Research

As a ground breaking, cross-departmental initiative, research and evaluation has a major role to play within the DSPD and Therapeutic Communities Programme. A comprehensive research programme has been at the centre of the initiative since its outset.

LABILE (lamotrigine and borderline personality disorder: investigating long term effectiveness) study

The National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme is funding the first large-scale NHS clinical trial of a drug therapy in borderline personality disorders.

The LABILE (lamotrigine and borderline personality disorder: investigating long term effectiveness) study aims to establish whether lamotrigine, a mood stabiliser, is a worthwhile treatment when balancing the possible benefits and the potential side effects.

It’s estimated that between 0.5% and 2% of people have borderline personality disorder, experiencing very high levels of emotional distress and often negative feelings about themselves. There are currently no medicines licensed for the treatment of this condition which is why this research is so vitally important. Small clinical trials have shown promising results for lamotrigine but the National Institute of Clinical Excellence (NICE) guidelines have recommended larger scale studies.

For more information please go to the HTA website:

Modern Mental Health

Modern Mental Health offers an alternative and thought-provoking perspective to the conventional and orthodox understanding of mental health and how to help those suffering with mental illness. Two chapters focus specifically on Personality Disorder, one from Professor Bob Hinshelwood and the other by Dr Heather Castillo of The Haven whose clients played a crucial role in the research study she writes about.  The individual contributors to this book share a passion for needs-informed person-centred care for those people affected by mental ill-health and a deep skepticism about the way help and support is organised and provided to the one in four people in the population who at some time will suffer mental health problems. The chapters include a diverse and rich mixture of stark personal testimony, reflective narrative, case studies in user-informed care, alternative models of intervention and support, rigorous empirical research and a forensic analysis of mental health law-making.  Although the overarching philosophy of this book is critical of contemporary psychiatric care, each chapter offers an individual perspective on an aspect of provision.  The 10 author contributors are a range of international academics, mental health professionals and mental health service users with a huge range of research, teaching and practice experience.

Modern Mental Health is available from Amazon.

Study of the legal status of Dangerous and Severe Personality Disorder (DSPD) patients and prisoners, and the impact of DSPD status on Parole Board and Mental Health Review Tribunal decision-making

The aim of the study was to identify the legal characteristics of Dangerous and Severe Personality Disorder (DSPD) patients and prisoners, record their Parole Board (PB) and Mental Health Reviews Tribunals (MHRT) during the study period, and explore PB and MHRT members’ views about decision-making in relation to DSPD patients and prisoners. The two papers based on this report have now been published.

The full references are:

Trebilcock, J. & Weaver, T. (2012) ‘It doesn’t have to be treatable’: Mental Health Review Tribunal (MHRT) members’ views about Dangerous and Severe Personality Disorder (DSPD). Journal of Forensic Psychiatry & Psychology, 23(2), 244-260.

Trebilcock, J. & Weaver, T. (2012) Changing legal characteristics of Dangerous and Severe Personality Disorder (DSPD) patients and prisoners. Journal of Forensic Psychiatry & Psychology, 23(2), 237-243.

Early years of dangerous and severe personality disorder programme

This summary is based on two linked studies of an innovative programme which took place between 2006 and 2009. The first focused on the treatment delivered to and experienced by dangerous and severe personality disorder (DSPD) prisoners/patients. It was called IDEA (Inclusion for DSPD: Evaluating assessment and treatment). The second study was concerned with management and staffing of the four high-secure DSPD units for men. It was called MEMOS (Management, organisation and staffing of DSPD). The report can be found on http://www.justice.gov.uk/publications/research-and-analysis/moj/dangerous-severe-personality-disorder.htm

Successes and failures of DSPD experiment

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.

For more information, the report can be found at: Successes and Failures of the DSPD Programme

The baby, the bathwater and the bath itself: a response to Tyrer et al.’s review of the successes and failures of dangerous and severe personality disorder

A recent paper (see above) by Tyrer et al. in this journal has reviewed the dangerous and severe personality disorder (DSPD) initiative in the assessment and management of severe personality disorder associated with high risk. This previous paper summarized the authors’ perceptions of the successes and failures of the DSPD pilot. In the present paper we identify some inaccuracies in the previous review and provide a critique of the conclusions reached.

Med Sci Law. 2011 Jul;51(3):129-33

Howells K, Jones L, Harris M, Wong S, Daffern M, Tombs D, Kane E, Gallagher J, Ijomah G, Krishnan G, Milton J, Thornton D.

Neural networks

PI: Professor Min Yang
The study is based on fresh analysis of existing data in the Prisoner Cohort Study.
While the results of this work have not resulted in a major breakthrough they have provided important pointers for future work.
The study will be relevant to anyone interested in how best to predict which offenders will or will not re-offend.
Further information: the report can be found on the Ministry of Justice Research website.

How do we know whether the programme is worthwhile?

The DSPD programme is still relatively new, and so far few people have completed treatment. Hence a full evaluation of the effects of treatment is some way into the future. However, there have been a number of preliminary findings. Because methods of treating severe personality disorder and its links to offending are relatively unproven, the Programme has also undertaken a range of more fundamental research across a range of areas to contribute to this evidence base.

An expert group, established to advise the DSPD programme, set out the following priorities for the DSPD research programme:

  • Improve knowledge around the causes of Personality Disorder (PD).
  • Explore the relationship between PD and serious offending behaviour.
  • Evaluate specific DSPD assessment and treatment programmes.

Therapeutic Communities have been running in the Prison Service, as well as elsewhere, for rather longer, and there is an accumulating body of evidence on their effects.

For further information on the DSPD and Therapeutic Communities research programme contact:
Email – ISMG.DSPD@noms.gsi.gov.uk

For more information on Ministry of Justice research and statistics, visit the Ministry of Justice website. For other research on forensic mental health, visit the National Programme of Forensic Mental Health website.

Improve knowledge around the causes of personality disorder (PD)

The Development of Antisocial behaviour and Psychopathic Tendencies (PI: Essi Viding) – Main findings:

  • Antisocial behaviour for those children displaying Psychopathic tendencies shows a strong genetic influence.
  • Antisocial behaviour for those children without these tendencies shows a strong environmental influence.
  • The strong genetic influence does not imply that nothing can be done to intervene but does argue for early environmental interventions for this sub-group.

Further information: see numerous published articles, including one by Essi Viding, Paul J. Frick and Robert Plomin in Supplement 49 (May 2007, Vol.190) of the British Journal of Psychiatry.

Developmental trajectories of serious sexual offenders (YAP Project)

Young Abusers Project (PI: Eilieen Vizard) – Main findings:

  • Subgroups of juvenile sexual abusers could be distinguished depending on a) age of onset of sexually abusive behaviour and b) emerging severe personality disorder traits.
  • Those in the early onset group had more adverse backgrounds and were more likely to abuse a variety of victims compared to those in the late onset group.
  • Those displaying emerging severe personality disorder traits also had more adverse backgrounds and showed higher rates of predatory behaviour compared to those in the non-ESPD group.
  • Those in the early onset group were more likely to have emerging severe personality disorder traits.

Further information: see the report ‘Links between juvenile sexually abusive behaviour and emerging severe personality disorder traits in childhood’, by Nicole Hickey, Eileen Vizard, Eamon McCrory and Lesley French available on the Department of Health website.

A longitudinal study of clinical, genetic and environmental risk factors for juvenile anti-social personality disorder in a high risk group

(PI: Anita Thaper) – Main findings:

  • Children with Attention Deficient Hyperactivity Disorder (ADHD) were at raised risk of developing conduct disorder and or displaying high levels of psychopathic trait.
  • Small genetic influences in the development of psychopathy were identified. The size of their effect suggests these genes can only be usefully considered in interaction with other factors (e.g. family environment).
  • Maternal smoking during pregnancy, low birth weight and birth complications all had an association with subsequent antisocial behaviour.
  • In conjunction with low birth weight, the gene COMT showed a strong relationship with subsequent antisocial behaviour.

Further information: the final report can be found on the National programme for Forensic Mental Health website.

Prisoner Cohort Study

Queen Mary College, London (PI: Professor Jeremy Coid) – Main findings:

  • In offenders who had committed violent and sexual offences, the extent of personality disorder was higher than for the general prison population. Fifteen per cent of the sample fulfilled the criteria for DSPD (as expressed in PD and risk measurements).
  • The DSPD concept does appear to identify a group who are more likely to reoffend, and who are considerably more likely to be reconvicted of major violence. This group differs from non-DSPD offenders in terms of age, ethnicity, socio-economic class, and marital status. Successful treatment or management of the link between recidivism and DSPD could lead to a significant reduction in the number of reconvictions in this group, and therefore in the overall prison population.
  • The research demonstrated for a number of established risk assessment instruments moderately high predictive accuracy for reconviction at an individual level. The best item-level predictors of reconviction tended to be based on previous criminal history.
  • In psychopathy as measured by the Psychopathy Checklist (Revised), previous criminality and impulsivity appear to be linked to reoffending.

An extension of the study is examining the potential for new statistical models to improve on existing models in predicting serious reoffending.
Further information: the final report is published on this website.

Neurobiological roots of violence

Institute of Psychiatry (PI: Professor Sheilagh Hodgins) – There may be an important neurobiological dimension to psychopathy which, if understood better than at present, could help inform interventions. Accordingly, the Institute of Psychiatry has been commissioned to carry out some ‘basic’ research involving violent offenders, to find out if there are neurobiological characteristics that help to differentiate psychopaths from more ‘reactive’ violent offenders.

Further information: work is still in progress (due to conclude late 2010).

Evaluation of the assessment procedure at two pilot sites in the DSPD programme

Imperial College, Arnold Lodge and Oxford University (IMPALOX) consortium (PI: Professor Peter Tyrer) – Main findings:

  • At 12-26 weeks, the Whitemoor assessment process was too long.
  • Limited reliability of assessments made the process poor in selecting individuals.
  • The assessment process was cost-ineffective in terms of improving social functioning and quality of life.
  • Lack of progress was frustrating for prisoners.
  • These findings relate to a historical situation and do not necessarily apply today.

Further information: the final report is published on this website.

Measure of change in psychopathy

Glasgow Caledonian University (PI: Professor David Cooke) – This project is developing a Comprehensive Assessment of Psychopathic Personality (CAPP), which will be optimised for detecting changes in the level of psychopathy, as well as potentially being applicable in a wider range of assessment settings.
Main findings – initial development of the CAPP, based on expert review, construes psychopathy as a construct comprising six domains:

  • Attachment
  • Behavioural
  • Cognitive
  • Dominance
  • Emotional
  • Self

The CAPP is being trialled in various settings.

Assessment of those with intellectual disability

Rampton Special Hospital (PI: Todd Hogue, now University of Lincoln) – Main findings:

  • Although use of standard assessments is possible for offenders with intellectual disability with care, and with the use of as wide a range of sources of information as possible, newer measures such as the SCJ-Risk (Hogue, 2003) and the Dynamic Risk Scale (Quinsey, 2004) also show promise with this group.
  • Little is know about psychopathy in intellectually disabled populations, and there is limited experience of using the PCL-R for these individuals. Special guidelines have been developed for scoring the PCL-R with this population.
  • Patients with intellectual disability in secure facilities are typically more aggressive, withdrawn, and anxious, depressed and exhibit lower self-esteem than those in community forensic care, but it is not known to what extent this might be a result of the setting.

Further information: there have been numerous publications in academic journals resulting from this work.

The Common Data Set

Imperial College (PI: Professor Tony Maden) – A common data set (as specified in the DSPD Planning and Delivery Guide) has been rolled out across the high secure units in a way that allows data to be collected and integrated into a main database for use in cross-site comparisons. The primary purpose of the data collection is to compare treatment progress and outcomes for those with and without psychopathic personalities.

Evaluate specific DSPD assessment and treatment programmes

A Review of Treatments for Severe Personality Disorder, St. George’s Hospital Medical School (PI: Fiona Warren) – Main findings:

  • There is little evidence addressing the efficacy of interventions and, because of poor methodology, no robust evaluations.
  • The most promising areas for intervention (in that there was limited but supportive evidence) are cognitive behavioural therapies and therapeutic community approaches. There is a lack of evidence, but not a conclusive rejection, on psychodynamic approaches, drug treatments and physical therapies.

Further information: the final report is published on this website.

A Systematic Review of the Effectiveness of Pharmacological and Psychological Treatments for those with Personality Disorder

(PI: Professor Conor Duggan) – Main findings:

  • Overall, the quality of evidence for treatments of personality disorder is extremely weak. However there is evidence that structured psychological interventions have a modest benefit in reducing offending.
  • Research should prioritise reviewing treatment for anti social personality disorder, as there is a high prevalence rate within prisons and hospitals. Furthermore potential research should review both negative and positive side affects of treatments in order to understand the effectiveness of treatments for personality disorders.
  • Potential studies should attempt to randomise inmates in one treatment or another treatment in order to test treatment programmes efficiency; the review strongly suggests a need for a comparison of the enhanced thinking skills programme and reasoning and rehabilitation programme as both programmes are currently running in prisons.

Further information: the final report can be found on the National Forensic Mental Health R&D Programme website.

RCT feasibility study at Whitemoor

Cambridge University (PI: Professor David Farrington) – Main findings:

  • A randomised controlled trial would be feasible, but only if the following conditions were in place:
    • The identification of several hundred appropriate referrals for the service
    • Increased case flow through assessment
    • Decrease in the length of treatment
  • Other key requirements would be:
    • Organisational support for the trial (including resolution with other organisational demands)
    • The development of valid, dynamic measures of the risk of serious offending.

Further information: the final report is published on this website.

Adjudications of those referred to the DSPD unit at HMP Whitemoor

Internal study by DSPD Research Team (PI: Ricky Taylor) – Main findings:

  • There was a reduction in the number of institutional misconducts that might have been expected on the basis of previous behaviour. Specifically 36.5 violent incidents were anticipated. In fact 10 such incidents were actually observed.
  • Because there is no comparison with similar prisoners not receiving the regime at the HMP Whitemoor unit, it is not clear whether the observed effect is actually due to differences in management.

Further information: the final report is published on this website.

Management of discretionary life-sentenced offenders

Oxford University (PI: Colin Roberts) – Main findings:

  • Although probation staff largely adhered to guidance on the management of these offenders on licence, practice was patchy and there was a need to collate good practice and update the guidance. This was in hand through the implementation of the new Offender Management Model.
  • The risk factors that had the greatest influence on likelihood of recall, once other factors were controlled for, were:
    • alcohol misuse following the first discretionary lifer panel release;
    • showing hostility towards the home probation officer during custody;
    • evidence of sexual motivation for the index offence; and
    • experiencing abuse during childhood.

Further information: the report can be found on the Home Office Research Development and Statistics (RDS) website.

Staffing of DSPD high-secure sites

(PI: Professor Len Bowers) – Main findings:

  • Staff (mainly prison officers) in Whitemoor Prison tended to hold relatively positive attitudes to personality disordered people.
  • Those officers with particularly positive attitudes were more likely to interact well with prisoners; this in turn was likely to maximise therapeutic efficacy and promote good order.

Further information: see various published articles, including Bowers, L., Carr-Walker, P., Paton, J., Nijman, H., Callaghan, P., Allan, T. and Alexander, J. (2005), ‘Changes in attitudes to personality disorder on a DSPD unit’, Criminal Behaviour & Mental Health, 15 (3), pp 171-183; Bowers, L. and Allan, T. (2006), ‘The attitude to personality disorder questionnaire: psychometric properties and results’, Journal of Personality Disorders, 20 (3), pp 281-293.

Ashworth Schema Therapy Evaluation

PI: Professor Nick Tarrier (June 2007 – December 2008), Professor Mairead Dolan (June 2004 – June 2007) – Main findings:
This study aimed to establish the feasibility of conducting a Randomised Control Trial (RCT) in a high secure hospital setting. It also evaluated the effectiveness of Schema Modal Therapy in a sample of offenders with personality disorder.
Main findings:

  • Conducting an RCT in a high secure hospital is feasible, although there are many challenges.
  • No significant treatment effect was found as a result of this RCT.
  • Future trials of Schema Modal Therapy in high secure and forensic settings need to consider the lessons learned.

Further information: the report can be found on the Ministry of Justice Research website on the Ministry of Justice Research Website.

Local Agency Network for Development and Support in the Community for Adults with Personality Disorder (LANDSCAPED)

PI: Professor Conor Duggan – Main findings:

  • Those who received the treatment had better social functioning and problem solving and lower index of anger expression than the control group and compared with pre-treatment.
  • Some of those who were expected to engage poorly, managed to attend more than half the sessions.
  • There were no differences on the psychometric measures between whether the clients only partially attended the intervention or completed it.

RESETTLE (CRACMS) evaluation

PI: Professor Jonathan Hill – Main findings:
No results are currently available for this project. The final report is due in 2011.
Further information: work is still in progress.

IDEA evaluation

Oxford University (PI: Professor Tom Burns) – This evaluation of the four high-secure sites is expected to make a substantial contribution to building up the evidence base for assessment and treatment services for relevant offenders, and to help shape future services both in prisons and special hospitals.

MEMOS  evaluation

Imperial College (PI: Tim Weaver) – This evaluation is intended to identify good practice in management and staffing across the four high secure DSPD sites. Click here for MEMOS FULL REPORT APPENDICES.

Successes and failures of DSPD experiment

A pilot study of a new intervention for hard to treat children with conduct disorders

PI: Professor Jonathan Hill – Main findings:

  • Randomisation in an applied clinical setting involving children with conduct problems, and their parents, was achieved.
  • Reflective Interpersonal Therapy for Children and Parents (RICAP) was more effective than treatment as usual in terms of one of the measures (but not the other) of children’s behaviour completed by parents.
  • There were no benefits of RICAP over treatment as usual according to teacher reports.

Further information: the report can be found on the National Institute for Health Research Portal website.

Pilot case-control study of an intensive multi-modal cognitive behavioural programme for adolescent offenders in secure care

PI: Dr Mairead Dolan – Main findings:
There was no significant effect of Cognitive Behavioural Therapy over Treatment as Usual in reducing the mental health and psychosocial needs and risks in conduct disordered adolescents in secure care.
Further information: the report can be found on the National Forensic Mental Health R&D Programme website.

CODES: Costs and Outcomes of DSPD Services

Imperial College (PI: Barbara Barrett) – Main findings:

  • Studies analysing costs of programmes for DSPD types of individuals are rare. Only 2 papers were found that examined the cost effectiveness of interventions/programmes, however both used the same economic model. These papers showed that sex offender programmes are of benefit to society.
  • Outcomes of treatment programmes are often measured via reconviction rates, with research showing that psychopathically disordered offenders have the highest reconviction rate. Patients with psychopathic disorder also have a shorter average stay than patients with mental illness. Outpatient interventions for male violent offenders are less effective on males with personality disorder than males without.

Further information: this work is incomplete, and may be extended.

Research on prison Therapeutic Communities

RCT feasibility study at Grendon, Home Office (Siobhan Campbell) – Main findings:

  • A randomised controlled trial at HMP Grendon would require a pool of around 215 suitable referrals.
  • Grendon’s democratic structure and current admission systems make organisational support unlikely.
  • A RCT at HMP Grendon would not currently be feasible.

Further information: the final report is published on this website.