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Treatment and Management of Personality Disorder in High Secure

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Treatment and Management of Personality Disorder in High Secure 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 personality disorder 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 hospitals. 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 Hospital. 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 Crowthorne, Berkshire 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.
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