stipulated that personality development 1 o r use wit h disordered offenders be treatable personality disordered offenders Treatment and before they were admitted to (Beck et al, 1990 Linehan. 1993. healthcare settings, there was no etc.). In this same period, there has criteria laid down at the time for been dramatic progress in management of treatability and there is little developing treatment programmes consensus even now as to what this for different offender groups, (e.g. involves. As a result, many patients sex offenders, violent offenders who seemed treatable for whatever etc.) and on the assessment of risk reason on admission, have proved (Marshall, et al. 1993: etc.) to be less responsive to whatever In the high secure . in high secure treatments were available, and there has been a gradual have become stuck in the system. recognition that the special needs of personality disordered patients hospitals Treatment - a brief need to be addressed more systematically and this is history beginning to be reflected in John Hodge assesses the changing There has been a consensus for treatment. In the three high secure role of the high secure hospitals. some time that personality disorder hospitals, these developments have does not respond well to the taken slightly different courses. biological treatments currently Also, although the earliest available. As a result the majority approach at Broadmoor is now Introduction of personality disordered patients nearly twenty years old. I think it People with personality disorders in high secure hospitals have at is still safe to say that all three are admitted to the three high sometime or other been referred to hospitals are still at an early stage secure hospitals in England and psychological services. Although, in the development of services to Wales under the 1983 Mental in the main, psychologists believe these paiients. Health Act. category of that they have a lot to offer to these In Broadmoor . 1 'Psychopathic Disorder . The clients, their assessment and Mednip Ward (which later became three hospitals are Ashworth treatment has tended to be very Woodstock Ward) was set up to Hospital, near Liverpool (formerly individualised, and very often cater for young male personality Moss Side and Park Lane focused on the offence behaviour disordered patients. A treatment Hospitals): Broadmoor Hospital in rather than on the personality model was developed based , and disorder per se. Although around an integration of Rampton Hospital in individual approaches vary, most psychodynamic and behavioural Nottinghamshire. While some psychologists would generally treatments. Delivery was based personality disordered offenders adopt a problem-solving approach around a mixture of group, are admitted to medium secure based on a functional analysis of individual, and milieu therapies. units, the majority currently the index offence and deal with The overall aim within this ward detained in health care settings are personality disorder issues as they was to prepare patients for in the high secure hospitals. arose within that framework. At discharge to less secure settings. While the hospitals have been the same time, the bulk of research This particular service has admitting and offering treatment to on personality disorder in high developed slowly over a personality disordered offenders secure hospitals, until relatively considerable period of time and for many years, the development recently, tended to wrestle with the has generated a rich series of of services to these patients has conceptual problems regarding the publications as people have been very slow and only relatively nature of personality disorder described and evaluated the work recently have there been concerted rather than generating treatment being done (Grounds, et al, 1987} options or evaluating the treatment attempts to create specialised units Tn Rampton Hospital, a for these patients. The main cause which was taking place (Blackburn. 1975). This phase of Psychological Treatment Unit was of this tardiness in developing developed in 1993. The initial services has been the lack of a clear individualised treatments co- existing with academic research concept of this unit was to provide conceptual framework in which to a consistent therapeutic milieu in understand the personality was perhaps inevitable given the relatively low priority these which offence-related and personal disordered and formulate their therapy could be offered. The unit problems. For example, although patients had on the medical and political agendas at that time. opened as a single small ward with the 1983 Menial Health Act a maximum of twelve patients and. In the last ten to fifteen years. as a result, initial teething "In the high secure hospitals, there has however, there has been a problems could be contained while considerable increase in research the management and treatment been a gradual recognition that the interest in developing not only our processes on the ward were special needs of personality disordered understanding of personality established. The Unit has now patients need to be addressed more disorder but also in developing developed into a three-ward unit strategies for treatment and called the PD Service, and the systematically and this is beginning to be intervention. The focus of this treatment model has developed reflected in treatment. In the three high research has been on people with from its original, fairly loose personality disorder in the concept towards one embracing secure hospitals, these developments communitv but it shows the concepts of Dialectic have taken slightly different courses." considerable promise for Behaviour Therapy and Cognitive

36 Cjm no. 37 Autumn 1999 Behaviour Therapy. At the present problem. Although it is clear to time, the predominant treatment in almost everyone who comes into "One possible learning point from the the service is structured group contact with PD offenders that they outcomes of the different service therapy, with individual work are suffering from some form of developments in the three Special occurring outside the groups. mental disorder, there has been no Evaluation of the treatment consensus as to the nature of that Hospitals might be that an effective programme is yet in its early mental disorder; there has been no approach probably requires a small start stages, but shows promise consensus as to where it might best 9 (Hughes, et al, 1997). be managed; and there has been no and a carefully planned development/ In Ashworth, the Personality consensus as to who is best Disorder Unit was set up in 1994 equipped to manage it. People gets a diagnosis because of the personality disorder is of value in and consists of six wards housing with PD in the prison systems behaviour they display. However, developing treatment packages. all the PD patients in Ashworth. generally cause the more once the label is applied, the The Unit was set up with very challenging management behaviour is then 'explained' by Personality disorder - the diagnosis. This circular positive aims which was to problems and prisons are often a personal view deveiop a more therapeutic ethos quite enthusiastic to transfer them causality does not progress our for patients in Ashworth, following to healthcare settings. People with knowledge in any way and Where there has been a great deal the Blom-Cooper Enquiry. PD in healthcare settings also contributes a great deal both to the of research attention over the last However, there was no clear cause management problems and stigmatisation of people with PD, ten years to our understanding and therapeutic model adopted at the where there is a lack of any and to the philosophy of treatment of PD, putting it into the early stages of the PDU. The obvious effective treatment, therapeutic nihilism. This context of the decades of research management problems suffered by healthcare workers often take the superficial sophistication in our on other mental health problems, the Unit eventually led to the view that they would be best description of personality it is still very much in its infancy. Fallon Inquiry, where one criticism returning to prison. disorders may be one of the major However, there are a number of barriers to our developing an themes emerging which, I think, was the lack of foresight and Personality disorder has been planning for the management understanding of them. make it possible to conceptualise bedevilled by a lack of personality disorder in other ways problems that would be likely in It cannot be denied that the professional consensus on its than diagnostic systems. I would dealing with such a large group of diagnostic systems provide a nature. It does not easily fit in with not claim that the personality disorder patients. shorthand for describing people medical concepts of 'mental conceptualisation I am about to who have similar clusters of One possible learning point illness' while, there is little link suggest is either comprehensive or problematic behaviour. However, from the outcomes of the different with personality theory in even very well developed at this there seems to be little use made service developments in the three academic psychology. The point. However, it may offer a of specific diagnoses in service Special Hospitals might be that an diagnostic systems used provide different perspective on the usual provision. At the present time, the effective approach probably no help in determining treatment. 'mad or bad' dichotomy that is trend is to put together people with requires a small start and a To make things worse, we keep often applied to these patients. carefully planned development. inventing new terms like 'Severe undifferentiated personality Where problems did emerge in the Personality Disorder', which disorders into the developing I believe there is now sufficient services, they could much more be simply add to the conceptual services. With one exception, evidence to support a view that contained in a small service than morass. Our lack of an specific diagnosis is unrelated to personality disorder can be seen as in one that was trying to deal with understanding of the nature of PD the treatments offered. The one an acquired developmental large numbers of PD patients at the has also led to a lack of research exception, of course, is borderline disorder leading to emotional and same time. This philosophy may on effective treatment, since personality disorder. Here, a interpersonal disability. I am be unattractive to Ministers who treatment processes are usually number of treatment approaches suggesting that it is an acquired have a political agenda for public based on some theoretical have been developed to developmental disorder because I safety and who wish to see an understanding of the problem. specifically address this particular think there is now sufficient approach in dealing with the group (e.g. Dialectic Behaviour evidence that events happening It is my view that some of our Therapy; (Linehan, 1994) and during the development of problem of personality disorder, current diagnostic systems do not and in particular personality Schema-focused Cognitive vulnerable people may pre-dispose help. These diagnostic systems Therapy; (Young, 1990)). There them more to developing a disordered offenders once and for were meant only to be descriptive all. However, this group of patients are probably a number of reasons personality disorder at a later stage. and designed to be atheoretical. why this particular group should I am suggesting a disability rather has demonstrated their ability to They make no statement about the challenge conventional manage- be separated out and targeted. In than an illness model because in development of personality general borderline personality most cases we are dealing with a ment and treatment. We must learn disorders and do not contribute from the lessons from the past. So disorder patients are the most chronic problem that is likely to much to our understanding of their obviously distressed by their respond only partially to treatment. what in fact is the problem they nature. The lack of theoretical base present? mental disorder. There is also In terms of the acquired in DSM-IV and ICD-10 leads to considerable and growing problems in developing effective developmental disorder, it is likely evidence of some of the reasons for that some individuals are or What is personality treatments or therapies linked to that distress being based on trauma the diagnosis. In addition to that, become more vulnerable to and abuse. Indeed there is a school development of PD. Such disorder? they are not very reliable. It has of thought which would suggest Personality disorder is probably been suggested that on average vulnerability factors might include that a diagnosis of borderline PD biologically based temperamental the most complex and someone with PD can meet the is the same as having a diagnosis heterogeneous problem in mental diagnostic criteria for three-and-a- features such as impulsivity, of Post-traumatic Stress Disorder. emotion dysregulation and low IQ. health. Despite its being half different disorders. However, However, there has been no similar recognised now for over 150 years, the major problem, is that since There may also be acquired focus of attention on any of the vulnerability factors such as brain there has been little progress up they are part of a diagnostic other personality disorders nor any until fairly recently in either our system, they are commonly used damage (which would depend on real evidence developed that the the extent, location and timing of understanding of the problem or to explain the behaviours they current differentiation of indeed in our management of the describe. In other words, someone the damage). Environmental

no. 37 Autumn 1999 37 factors would include such issues some form of emotional disorder (Blackburn & Renwick, years or so to explain the reactions as abuse and/or trauma, neglect, dysregulation or over regulation. 1996; Blackburn, 1998). The of people exposed to indifference, changes in (It is arguable that people with anti- approach offers ways of measuring overwhelming and life-threatening caretakers, indulgence. There is a social personality disorder are people's interactions using the dramatic situations (Bloom & fair amount of literature to suggest over-regulated emotionally rather interpersonal circle or circumflex Reichert, 1998). Studies of people that these environmental factors than under-regulated as might be and to address interpersonal with PD have shown them to be have more or less impact on felt for people with borderline PD.) problems using interpersonal much more likely to have been individuals depending on the theory based on the work of exposed to trauma in their past and presence or otherwise of protective The development of Keisler and others in the USA ( to suffer symptoms of Post factors such as caring relationships Keisler, 1983). Traumatic Stress Disorder. While and the opportunity to avoid and a conceptual Attachment theory initially much of the research on post therefore incubate problems. A framework developed by Bowlby (1969) has traumatic stress disorder has been lack of these protective factors I said earlier that there has been a also been proposed more recently focused on people with PTSD would therefore enhance the great deal of research over the last as a way of conceptualising and diagnosis, there is considerable likelihood of the development of ten years on our understanding and understanding the problems of interest in its application to PD. It a personality disorder. treatment of PD. I do not propose many people with PD. In essence, seems likely that many of their I would be the first to admit to go into this in any detail but an the argument is that people with inappropriate beliefs and that this concept of PD is hardly overview may provide some kind PD develop Avoidant and/or behaviours may well have had rocket science. However, I believe of flavour of the kind of work Anxious Attachment Styles and their origin in early childhood it encapsulates the general which is going on and the very rarely have Secure abuse and trauma (Hodge, 1992). direction of current psychological considerable promise that some of Attachment Styles. Attachment These conceptual frameworks, research. Its singular advantage is this work is showing. Theory is quite strongly a list that I do not claim to be that it offers some explanation for empirically based and it may have comprehensive, are al re ad v Marcia Linehan began to work beginning to generate many rich the diversity and complexity of the with women who were self- considerable potential for helping problem we are dealing with. If develop a conceptualisation of ideas for the development of harming and attempting suicide. treatment and prevention we were to consider the range of She developed a theory of Emotion some of the problems of PD. different types of vulnerability (Adshead. 1998) approaches that may in the future Dysregulation to explain why may have considerable impact on factors, and their almost infinite Aaron Beck (Beck et al, 1990) these women were behaving in this our ability to provide services to possible interactions during the and Geoffrey Young (Young. way and a treatment approach people with PD. development of an individual, the called Dialectic Behaviour 1990) have developed different complexity of the outcome Therapy to address the problems versions of Schema-Foe used becomes inevitable. presented by these women, She Cognitive Behaviour Therapy in Evidence base dealing with personality disorders. Considering personality then became aware that these Unfortunately, and partially due to Beck's approach has been to disorder to be a disability rather women would all attract a the fact that interest in research in postulate a number of probable than an illness offers us access to diagnosis of borderline personality PD is a relatively recent schemas based on DSM-III-R the different conceptual disorder. Dialectic behaviour phenomenon, the evidence base Diagnostic Categories, while frameworks we use for supporting therapy (Linehan. 1994) is now for most of the treatments in Young had adopted a more disabilities of all types. If we were seen as one of the most promising current use is sparse. This places empirical approach of trying to to see our PD patients as disabled, treatments for borderline PD and an onus on all practitioners identify what he calls early both in their ability to regulate their is under consideration for being currently involved in providing maladaptive schemas from a emotions and also in their ability applied to other types of PD. The services to clients with PD in research base. Schemas are to interact with others: if this treatment provides a structured whatever setting to measure, essentially core beliefs which disability were viewed as a result framework to conceptualise evaluate and report on the people use to interpret their of the interaction between personal people's problems and to address effectiveness or otherwise of their environment and guide their vulnerability and maladaptive these in a systematic way. work. In this way we could rapidlv behaviour. Cognitive-behavioural learning experiences throughout Another way of looking at PD develop an evidence-base for theory postulates that in people their developmental years, then is to examine the typical practice, with PD there are a number of this might offer a different interpersonal strategies that people interacting maladaptive schemas Psychotherapy has long been perspective in developing with PD use in interacting with that not only lead to them used in healthcare settings for appropriate services for them in the other people. There has been a misinterpreting their environment, people with PD. In general this is future. A disability model is also long tradition of work on but also to maintaining their usually dynamic psychotherapy more credible than an illness interpersonal theory in the USA, inappropriate behaviour. Schema and based on psychoanalysis or model, and carries with it a based originally on the work of Focused Cognitive Therapy has one of its derivatives. different value system, which may psychiatrist, Harry Stack Sullivan. developed as a therapeutic package Unfortunately, despite the length enable staff and others to more This work has been relatively little and is now in wide use for a range of time that psychotherapy has effectively interact and deliver known in clinical settings in this of different personality disorders been used in this way and despite services. country until recently when Ron in a range of different settings. occasional case reports of Whatever the conceptual Blackburn began to integrate the successful treatment, there is no framework we eventually develop work on interpersonal theory with Finally, Trauma Theory has body of evidence for the to understand PD, there does his previous work on psychopathic also developed over the last ten effectiveness of psychotherapy appear to be a number of common with PD. issues across the wide range of "We seem to have a tendency to jump on Therapeutic communities have personality disorders which are the bandwagon of single promising also been used a great deal with more or less present in most people people with PD and are in current with any form of PD. Most have a solutinos. At present therapeutic use. The Henderson Hospital and very low self-esteem. Most have communities and Dialectic Behaviour Grendon Prison both use a variant interpersonal problems and a very of therapeutic community to deal rigid thinking style and most have Therapy seem to be the favourites." with people with PD. However.

38 Cjm no. 37 Autumn 1999 "/ would propose that whatever new is unlikely to respond to any single York: Basic. solution. It may well be that Grounds, A.T., Quayle, M.T. services develop, they must contain the different types of PD may respond France, J., Brett, T., Cox, M. & flexibility for different treatment to different types or combinations Hamilton, J.R. (1987) A unit for approaches to be offered. Possibly this of treatments or that some of the 'Psychopathic Disorder' patients current initiatives may prove in Broadmoor Hospital. Medicine, might best be done by offering different superior to others. The simple fact Science and the Law. 27(1), 21-31. approaches in different settings so that is that we do not know yet. Hodge, J. E. (1992) Addiction to On that basis, I would propose violence: A new model of staff can 'specialise' and become expert that whatever new services psychopathy. Criminal Behaviour in the particular treatment model they develop, they must contain the and Mental Health, 2, 212-223. offer" flexibility for different treatment Hughes, G., Hogue, T., Hollin, C. approaches to be offered. Possibly & Champion, H. (1997) First- this might best be done by offering stage evaluation of a treatment most therapeutic communities are very likely that one component of different approaches in different programme for personality highly selective of their effective treatment will depend on settings so that staff can disordered offenders. Journal of participants and the evidence of consistent interpersonal reactions 'specialise' and become expert in Forensic Psychiatry, 8, 515-527. their long-term effectiveness is with highly trained staff. As yet the particular treatment model they Keisler, D.J. (1983) The 1982 unclear. There seem to be some we are at a very early stage in offer. A range of treatments in Interpersonal Circle: A taxonomy gains while people remain resident developing the training that staff different settings would provide for complementarity in human within the therapeutic community, will need effectively to work with the most appropriate flexibility transactions. Psychological but less clear evidence that these people with personality disorders. both to evaluate what it is we are Review, 90, 185-214. gains hold after they have left. It is clear also that there is doing and also to identify what Linehan, M. (1994) Cognitive- Dialectic Behaviour Therapy going to be a long-term need for interventions show best promise behavioural Treatment of is the one treatment which has been individually tailored treatment with different types of personality Borderline Personality Disorder. subject to a randomised control plans since PD is highly complex disorder. It goes without saying New York: Guilford. trial of its effectiveness. In a and variable. Arguably no two that each treatment model should Linehan, M.M., Armstrong, H.E., relatively small study on women people with PD are sufficiently be properly evaluated and that a Suarez, A., Allman, D. & Heard, who were exhibiting para-suicidal alike to respond to completely major function of any new service, H.L. (1991) Cognitive- behaviour, DBT was found to lead identical treatment programmes. however organised, will be behavioural treatment of to therapeutic improvement However, this tends to be the robustly to research and chronically para-suicidal (Linehan et al, 1991). nature of psychological treatment continuously improve its practices. borderline patients. Archives of Unfortunately this was a small anyway and it may be that the bulk General Psychiatry, 48, 1060- study using a fairly narrow range of treatment could be 1064. of subjects. At present DBT is used accomplished in treatment in a much wider range of settings modules, the range and nature of John Hodge is Head of Marshall, W.L., Eccles, A. & and of patients than its evidence which may vary for different Professional Practice, Rampton Barbaree, H.E. (1993) A three- base would support, although people. Hospital. tiered approach to the research is being done to evaluate rehabilitation of incarcerated sex its effectiveness in these settings. References: offenders. Behavioural Sciences A themed' strategy Adshead, G. (1998) Psychiatric andtheLaw. 11,441-445. Schema-focused Cognitive So what development strategy can staff as attachment figures: Young, J.E. (1990) Cognitive Therapy shows a great deal of we suggest on the basis of our understanding management Therapy for Personality promise, but as yet no controlled current knowledge of PD and its problems in psychiatric services in Disorders: A Schema-focused clinical trials with PD patients treatment for the development of the light of attachment theory. Approach. Saratosa FL: have been published. a Personality Disorder Service? I British Journal of Psychiatry, 172, Professional Resource Exchange Interpersonal Therapy also am not going to make any 64-69. shows a great deal of promise with comment on whether we should be Beck, A.T., Freeman, A. & PD patients but again no controlled developing the service within our Associates (1990) Cognitive clinical trials have been published current institutions or whether it Therapy of Personality Disorders. which would demonstrate its should be developed as a new New York: Guilford Press effectiveness. "third way". However, I do think Blackburn, R. (1998) Relationship we have enough information to of personality disorders to observer Future directions begin to make some decisions ratings of interpersonal style in Clearly there are a number of about the necessary qualities that forensic psychiatric patients. promising treatments beginning to such a service will need to have. Journal of Personality Disorders, emerge and our understanding of It is clear that there is a range 12(l),77-85. PD will develop with them. of treatment initiatives currently in Blackburn, R. & Renwick, S.J. However, it seems to me far too development, which show promise (1996) Rating scales for early to commit to any one in the understanding and treatment measuring the interpersonal circle treatment or conceptual ofPD. It is far too early to discard in forensic psychiatric patients. framework of PD and it is very any of these, or indeed to discard Psychological Assessment, 8(1), possible that different people and/ any yet to be developed. We seem 76-84. or different personality disorders to have a tendency to jump on the Bloom, S.L. & Reichert, M. (1998) (in whatever way they are bandwagon of single promising Bearing Witness: Violence and eventually conceptualised) may solutions. At present therapeutic Collective Responsibility. New well respond to different communities and Dialectic York: Haworth Maltreatment and treatments. Given the accruing Behaviour Therapy seem to be the Trauma Press. evidence that PD is akin to a long favourites. The range and Bowlby,J.(1969) Attachment and term developmental disorder, it is complexity of personality disorder Loss. Vol 1: Attachment. New

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