Tony Maden

The successes and failures of the DSPD experiment: the assessment and management of severe personality disorder

In the last 10 years a sum in excess of £200 million has been spent in developing a new programme of treatment for those deemed to have dangerous and severe personality disorder (DSPD) in England. This proto-diagnosis is a new concept in forensic psychiatric practice and, although its conception was bold, it carried considerable risks in implementation as so little was known about the effective management of this group of disorders. We review the successes and failures of this pioneering programme a decade after its introduction and conclude that although much has been gained from the experiment – particularly in developing services for those with personality disorder in general – it has been less effective in managing those whom it was primarily targeting and may not have been cost-effective.

A national survey of substance misuse and treatment outcome in psychiatric patients in medium security

This is the first national study of outcome in medium security, based on all 959 discharges between 1/4/97 and 31/3/98. Case notes were used to collect data about demographic and clinical characteristics, including substance misuse. Criminal and hospital records, plus a questionnaire sent to the responsible consultant, were used to measure outcome in the 12 months following discharge. Drug use was common, with more than three quarters (76%) of the patients ever having used any drug, including 51% with a clinically significant drug problem and 40% with alcohol problems. There were strong associations between substance misuse and age, ethnicity, diagnosis and length of stay. Patients with substance misuse problems were significantly more likely to be re-convicted during the follow up period but were not significantly more likely to be re-hospitalized. Those with alcohol problems had significantly more re-admissions than those without. Formal substance misuse treatment programmes were rare in the units surveyed, and our findings suggest that there is a large unmet need for services among mentally disordered offenders in medium security.

The assessment of dangerous and severe personality disorder: lessons from a randomised controlled trial linked to qualitative analysis

Randomised controlled trials are difficult to carry out in high security prisons and very few have succeeded. We describe here a randomised controlled trial of early versus late assessment for the pilot phase of the new DSPD programme for dangerous and severe personality disorder, which assessed prisoners (n = 75) at baseline, then six months, and then one year after randomisation. The trial enjoyed 100% success in getting records and obtained useful qualitative data that helped to explain the findings, but the trial was compromised by repeated protocol violations on grounds that were seldom acknowledged openly but which we conclude were primarily due to ignorance of the purpose of such trials. This led to such contamination of the two arms of the trial that no clear conclusions could be drawn from the trial itself, except that relative costs showed expected differences. However, the trial also showed that the assessment programme was associated with better quality of life in terms of social relationships (p = .03), with an increase in aggression (p = .01), and with worse social functioning in those with less severe personality disorder (p < .01), with the qualitative data suggesting that frustration and unfulfilled expectations lay behind these findings. Suggestions are made about revisions to the assessment process and the changes necessary for successful trials to be mounted in the future.

Compulsory treatment of dangerous offenders with severe personality disorders: a comparison of the English DSPD and Dutch TBS systems

British society has come to see itself as at risk from violent and antisocial behaviour from people with mental disorders. One manifestation of this is the DSPD programme for offenders with severe personality disorders, inspired by the Dutch TBS system. The TBS legislation was introduced to combat the frequent reoffending of “psychopaths”. The number of TBS hospital beds has increased rapidly, from 400 in 1975 to more than 1,600 in 2006. This is mainly due to the growing confidence of Dutch courts that the order protects the public and minimises recidivism. Five-year recidivism rates among discharged TBS patients have fallen from 52% in 1974 to 17% in 1998. In this article, we describe the main differences between the two systems in terms of philosophy, treatment programmes, outcomes and costs. The DSPD programme has deviated substantially from the TBS model in ways that may prevent it being as effective. It has not, in our opinion. properly implemented the patient responsibility, the rehabilitation focus, or the clear care pathways of the Dutch system. We are concerned that unless these issues are addressed, DSPD services will not live up to expectations and a chance to help personality disordered offenders will be lost.

The Quantification of Violence Scale: a Simple Method of Recording Significant Violence

Background: Although there are many rating scales recording the incidence and intensity of violence there are none that are specifically concerned with the measurement and assessment of severe violence. Aims: To develop a scale sensitive to variation centred on severe violence, establish its normative values, test its feasibility, and assess its reliability and validity in different populations. Method: The Quantification of Violence Scale (QOVS) was developed in two stages. First, a list of 30 commonly eXperienced violent episodes in clinical psychiatric practice were evaluated and tested by weighting each episode by severity. Second, a numerical scale used to record the severity of the episode according to its degree of planning, intent and consequences. Violent episodes in two clinical populations were compared using the Modified Overt Aggression Scale (MOAS) and the preliminary version of the QOVS over periods up to 18 months, following which the numerical scale was developed. Results: Good (0.60—0.74) to EXcellent (> 0.75) test—retest and inter-rater reliability agreement was obtained with both forms of the scale (intra-class correlations of 0.75 and 0.69 respectively), and similar agreement with MOAS scores was reached (0.67) in clinical populations. The scale was quick and easy to use in practice, and a score defining severe violence (9 on the numerical scale and 16 on the matched scale) was determined. Conclusions: The QOVS, in its two forms, is a useful measure of recording significant violence in clinical and forensic practice.

Editorial: Substance misuse in secure psychiatric hospitals

The issue of substance misuse in psychiatric units, especially secure ones, is rather like the ghost at the feast. Everybody knows that patients have access to illicit drugs and other harmful substances in hospital, but there is very little enthusiasm for tackling the problem. Worse, in many quarters there is a perception that the problem is insoluble: a self-defeating assumption that nothing will stop inpatients using drugs, or that the cost in both money and liberty would be insupportable. How can this widespread professional apathy be explained? In this issue, we present results from a study showing that the problem is greater than previously recognised (Scott, Whyte, Burrnett, Hawley and Maden (2004)). The key findings are that:

Critique of the assessment phase of the DSPD programme

We welcome the opportunity to reply to the criticisms of Ramsay and his colleagues (2009) and to set our work in the context of the assessment and treatment programme for dangerous and severe personality disorders (DSPD). Our work, which was commissioned early in the course of the programme, was originally planned as an investigation in cost-effectiveness, which explains the attention given to the collection of full and accurate data with regard to costs (Barrett & Byford, 2007). This was also initiated at a time when the notion of severe personality disorder was rudimentary and which only now is being recognised as having major health implications (Pulay et al., 2008). Our paper (Tyrer et al., 2009) only focuses on our combined qualitative and quantitative work linked to the randomised controlled trial of assessment and does not address many of the other issues published in the earlier Home Office report detailing the work of the whole project (Tyrer et al., 2007). It is also worth emphasising that a scientific publication in a learned journal has the merit of independent peer review and differs from a report written for an organisation such as the Home Office. Such reports are constrained by the insistence on internal as well as external scrutiny, and the final version is an amalgam of the two that is not completely free of bowdlerisation. We believe the Tyrer et al. (2007) paper to be the first published in a peer-reviewed journal that examines the assessment process of the DSPD programme. As we began our work very early in the programme and have already acknowledged that what we found does not necessarily reflect what has happened since. Nevertheless, early detection may prevent later disaster, and our study merely evaluated a new programme, the development of which was not subjected to any public scrutiny. The evidence that the

On the state of prison research

The Future Organisation of Prison Health Care, a joint enterprise by HM Prison Service and the NHS Executive (Department of Health, 1999), launched the latest in a series of attempts to improve the health care available to prisoners. One of the actions recommended in that report was that ‘a coherent programme of research to support the prison health development agenda should be devised and implemented’. But how useful has prison research been over the years, in supporting the development of better services? Before considering particular projects, it is necessary to be clear about the rules by which such research must be judged. This is the world of applied science. It is no use counting the Nobel prizes or other measures of academic success. Researchers in this field can be forgiven if their findings are ephemeral and do not generalize to other settings or countries, but they must contribute to better treatment. We should be clear also about who is being judged: not researchers, but those who commission research. As government departments abandon responsive funding, so research proposals are increasingly written by civil servants. Academics can do only the projects put out to tender, so they cannot be blamed for the strategic direction, or the lack of it. When pragmatic standards are applied, one wonders why so much money is spent on prevalence studies. As Professor Griffith Edwards observed in 1970, surveys of prisoners always find a higher level of psychopathology than there is in the community. The studies never agree on the precise level of psychopathology, but the differences arise from variations in methodology and, apart from other researchers, who cares? The priority should be to study interventions. The Journal of Forensic Psychiatry & Psychology