Chapter Two

Managing Dangerous People with Severe Personality Disorder

Introduction

2.1    The consultation paper Managing Dangerous People with Severe Personality Disorder7, published in July 1999, set out the Government's proposals for tackling the challenge to public safety presented by the very small minority of people with severe personality disorder, who because of their disorder, pose a high risk of serious offending. There are two key elements to these proposals:

• to ensure that dangerous people with severe personality disorder are kept in detention for as long as they pose a high risk to others; and,

• to provide high quality services to enable them to deal with the consequences of their disorder, reduce their risk to others and so work towards successful re-integration into the community.

The problem

2.2    Successive Governments have grappled with the problems posed by people who are DSPD. At present neither mental health nor criminal justice legislation deals adequately with the risks this group pose to the public. In many cases, an individual who is DSPD has to be released from prison at the end of a determinate sentence even though they are assessed as presenting a continuing risk of harm to others. Individuals who present a risk to others because of their severe personality disorder are rarely detained under the Mental Health Act 1983 because they are assessed as being unlikely to benefit from the sorts of treatment currently available in hospital.

2.3    The deficiencies in the law are accompanied by a lack of specialist provision for the assessment and treatment of this group. Until now, a lack of strategic direction has meant little progress in developing a robust long term solution to this problem.

The Government's proposals

2.4    The consultation paper described two possible approaches. Option A built on existing service structures and makes changes to existing powers of detention ­ both criminal justice and mental health powers. Option B proposed the creation of a new service and new civil and criminal powers for the detention of this group, including powers for supervision and recall following detention.

The consultation process

2.5    The consultation paper marked the beginning of a major debate about the most effective and ethical ways of dealing with this group. We received 290 responses. Many of these were from organisations representing a large number of constituents who had themselves carried out extensive internal consultation. A broad range of views was put forward. Whilst those who responded overwhelmingly agreed that present arrangements were inadequate, there was disagreement as to how best to proceed.

2.6    Of those expressing a preference between the two options, the majority preferred Option B in the long term, though there was some concern about aspects of these proposals. The main opposition, on civil liberty grounds, was to the proposal to detain in civil cases. In part, concerns were based on what we believe are misplaced fears about the nature of the proposals and their scope. It was wrongly suggested that these proposals were about the widespread detention of all those who may have suffered from a personality disorder ­ however mild ­ or whose offending history meant that they may have posed a risk to others at some point in the past. Concerns were also expressed about:

• the absence of dedicated specialist services and fears that any individual detained under new powers would be held in unsuitable conditions;

• our ability ­ with our current knowledge ­ accurately to assess and diagnose such individuals and subsequently to manage them safely in a suitable therapeutic environment which enables them to work towards a successful re-integration into the community.

2.7    However, despite these concerns, it was generally felt that the high quality services required for this group were more likely to be achieved under Option B.

2.8    Respondents welcomed the Government's emphasis on research and in particular the need for further research into risk assessment processes and treatment. There was general support for a multi-disciplinary approach to the assessment and treatment of this group and recognition that specialist training for a multi-disciplinary workforce is essential.

2.9    During the consultation period, we also enlisted the help of 70 experts and practitioners in the mental health and criminal justice systems to examine the practical details of the assessment process that will underpin new arrangements. A key aspect of this work has been the development of an assessment process, which is being piloted in high security settings in both the NHS and the Prison Service. The proposals will also feed into the pilot projects and the research agenda as new services are developed, for example, proposals to ensure that assessment processes are non-discriminatory and take full account of the special needs of those from ethnic minority communities, women, and those suffering from co-existing mental illness or problems relating to drug or alcohol misuse.

2.10    We have taken account of the House of Commons Home Affairs Committee Report published on 14 March 2000, which unanimously supported the proposals, and the views of the Health Select Committee, who published their Report into NHS Mental Health Services on 24 July 2000, as well as the large number of debates and conferences prompted by the proposals.

Cost benefit analysis

2.11    A cost benefit analysis was carried out to model the treatment and detention of those who are dangerous and severely personality disordered under the two options set out in the consultation paper. This analysis provided a very broad indication of the likely scale of costs under both options because of uncertainties about, for example, the numbers of those who will be assessed as being dangerous and severely personality disordered, the effectiveness of treatment and therefore the average length of detention, and the precise number of staff and mix of skills required. In order to refine these costs, further work is therefore required over the piloting period to clarify these issues. This work will form an important part of the research strategy and will be made public when it is available.

The way forward

2.12    The Government has decided that before taking final decisions on how best to provide services for this group in the long term, it needs to pilot and evaluate the assessment process and the various treatments available for this group within existing service structures. At the same time, we will bring forward those legislative changes that will be required whether Option A or Option B is adopted. Our proposals for reform of the Mental Health Act 1983 will provide a new framework of powers which will provide for the detention of dangerous people with severe personality disorder in a therapeutic environment for as long as they pose a risk to others as a result of their mental disorder.

2.13    Because these powers will be based on the presence of a mental disorder new powers for detention will apply to individuals in civil proceedings, as well as to those being sentenced for an offence. But in practice, the nature of the assessment process means that it is highly unlikely that any individual without a long track record of increasingly serious offending will be affected by these new powers. The Government is committed to ensuring that any new powers are fully compatible with the Human Rights Act 1998, and proper safeguards have been developed as part of these proposals.

2.14    Chapters Three and Four of this part of the White Paper describe the new powers in mental health legislation and how they will be applied to the DSPD group. Chapter Six includes a description of how specialist DSPD services will be organised and developed in both the NHS and the prison service over the next three years, in order to ensure that by the end of the period the Government is well placed to take longer term decisions.

2.15    Our proposals set out in this White Paper, and the sequencing of their introduction provide a practical way of making progress on these issues of concern whilst also addressing the fundamental challenge of public protection. This is not a problem which can be solved in its entirety at a stroke. It will require years of research, service development, specialist staff training, work to determine the best possible environmental setting and most effective treatments before we can be sure that we have the most effective services for this group. Indeed we can always improve services and knowledge. But that cannot be a reason to fail now to embark on the process or to take powers which are needed to protect the public.

Managing the programme of change

2.16    These changes cannot be accomplished without the co-operation of a wide group of stakeholders in this process. We have established an inter-departmental programme which brings together officials from the Department of Health, the Prison Service and the Home Office working as part of a single team to co-ordinate every aspect of these changes. Distinct projects have been established to cover:

• treatment and assessment;

• human resources and training;

• construction;

• legislation;

• women's services;

• community services;

• research and development.

    These are underpinned by a communication project and a project to enable proper business planning for the expansion of services.

2.17    These projects also involve a great many external stakeholders but especially managers, clinicians and practitioners in the NHS and the Prison Service, academics and the research community. Many of these are involved in the various project teams and supporting advisory groups. We are committed to working in partnership with these and other groups to ensure that services and powers are developed which can be used effectively on the ground.

Definitions

2.18    It should be stressed that the phrase 'dangerous people with severe personality disorder' is a working definition. It is designed to cover individuals who:

• show significant disorder of personality;

• present a significant risk of causing serious physical or psychological harm from which the victim would find it difficult or impossible to recover, e.g. homicide, rape, arson; and in whom,

• the risk presented appears to be functionally linked to the personality disorder.

    We intend to refine this definition during the pilot period as we develop a clearer picture of the nature and characteristics of this group.