of the forensic population, with specialist treatment programmes currently being set up in category B and C prisons. This is a move away from assessment of the danger to society posed by high risk offenders. This isperhaps one of the most positive benefits of the DSPD programme and offers hope to those men like Paul mentioned earlier who are desperate for help.
A predominant feature of the literature around the DSPDprogramme is the ethical minefield surrounding the compulsory treatment of mentally disordered offenders who pose a risk to others.Sen and Adshead (2007) argue that the greatest irony of the situation is that the subject himself is often a victim of abuse in their earlier years and society has failed to offer protection when he/she was most in need of it. Thus, forensic psychiatrists, and forensic staff in general, as agents of society, are a means by which society can repay its debts to these individuals (Sen and Adshead 2007).
In terms of acceptable clinical practice, it is noteworthy that the DSPD initiative had very little service user involvement, which may be attributable to the high-security context within which it took place. Howeverthe question as to why so little attempt was made to include the people at the heart of the programme in its inception and delivery remains unanswered. This lack of service user involvement reflects a power imbalance in forensic research in general which future research initiatives need to address.It is acknowledged that there is a ‘moral imperative’ to promote user involvement in research (Fisher 2002, Tew et al. 2006, cited in
Evans and Hardy, 2010, p.67) and social work has a valid contribution to make in encouraging this to take place, albeit at a micro level in a highly challenging environment.
The social construction of identity, explored by Adshead (2011), has particularly impacted upon my thinking with regard to my future professional practice. I have realised that identity is not defined through societal mechanisms such as the courtroom, or the media and written reports. I will attempt to hold this in mind when writing an assessment. Although people may have been very cruel and their narrative of events may lack veracity, this review has shown me that everyone has a voice and a right to be heard. It is also important to maintain professional optimism that people have the capacity to take responsibility for their actions and the capacity to change. ‘We should acknowledge the existence of violence, economic problems, oppression, but hold that even in such situations there are possibilities’ (Parton and O’Byrne 2000, p.58). When reading documentation about the perpetrators of violence, I will bear in mind that prediction of future ‘dangerousness’is not a rigorous science and be careful about making assumptions, whilst counterbalancing this with agency policy and a duty of care in relation to public protection.This review has also given me an understanding that it is extremely important that work be done with the perpetrators of violence as well as the victims.
The most significant thing I have learnt from this review is the power of language. I will be mindful of the stigmatising language which has been used to describe individuals with severe mental health issues and be careful with my own choice of words, particularly when writing about an individual. Assessments which close down possibilities have been seen to have the potential to cause ‘iatrogenic injury’, whereas ‘iatrogenic healing’ has been used to describe
practice that ‘encourages, respects, validates and opens up possibilities for change’ (O’Hanlon, cited in Parton and O’Byrne 2000, p. 56).
The research under review has clearly shown the lack of literature on the forensic social work role. This would have been a useful starting point and withhindsight, it would have been beneficial to undertake a comparative study examining the forensic social work role in both the Scottish criminal justice system and that of England and Wales. A different approach which may have yielded more findings could have been to explore the social work role in relation to the therapeutic community approach which is a well-established method of treating patients with personality disorder (DH 2011).
The International Association of the Schools of Social Work (IASSW) and the International Federation of Social Work (IFSW) have agreed to a definition which locates social work firmly within a social transformation agenda:
The social work profession promotes social change, problem solving in human relationships, and the empowerment and liberation of people to enhance well-being. . . Principles of human rights and social justice are fundamental to social work
(IASSW and IFSW 2004, cited in McLaughlin 2012, p.3).
The social justice model offered by social work has a unique contribution to a wider debate regarding mental health and should therefore be intrinsic to any future policy initiatives. Social work already plays an integral role in mental health services and could also sit at the interface between mental health and criminal justice services.In line with Duggan’s (2011) recommendation, this paper proposes that social workers, particularly those with AMPH status, be deployed in all forensic settings in England and Wales. The funding for this could
be sourced from the disbanded DSPD programme. This paper also recommends that compulsory mental health screening be instigated in prisons, upon reception into custody.
In a societal context where DSPD represents ‘a psychiatric manifestation of the risk society’ (Corbett and Westwood 2005, p. 121), it is morally imperative to counteract such stigmatising of the mentally unwell.Although somewhat utopian,Hyslop aptly states: ‘it is incumbent upon us to critically reconsider the notion that social work is aligned with social justice and human emancipation’ (2011, p.404). Such values can truly be brought to bear in a criminal justice context and therefore it is essential that social work plays an integral role in future discourse regarding the treatment of individuals with mental health issues amongstthe forensic population
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Saradjian, J., Murphy, N., Casey H. (2010) ‘Report on the first cohort of prisoners that completed treatment in the Fens Unit, Dangerous and Severe Personality Disorder Unit at HMP Whitemoor’,Prison Service Journal, 192.
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Appendix 1 – Searching Strategy Table
|Date||Name of database||Search terms||A hits||B relevant||C Duplicated/
|19/06/12||Community Care||Social work in prison||1|
|29/06/12||Google Scholar||Social Work in prison||45||1|
|30/06/12||Google Scholar||Social work in prison||1, 020, 000||3||Refined search|
|30/06/12||Google Scholar||Hand search for references||101|
|30/06/12||Google Scholar||Social work in prison in England||350.000||Refined search|
|30/06/12||Google Scholar||Personality Disorder treatment in prison||64, 200||8||Refined search||1|
|30/06/12||Hand search for references from article on personality disorder||13||5||3|
|30/06/12||Hand search for references from article on social work||21||0|
|04/07/12||Google Scholar||Articles by Gwen Adshead||497||2||Refined search|
|05/07/12||Gwen Adshead||75, 000||4||Refined search||1|
|05/07/12||Google Scholar||Gwen Adshead articles||243||7||Refined search||1|
|05/07/12||Google Scholar||References from article by Gwen Adshead||57||Refined search|
|05/07/12||Google Scholar||Connor Duggan||9,500||2||Refined search|
|09/07/12||University of Sussex
|05/07/12||University of Sussex library
|09/07/12||Hand search for references
|Community Care magazine||Social work in prison||1950||37||Refined search|
|09/07/12||Community Care Magazine||Shortages warning over personality disorder services||9||3||1|
|09/07/12||Google search||Knowledge and Understanding Framework||17,000,000||9||Refined search||2|
|Date||Name of database||Search terms||A hits||B relevant||C Comments/
|09/07/12||Community Care magazine||How therapeutic communities can help rebuild lives||54||4||1|
|09/07/12||Knowledge and Understanding framework||17,000,000||1||Refined search|
|09/07/12||Scholarly articles for knowledge and understanding framework||3,180,000||9||Refined search|
|09/07/12||Personality Disorder Programme||13, 000, 000||3||Refined search|
|09/07/12||www.personality disorder.org.uk||Knowledge and Understanding Framework||1|
|09/07/12||www.personality disorder.org.uk||Latest news
Offender personality disorder pathway: strategy for participation and engagement approved
|11/07/12||www.personalitydisorder.org.uk||Borderline Personality Disorder||18||1|
|11/07/12||www.personalitydisorder.org.uk||A strategy for inclusion-Wigan Multi-Agency Personality Disorder strategy||1|
|11/07/2012||www.personalitydisorder.org.uk||Personality disorder everybody’s business DOH video||3|
|11/07/2012||www.personalitydisorder.org.uk||Borderline Personality Disorder video||1||1|
|11/07/2012||www.personalitydisorder.org.uk||Anti-Social personality Disorder video||1||1|
|11/07/2012||www.personalitydisorder.org.uk||What is STEPPS-Sussex Partnership sets out it s work with those affected by BPD||2||2|
|NICE guidelines||96,500,000||8||Refined search|
|11/07/12||NICE guidelines personality disorder||418,000||97||Refined search||5|
|11/07/12||Consultation on the offender personality disorder pathway implementation plan||10||1|
|11/07/12||NICE||Personality disorder||451||Refined search|
|16/07/12||NICE guidance on personality disorder||412, 000||11||Refined search|
|16/07/12||NICE||Personality disorder and prison||38||12||3|
|18/07/12||University of Sussex library||Adshead, G||1||0|
|18/07/12||University of Sussex library
|18/07/12||University of Sussex library||Adshead Gwen||2||2|
|20/07/12||ASSIA||“Personality Disorder” AND “forensic settings”||11||10||1||1|
|20/07/12||ASSIA||“Personality Disorder” AND “men”||192||Refined search|
|20/07/12||ASSIA||“Personality Disorder” AND “men” AND “forensic settings”||2||2||1||2|
“Personality Disorder” AND “men”
|20/07/12||ASSIA||Advanced search Abstract
AND “men” AND cp “United Kingdom”
AND “men” AND cp “United Kingdom” and “forensic settings”
AND “men” AND cp “United Kingdom” and forensic settings
AND “treatment” AND cp “United Kingdom”
AND “men” AND cp “United Kingdom”AND forensic or forensics
“Borderline Personality Disorder”
AND “men” AND cp “United Kingdom”
|23/07/12||Community Care||Recent research
|23/07/2012||Community Care||Recent research Personality Disorder||251||Refined search|
|23/07/2012||Community Care||Recent research Personality Disorder and prisons||70||6|
|23/07/12||ASSIA||Offender personality disorder consultation||5||4||2|
|23/07/12||ASSIA||Offender NEAR personality disorder||176|
|23/07/12||ASSIA||Offender NEAR personality disorder AND Social Work||14||8||3|
|23/07/12||ASSIA||Offender NEAR personality disorder AND “Social Work”||1||0|
|23/07/12||ASSIA||Offender AND personality disorder AND Social Work||20||12||3||3|
|23/07/2012||University of Sussex Library Find it @Sussex||Hand search for References||10||5||2||2|
|ASSIA||Personality Disorder OR prison||10,390||Refined search|
|24/07/12||ASSIA||Personality Disorder OR prison||10,390||1||Refined search|
|24/07/2012||ASSIA||Personality Disorder OR prison||7147||7||Refined search|
|24/07/12||ASSIA||“Personality Disorder” AND “Prison”||80||37||1||5|
|24/07/12||ASSIA||“Personality Disorder” AND “Prison” AND “Social Work”||0|
|24/07/12||ASSIA||“Personality Disorder” AND “Prison” AND (“Social Work”)||0|
|24/07/12||ASSIA||“Personality Disorder” AND “Prison” AND “male”||12||8||8||1|
|2407/12||ASSIA||Social work and prison||699||1||Refined search|
|24/07/12||ASSIA||“Social work” AND “prison”||28||10||1|
|24/07/12||Assia||“Social work” AND “prison” AND “male”||80||0|
|24/07/12||ASSIA||“Social work?” and “prison?”||
|24/07/12||ASSIA||Social work? AND prison?||28||10|
|24/07/12||ASSIA||Social work* AND prison*
|24/07/12||ASSIA||Advanced search pub (“Social Work”) AND all(prison or prisoners) after 2000
|24/07/12||ASSIA||Advanced search pub (“Social Work”) AND personality disorder NOT prison after 2000||35||16||1||1|
|25/07/12||ASSIA||Social work with men in prison||38||3||1||1|
|27/07/12||Online journals||Personality Disorders||21, 542||Refined search|
|27/07/12||Online journals||Personality Disorders
|27/07/12||Online journals||Personality Disorders in men in prison
Sort by date 2000
Sort by journal –psychological assessment
|27/07/12||Personality and mental health journal||Personality disorder||216||18||2||6|
|27/07/12||Personality and mental health journal||Personality disorder and prison||33||18||2||6|
|31/07/2012||Electronic Journals||Personality disorders||0|
|31/07/2012||Psychinfo||Personality disorder AND prison||1112||Refined search|
|31/07/2012||Psychinfo||Personality disorder AND Social work||2695||Refined search|
|31/07/2012||Psychinfo||“Personality disorder” AND “Social work”||295||Refined search|
|31/07/2012||Psychinfo||“Personality disorder” AND “Social work” AND “men”||13||1|
|31/07/12||Cross References||Screening for Personality Disorder|
|31/7/12||Criminal Behaviour and Mental health||Article On Personality Disorder||1||0|
|31/7/12||Personality and Mental Health Journal||offenders||30,877|
|31/7/12||Personality and Mental Health
|Personality disorder and prison all content||7083|
|31/7/12||Personality and Mental Health Journal||Personality disorder and prison||33||18|
|31/7/12||Wiley Online Library||Social work||727859|
|31/7/12||Wiley Online Library||“Social work” AND “prison”||3643|
|31/7/12||Wiley Online Library||“Social work” AND “prison” AND “men”||2731|
|31/7/12||Wiley Online Library||“Social work” AND “prison” AND “men”
|31/7/12||Wiley Online Library||“Social work” AND “prison” AND “men” And personality disorder||307||1|
|31/07/12||Social Care Online||Personality Disorder||4003|
|31/07/12||Social Care Online||Personality Disorder AND prisons||5337|
|31/07/12||Social Care Online||Personality Disorder
and prison Advanced search
|31/07/12||Social Care Online||Personality Disorder
|31/07/12||Social Care Online||Personality Disorder
AND prisons Advanced search
|02/08/12||Social Care Online||Forensic social Work||161||Refined search|
|02/08/12||Social Care Online||Refine search results
Forensic social Work and prison
|02/08/12||Prison Service Journal||Forensic Social Work||0||0|
|02/08/12||ASSIA||Forensic social work||283|
|02/08/12||ASSIA||“forensic social work”||8||0|
Social work and forensic
|09/08/12||Journal of Social Work||Social work in prisons|
|09/08/12||Journal of Social Work Practice in the addictions||Social work in prison||35|
|09/08/12||Social Work Education||Social work in prison||42|
|09/08/12||Social Work Education||Social work with offenders||39,114||Refined search|
|09/08/12||Social Work Education||Prison||55,478||Refined search|
|09/08/12||Social Work Education||Personality disorder||22656||Refined search|
|09/08/12||Social Work Education||“Social work” NEAR “ “prison”||1330||Refined search|
|09/08/12||Social Work Education||“Social work” AND “prison”||3982||Refined search|
|09/08/12||Social Work Education||Advanced search
Social work in prisons
|09/08/12||Journal of Social Work Practice||Prison||1|
|10/08/2012||ASSIA||Social work in Scottish prisons||6||1|
|10/08/12||ASSIA||Forensic social work in Scottish prisons||0||0|
|10/08/12||Social Care Online||Social work in British prisons||0||0|
|10/08/12||Social Care Online||Social work in Scottish prisons||0||0|
|10/08/12||Social Care Online||Social work with men in prison||0||0|
|10/08/12||Social Care Online||Social work with offenders||0||0|
Social Care Online
|Social work and prisoners||168||Refined search|
Social Care Online
|Social work and prison||155||Refined search|
Social Care Online
|Social work and men and prison||15||0|
|14/08/12||Journal of Social Work Practice||Searched through recent editions for relevant articles pertaining to social work in a forensic setting||2||2|
|15/08/12||Journal of Social work Practice in the addictions (entire site)||Social work in prisons||42, 927|
|15/08/12||Google Scholar search for article on freedom|
|15/08/12||Journal of Social Work
|15/08/2012||Wiley Online library||Personality and mental health||82396||Refined search|
|03/09/2012||References found through article||Journal of Forensic Psychiatry and Psychology||11||10|
|07/09/2012||References found through article||Adshead|
|07/09/2012||References found through article||social work in prisons|
|07/09/12||References found through article||Prison Service Journal article||4|
|11/09/2012||References found through article||Journal of Forensic Psychiatry and Psychology||5|
|Journal of Forensic Psychiatry and Psychology||1||1||1|
|08/08/2013||References found through article||Response to the Offender Personality Disorder Consultation||2||1|
|09/08/2013||Google scholar||Social supervisor||559,000||Refined search|
|09/08/2013||Google scholar||Social supervisor forensic||28,400||Refined search|
|09/08/2013||ASSIA||Social supervisor||2277||Refined search|
|09/08/2013||ASSIA||Social supervisor forensic||3|
|09/08/2013||ASSIA||Social supervisor role forensic mental health||0||0|
|09/08/2013||ASSIA||Social supervisor AND social worker||389||Refined search|
|ASSIA||Social supervisor AND social worker AND forensic||1||0|
|09/08/2013||Google scholar||Social supervisor role social work||505,000||Refined search|
|09/08/2013||Google scholar||social work supervision of forensic patients||29,300||Refined search|
Inclusion and Exclusion Criteria
|Published between 1999 until 2012||Published before 1999|
|Published in the United Kingdom||Published outside the United Kingdom|
|Available in English||Available in a language other than English|
|Discusses or reports on dangerous and severe personality disorder/DSPD||Does not discuss or report on dangerous and severe personality disorder/DSPD|
|Discusses or reports on personality disorder||Discusses or reports on comorbid conditions|
|Discusses or reports on treatment options for personality disorder||Does not discuss or report on treatment options for personality disorder|
|Discusses or reports on forensic social work in England and Wales||Does not discuss or report on forensic social work in England and Wales|
|Discusses or reports on men||Discusses or reports on women|
 All names have been changed to preserve anonymity
 Names have been changed to protect identity