Book Review: Dangerous and Severe Personality Disorder Response and Role of the Psychiatric Team
| Pages | 38-40 |
| DOI | https://doi.org/10.1108/13619322200400021 |
| Published date | 01 June 2004 |
| Date | 01 June 2004 |
| Author | Tony Maden |
| Subject Matter | Health & social care |
Book review
Dangerous and Severe Personality Disorder
Response and Role of the Psychiatric Team
By Len Bowers
London: Routledge (2002)
angerous and severe personality
disorder (DSPD) is a term coined by civil servants in
1999 to denote a group of high-risk patients whose
needs were not being met by forensic mental health
services. The root of the government’s concern was
that the Mental Health Act 1983 allowed doctors to
reject such patients almost at whim. The Act
stipulates that treatment must be likely to ameliorate
or prevent deterioration in the condition of any patient
detained because of psychopathic disorder. Treatment
is never straightforward and little research has been
done on it, so it is always possible to claim that a
patient fails the treatability test. The original intention
was that new mental health legislation would remove
the treatability criterion, and may include DSPD as a
new category of mental disorder allowing detention.
It now seems unlikely that DSPD will appear in
any new mental health legislation and the government
has taken the (very sensible) line of getting on with
developing a treatment programme, rather than
worrying too much about the legal framework. The
pilot programme begins with 300 beds in high security,
half in hospital and half in prison. The working
admission criteria for high security DSPD services are:
a severe disorder of personality; a high (greater than
50%) risk of committing a serious offence; and a
functional link between the personality disorder and
the risk.
The emphasis is on operational and standardised
definitions. Severe personality disorder is defined with
reference to Hare’s Psychopathy Check List, Revised
(PCL-R) and the risk of offending should be assessed
using standardised measures to guide clinical
judgment. The operational definition of a serious
offence is one likely to cause physical or psychological
harm from which the victim would find it difficult or
impossible to recover. The service excludes patients
with serious mental illness.
DBroadmoor’s 10-bed pilot ward opened in April
2003, with a 70-bed unit under construction, and
Rampton’s 70-bed unit opened at the beginning of
2004. Treatment services are still developing. It is no
surprise to find that the approach is eclectic, given the
lack of research on effective interventions in this
group of patients, but common elements are
emerging. Therapy is guided by standardised
assessments and a strategy of risk reduction through
intensive cognitive behavioural treatments. All
services aim for a structured regime in which patients
are timetabled to engage in structured activities
throughout the working day. The role of the
psychiatric team is therefore to deliver and monitor an
intensive package of psychological therapy within a
high-secure environment that has little or no
experience of functioning in this way. It is not entirely
unfair to suggest that, historically, the therapeutic
approach of the special hospitals in dealing with
personality disorder could be summed up in the
phrase ‘time, the great healer’.
I have given a brief synopsis of the development
and current state of DSPD services in the English
high-security hospitals as, amazingly, none of this
information appears in Len Bowers’ book. There is
certainly no need for that familiar worry – whether or
not it is worth investing in the book once you have
read the review. In this case, there is no overlap. The
book is a workmanlike account of a study of nurses
working with personality disordered patients in special
hospitals, in the pre-DSPD era. If that is what you
want to read about, get this book. If you want to know
about DSPD, look elsewhere. It does not do what it
says on the tin.
Tony Maden
Professor of Forensic Psychiatry
Imperial College London
Clinical Director of DSPD Services at Broadmoor
Hospital
38 The Mental Health Review Volume 9 Issue 2 June 2004 ©Pavilion Publishing (Brighton) 2004
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