Kim Work

Personality Disorder
Dangerous and Severe Personality Disorder Program

By [Name]
[Name of the Class]

[Name of the Institute]
[Name of the City]
Abstract
Background: The dangerous and severe personality disorder programme was instigated on
the basis of law and order situation, constructed on the false premises. Aim: To critically
explore the effectiveness and benefits of the DSPD programme. Methodology: Qualitative
approach has been implemented to identify the incentives of the DSPD programme. A
systematic review approach has been further applied to extract studies. 10 studies have been
included on the basis of search strategy process. These studies were selected to provide indepth significance regarding the DSPD programme. Results: The instigation of the DSPD
programme has been effective throughout the handling of PD individuals. The higher costs of
the DSPD programme have restricted to complete the treatment among participants.
Incentives are explored from the DSPD programme in order to identify the BPD and ASPD
behaviours. Conclusion: The presence of personality disorders have been emerged from the
difficult problems of dangerousness. Several different units have been established to provide
treatment to personality disordered individuals.
Keywords: Criminal, Dangerous, Offenders, Personality Disorder, Severe
CHAPTER 1: INTRODUCTION
1.1 Background of the Study
The dangerous and severe personality disorder (DSPD) pilot scheme was instigated
by the Home Office and Department of Health and Government of United Kingdom in 1999.
It was designed to provide a solution to the problems occurred by those individuals having a
personality disorder (PD). The risk was highly associated under the Mental Health Act (2007)
and was nearby the end of or had no custodial tariff. Under the Mental Health Act (1983),
these individuals were classified as untreatable despite presenting as high risk they would
be released back into the community. The Mental Health Act (1983) treatability clause stated
that imprisonment could only be achieved throughout the hospital setting in case the
treatment is effective to cure individuals (Tyrer et al 2010; Vollm and Konappa, 2012).
The tragic incidents like the Michel Stone case was believed as the major cause
revealed in the policies of government along with the psychiatric community, which perceive
to avoid the complex subject cluster (Maden 2007). Lin Russell and her 6 years daughter was
attacked and killed by a renowned psychopath, Michael Stone as they walked home. The
eldest daughter was also battered but she survived, the familys pet dog was also killed. The
Michael Stone case contributed to the development of the Dangerous and Severe Personality
Disorder (DSPD) program combined with the Mental Health Act and the development of four
specialist units. The existing frameworks were constructed within the two units of the prison
system at Frankland and Whitemoor. The other two were developed within the National
Health Service at Rampton and Broadmoor (Tyrer et al 2010).
The DSPD program at the Peak offered 12 therapies where Dialectical Behavioural
Therapy aimed to reduce violent behaviour and self-harm (Linehan 1993). Cognitive
Analytical Therapy was revealed for the development of problem-solving skills and insight
(Ryle 1997). Other existing therapies were also accessible for targeting criminogenic needs
including sex offender program and substance misuse program (Hogue et al., 2007). By each
unit having the ability to function autonomously, therapies have been designed and developed
to treat Personality Disorder. Duggan et al (2007) identified over ten different therapies and
interventions from the analysis of 27 random controlled trials. Most commonly utilised
therapies were Cognitive Analytical Therapy, Dialectical Behavioural Therapy and
psychoanalytical based therapies. These were often used alongside pharmacological
interventions.
Offenders and patients discovered with Borderline Personality Disorder responded
better to Dialectical Behaviour Therapy. Offenders and patients discovered with Antisocial
Personality Disorder responded better to Cognitive Behavioural Therapy. Individuals
diagnosed with Avoidant Personality Disorder or Mixed Personality Disorders responded
better to psychodynamic based therapies (Vollm and Konappa 2012).
1.2 Problem Statement
The extent of personality disorder has been accounted around 78% among male
remand and 64% among male sentenced prisoners in the prison population of United
Kingdom. In western countries, the prevalence rate of personality disorder is reported to be
65% of the entire offenders in prisons having mental disorders. However, the functional
association between offending behaviour and personality disorder is not apparently observed
throughout the course (Scott, 2014). A complex pattern of ingrained psychological traits is
constructed within the personality. Personality is recognized to be in the disordered state
when traits causing significant harm persistently illustrating inflexible and maladaptive
symptoms. The international classification of diseases 10 (ICD-10) and the diagnostic and
statistical manual of mental disorders IV-TR (DSM-IV-TR) are the major diagnostic
evaluation systems, identifying the extent of personality disorders (Kohut, 2013).
The biological, psychological and social factors creation is fundamental in the

progression of personality disorders. Different temperaments and inherited elements augment
the vulnerability of an individual to construct disordered personality considering the
biological argument (Howard, 2015). The diagnosis of personality disease is potentially to be
observed among those individuals experiencing child abuse and neglect. Individuals
personality functioning is affected from the adverse experiences in childhood showing
exposure or maltreatment. Higher extent of personality disorders have been reported in
prisons even though envelopment in criminal behaviour is not predicted through the diagnosis
of personality disorders (Clark, 2014). Thereby, the extensive rates of serious crimes might be
observed from the offenders with a personality disease. The perceived failures of mental
health services have been overwhelmed from the developments in probation, prison and
psychiatric services. The main notion behind these progressions was to endow supervision,
treatment and effective support to PD offenders (Scally, 2016).
1.3 Aims and Objectives
The study aimed to critically identify the efficacy and incentives of the DSPD
programme. Following objectives have been devised to further extend the significance of
research.
1.3.1 Objectives
To comprehend the literature review in regards to the DSPD programme

To examine the incentives and effectiveness in terms of costs of DSPD
programme
To discover and evaluate the challenges experienced in the DSPD programme
To discover unconventional initiatives and programmes for personality
disorder
1.3.2 Research Questions
What are the benefits of the DSPD programme for individuals experiencing
personality disorders?
What are the challenges of the DSPD programme in therapeutic and forensic services?
What are the initiatives and alternative programmes for personality disorder?
1.4 Significance of the Study

The development of the DSPD programme has made significant enhancement to
examine the prevalence of antisocial personality disorder. The entire focus of progressing the
DSPD programme was to provide accessibility to the DSPD units involving secure care and
high security for individuals (OLoughlin, 2014). Thereby, the clinical needs and definitions
were being the major focus of DSPD programme. The effectiveness of clinical progressions
has been dependent on the basis of service developments in order to acquire behaviours,
lifestyles and traits of certain masses. Eagerness has been demonstrated to prevent severe
personality disorder within the DSPD consultation programme to tackle the roots of criminal,
dangerous, and adult antisocial behaviour (Sinclair et al., 2012).
Personality disorders have been followed with management of dangerous offenders
through numerous pathways in the United Kingdom. These managements have expanded
from the treatments and initiatives controlled by numerous philosophies and service users. It
has been observed that the expansion of new treatments and buildings added significant
investment in the DSPD programme (Bowen, 2013). Different aspects of the programme
have been evaluated from the consumption of approximately 10 million on DSPD
initiatives. Considerations about the personality disorder treatability have become
progressively essential in the DSPD programme (Freestone et al., 2013). The proficient
instigation of initiatives concerning the treatability of PD has been sighted into new units
including Nottingham Personality Disorder Institute and British and Irish Group for the Study
of Personality Disorder (BIGSPD). These centres have progressively expanded the clinical
manifestations in the development, treatment and aetiology of PD. Thereby, the demanding
features of the DSPD initiatives have ensured the practices and services of mental health
practitioners for the therapeutic regime and public protection (Vllm and Konappa, 2012).
CHAPTER 2: LITERATURE REVIEW

2.1 Legal Controversies of Personality Disorder
In accordance to the DSM-IV-TR, personality disorder (PD) is regarded as the
continuous trends of inner behaviour and experience, deviating from the anticipations of
culture of an individual. However, it is inflexible and pervasive that causes the way towards
the suffering or deficiency (Gilbert et al., 2015). Anti-social personality disorder (ASPD) has
been occurred among 47% of male prisoners in the United Kingdom whereas 21% female
prisoners have been attributed with ASPD and 25% with border-line personality disorder
(BPD) (Cloninger and Svrakic, 2016). It has been adhered that uncontrolled disregard for the
safety, lack of remorse and impulsiveness are the major causes in the failure of ASPD
towards social norms. The intense interpersonal relationships and chronic feelings of
emptiness are associated with the distinctive aspects of BPD in order to avoid relinquishment.
Thereby, criminal behaviours are incorporated in both disorders and diagnostic criteria as
well as higher extent of BPD and ASPD are revealed in prison masses (Draycott, Kirkpatrick
and Askari, 2012).
It has been examined that there are rare evidence exist regarding the treatment of BPD
and ASPD. Furthermore, the use of pharmacological and psychological interventions
incorporated with ASPD is not extensively evident. Prior studies have stated that there is
nearby association between diagnosis of personality disorder and childhood abuse (Stoffers et
al., 2012; Tyrer et al., 2014). The prevalence of borderline personality disorder diagnosis has
been emerged among 81% women with 69% sexually abused and 60% reporting domestic
violence. According to the study, the prevalence rate of BPD emerged among 15.2%
individuals, witnessing suicidal behaviour. It has been adhered that diagnosis of PD is
reported from the particular types of stress and vulnerability (Howard et al., 2012). The need
for self-protection from psychological distress has been mediated with the temperament-
related emotions and behaviours. Impulsive responses, aggression, and low mood influence
are entailed in these emotions and behaviours. According to the study, numerous forms of
personality pathology are indirectly interlinked with the attachment patterns, illustrating as
the psychiatric practise. Thus, the instigation of DSPD programme was to examine the effects
of treatment on the population witnessing personality disorders (Bateman, Bolton and
Fonagy, 2013).
2.2 Cost-Effectiveness of DSPD Programme
The confinement, punishment and behaviour of dangerous individuals having
personality disorders have been concerned regarding the mental health systems and criminal
justice systems. The existed arguments about the detention of such prisoners have been
persistent along with the treatment they received in the hospitals (Barrett and Byford, 2012).
Substantial costs have been consumed on dangerous severe personality disorder programme
for the individuals having personality disorders in the United Kingdom. The ultimate aim of
the DSPD programme has been impartial within highly secure hospitals and deployed an
assortment of therapeutic approaches such as dialectical behaviour therapy and behavioural
therapy. The major focus of these services was to encourage the modifications and to
eradicate the threats of serious tendency (Bennett and Hunter, 2016).
The announced policy of DSPD programme by the government has funded 22
million to refurbish the HMP Whitemoor units and new units at Broadmoor and HMP
Frankland and Rampton hospitals. The services of DSPD programme was also funded,
providing specialist medium NHS services with a budget of 7 million per year. The
assessment of the DSPD programme witnessed that cost of 3500 has been spent on the
prisoners having personality disorders as compared to control prisoners over the period of six
months (Gask, Evans and Kessler, 2013). Manifold studies have undertaken the costs and
incentives of DSPD intervention programs for same masses. The study constructed a model
10
for the evaluation of Massachusetts treatment centre among violent sex offenders. It has been
examined that monetary incentives are deemed essential for the improvement of sex
offenders. Another study implemented cognitive behavioural treatment programme for
paedophiles within Australian prisons (Yu, Geddes and Fazel, 2012). The findings of the
study have been evident in illustrating the effectiveness of the intervention programme. The
potential costs and incentives of the DSPD programme have been evaluated through a
Markov decision model. The model has revealed that anticipated costs of the programme
progressively augment as compared to the monetary value of the anticipated incentives
(Young et al., 2012).
Figure 1: Structure of the DSPD Programme
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2.3 Cognitive-Behavioural Programmes for Offenders

In the United Kingdom, the offending behaviour programmes have been apparent
throughout the criminal justice system. The programmes of cognitive and behavioural have
been apparently observed in the National Health Service; however, the forensic services of
the cognitive and behavioural programmes are deliberate in the treatment of underlying
disorder (Draycott, Kirkpatrick and Askari, 2012). The prevention of repetition has not been
considered as the initial objective among the services provided by mental health institutes
even though practitioners argued that reoffending endowed best treatment to the mental
health patients. Thereby, cognitive and behavioural programmes are now opted by myriad
forensic services in prisons (Baer et al., 2012).
Scott (2014) has examined 40 studies involving 9454 sexual offenders with at least a
matched and untreated group. The results of the meta-analysis have shown that there is slight
minimization in the reoffending rates of the treated group. The reoffending rates for the
sexual offenders were found to be 12 v. 16% as compared to 26 v. 38% for all offenders in
treated and untreated groups. Furthermore, the scholars have argued that results of the metaanalysis would be far better if existing standards for the offending behaviour included in the
treatment (Scally, 2016; Clark, 2014). The management of sexual offending has been
optimized with the emergence of a deceptively efficient treatment; however, it must be kept
inside the restriction as types of treatment varies for every offender. It is deemed that
accomplishment of the treatment is essential when narrowed to a domestic setting and in the
paucity of personality disorder. In addition, the success of treatment is effective when
offenders lose in terms of self-image, social standing and employment (Howard, 2015).
According to the study, it has been examined that the treatment is more complex to be
treated among destructive offenders as well as strangers with high psychopathy scores
(Sinclair et al., 2012). Thereby, it can be suggested that the purpose of initiative DSPD
programme is not achievable as designed for personality disorder offenders. The results of the
12
Cochrane meta-analysis have been poorly evident due to methodological restriction whereas
the political and institutional pressure was significantly emphasized to ensure the instigation
of DSPD programme. It is likely to assume that the cognitive-behavioural treatment might be
effective in the accomplishment of DSPD programme but further consequences are presumed
(OLoughlin, 2014; Bowen, 2013).
2.4 Challenges in the DSPD Programme
The existence of DPSD programme was specifically recognised as the alternative
approach to deal with the cluster of individuals who were found to be at the restriction among
the criminal and health justice systems. The initiatives of the DSPD programme was
determined to undertake the significant risks of personality disorder individuals and to adhere
the functional link between risks and disordered symptoms (Tyrer, 2013). Theoretical
approaches have been broadly existed to comprehend the causes of personality disorder
encompassing probable theories. According to the study, it has been observed that the
structured assessments are essential for both offending behaviour and personality disorder
components of DSPD. These structured assessments are required to conceal cognitive,
affective, interpersonal, self-regulatory and behavioural dimensions (Bowen, 2013).
The paucity of theories and anticipations throughout the planning and implementation
have been witnessed from the initiative of the DSPD programme. Non-completion and lowengagement in therapeutic programmes are the essential dilemmas occurred in the
rehabilitation and treatment of the offenders (Howard, 2015). The probable outcomes of the
low engagement entails poor institutional support, poor treatment outcomes and eradicated
staff morale. Low responsivity, resistance and low motivation are often utilized to express the
low engagement of the theoretical attempts (Gilbert et al., 2015). However, these terms
constructed problems for the therapeutic programmes and; therefore, the concepts are
incorporated under the term treatment readiness. It has been suggested from the clinical
13
evidence that personality disorder offenders are usually unready for treatment due to their
internal and external characteristics. Thereby, it allows the structured assessment to be
followed from the alterations of readiness in the services of individuals with DSPD (Draycott,
Kirkpatrick and Askari, 2012).
Planning and monitoring, understanding patient perception and the point of referral
are the key aspects on which the clinical evaluation of readiness relied. Self-harm, sexually
abusive behaviour and aggression are the major issues that confront the cohesive and
optimistic therapeutic environment. The accomplishment of therapeutic objectives can be
disturbed from the behaviours of personality disorder individuals (Cloninger and Svrakic,
2016). The fear of victimization can restrict patients to attend programmes and therapeutic
activities. The distraction of patients towards the treatment tasks is observed from the tense
and hostile therapeutic environment as well as to corrode confidence, optimism and
persistence of staff regarding therapeutic activities. A sense of predictability regarding the
environment has been experienced by patients in DSPD units whereas participation is
required to strengthen the therapeutic programmes. Therefore, staff morale and positive
therapeutic environment should be sustained in order to preserve cohesive and optimistic
therapeutic environment (Vllm, and Konappa, 2012).
Tyrer et al (2010) document widespread causes and negative aspects. Many criticisms
were raised including a shortage of professional input throughout the admission criteria
terminology, no apparent dangerousness definitions and the DSPD label utilization. It was
alleged that the DSPD units were used only for warehousing with little treatment to offer.
Howells et al (2011) discussed inaccuracies and misconceptions discovered in the paper. It is
claimed that the DSPD label was used as a diagnosis; therefore, no evidence was found.
Individuals admitted to the DSPD Program did pose a higher risk and displayed Personality
Disorder traits when compared to the non-DSPD groups (Kirkpatrick, Draycott, Freestone et
14
al 2010). The issue regarding lack of treatment is that none of the four DSPD units reached
full capacity until 2009, so due to the lack of trained staff and full quota of patients being
admitted, treatment pathways did not run as planned in the beginning (Howells, et al 2011).
The treatment pathways required a high level of therapeutic input. In this case at least
25 hours of therapeutic activities and interventions was necessary from all of the multidisciplinary team. Interventions and treatment pathways were different in all four units as
autonomy was allowed to each unit to select their own therapies and treatment pathways. This
resulted in a diverse range of therapies available when comparing the four units (Vollm and
Konappa 2012). At Rampton hospital, a difficult individualized treatment pathway is utilized
to approach certain aspects as theses pathways are concerned with the needs of highly
secured environment (Hogue et al., 2007). This approach using a principle can be tailored
through the amalgamation of formal risk evaluation and functional investigation (Howells et
al., 2007).
2.5 Therapeutic Interventions of DSPD Programme
The differences between the diagnoses and responses to therapeutic interventions
were minimal (Weinberg et al., 2006; Davidson et al., 2006). Therefore, no clear answer was
to be found in recommending certain therapies to certain diagnoses. This might be explained
by Personality Disorder symptoms not remaining stable as originally thought before. The
pathological features of Personality Disorder are not constant and more progressively
heterogeneous as compared to prior ones (Ready and Robinson 2008; Roberts, Caspi and
Moffit 2003; Hopwood, Baker & Morey, 2008). This does support the age-related decline of
pathological traits in Personality Disorders. Over a ten-year period, the Personality Disorder
traits were quite stable; however, the Personality Disorder symptoms fluctuated according to
the environment, which further highlighted the level of heterogeneity in the population.
15
Randomised Controlled Trials are considered to be the gold standard in the evaluation
of treatment efficacy. They evaluate the impact of treatment but having an untreated control
group could be considered unethical as a group meeting criteria for a DSPD program being
left untreated could pose serious risk problems to self and others (Draycott, Kirkpatrick and
Askari 2012). The HCR- 20 (Webster et al., 1997) risk measure has been implemented in
studies to establish modifications over time in patients meeting criteria for Personality
Disorder and Dangerous and Severe Personality Disorder (Morrissey, Beeley and Milton
2014). The study demonstrated changes as a result of the treatment so this could be used to
demonstrate treatment efficacy. Vollm and Konappa (2012) conducted a systematic review
relating to the DSPD Program regarding treatment efficacy. Results showed a dearth of
evaluative studies, extensive and empirical research papers. It has been assumed that
treatment pathways and environmental influence were not revealed from the empirical
research papers. Thereby, the assessment of the treatment effectiveness of the DSPD
programme was not adhered through the evidence provided in the studies.
The DSPD pilot is being phased out and it is a question of assessing whether the
DSPD units have been an effective investment in terms of cost. Unfortunately the paucity of
evidence sketches a definitive and complex conclusion. This is perhaps due to the relatively
initial period of the programme as well as the extensive implementation of the evidence;
however, the distinct lack of information raises concern (Vollm and Konappa 2012).
Traditionally a difficult and stigmatized population has enabled the exploration of different
treatments for personality disorders (Tyrer et al 2010). The National Institute for Health and
Clinical Excellence have made recommendations for PD services to be available throughout
the UK. Myriad treatments have been established with a strong evidence foundation, leading
to a positive effect on staff morale with this difficult client group (Bowers, Carr-Walker and
Paton, 2005). The admission criteria for DSPD was not based on strong evidence, however, in
16
the upcoming ICD 11 personality disorder classifications is similar to those used to assess
severity and avoid excessive co morbid traits (Tyrer 2013).
The DSPD population hypothetically illustrates the risk than other populations;
however, the severity is no greater than other individuals with personality disorder. Initially
the majority of referrals to DSPD units were prisoners nearby the end of their sentences,
which claims that the hospitals were simply a place for individuals attributed as having high
risk and released back throughout the population (Howells et al., 2011). The observed
reductions in risk and improvements in mental health have been minimal. Aggressive
behaviour and self-harming was observed to increase in detainees although this may be due to
problems with the management of the detention system. The study highlighted inefficiencies
during admission and assessments leading to substantial delays as there was no clear
pathways to progress was accessible. Furthermore, there was limited time spent in therapy
considering the number of staff available (Draycott, Kirkpatrick and Askari, 2012).
2.6 DSPD Pilot Schemes
The reasons for devising the DSPD pilot schemes remain uncertain but the pertinent
information are the major financial investments and superficial causes of the programme
schemes. However, consideration must be given to the future of the detained population
(Kirkpatrick et al 2010). The study suggests focusing on the initial roots of the pilot that
would be more beneficial to the detained population and also reduce the required financial
investment. Originally the pilot scheme was supposed to be based on the Dutch ter
beschikking stelling (TBS) system. However, the expansion and employment of the system
was completely deviated throughout its instigation. Therefore, the TBS system treated a
similar population for approximately half of the cost of the DSPD pilots and for a longer
period of time.
17
DSPD units usually confront with clear goals for development through the system
while the TBS developed an apparent developed pathway at all levels considering the high
secure care and support for the community. Noticeably, maintaining a strong rehabilitation
ethos, focussing on paid work, regular leave and responsibilities involved in independent
living enabled this progression (Volm and Konappa 2012). The focus of the system would be
shifts to enhance the quality of life instead of treatment in case there is no progression
observed. This is facilitated by focusing on the objectives and apparently eradicating the costs
down to support community. The TBS program still has the problem of identifying the
effective treatment and to prevent the higher expenditure incurred by the DSPD pilot, which
perhaps qualify this system as a future alternative.
The DSPD Programme has been subjected to controversy and contradiction since it
was introduced and continues; however, this program is now decommissioned from the
government. The service was deemed a failure by many institutes because it was classified as
a costly program with limited evidence demonstrating success. This review of papers
available has questioned whether achievements have been acknowledged and failure is a fair
description. Contradiction and debate continues regarding the initial aims for the DSPD
Program. The expected detention time, the suitability of the assessment process, public
protection, effective treatment and reduced risks are the major concerns in the contradiction
and arguments for the DSPD program. In relation to research, there is no argument as to
whether the available studies have been beneficial to the DSPD Programme but initial
proposals highlighted the need for knowledge as to why people develop DSPD and how it
can be prevented and; therefore, information in this area is limited. Staff working in DSPD
units should be studied as participants experienced a high dropout rate. It would be
interesting to explore whether this would still occur that the service is no longer under
scrutiny due to the fear of repercussion.
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CHAPTER 3: METHODOLOGY
3.1 Research Design
Qualitative research approach has been implemented in the study to examine the
effects of dangerous severe personality disorder programme on the individuals experiencing
with these complexities. A systematic literature review has been applied for extracting the
studies regarding the DSPD programme. Systematic review is regarded as the specific
qualitative approach used to recognize and construct the factual information within the
research. As the research setting is based on the mental health units and hospitals; therefore,
the main agenda was to extract studies addressing the implementation of DSPD programme
for the treatment of personality disorder individuals. The data collection, inclusion and
exclusion procedure for the studies were specifically built on the basis of systematic review
approach. The main determination of applying systematic review in qualitative studies was to
diminish biasness and provide readers to evaluate the assumptions of research. This approach
also facilitated other individuals to address the systematic review by incorporating latest
evidence.
3.2 Inclusion and Exclusion Criteria
The articles were selected in the qualitative approach on the basis of inclusion and
exclusion criteria. The inclusion criteria for the study have selected studies with clinical or
semi-structured interviews using explicit criteria to diagnose personality disorders.
Furthermore, case-control and cohort studies were also included in the study determining the
issues of personality disorders behaviours among offenders as compared to control groups.
The inclusion criteria of the study was based upon the full-scale articles addressing the
success of the DSPD programme, challenges in the DSPD programme and therapies and
19
treatment involved in the DSPD programme. Studies approaching cost-effectiveness

techniques were also included in the study.
The exclusion criteria have excluded the studies in case the existence of personality
disorders were evaluated using questionnaires. Moreover, these studies were not included as
they overestimate the prevalence extent on the basis of self-report instruments. The studies
restricted to one type of therapies were also excluded from the selection criteria. Furthermore,
the studies were excluded, which provides no comparison between therapies and treatment
programs. The studies were also excluded as they did not provide information regarding
personality disorders for male offenders.
3.4 Sources and Strategy
The search strategy was devised to acquire the aim and objectives of the research. The
research topic was revolving around the effectiveness of DSPD programme; therefore, all the
sources and search strategy were comprised on the particular study area. The topic DSPD
programme was divided into two parts in accordance to the research questions in the initial
process. Furthermore, these concepts were acquired independently to recognize the core aim
behind the concept of different sources and databases. The concept table was devised for the
extraction of search strategy. The search strategy was based on the keywords extracted from
the topic of the study. The assistance of keywords was successful in obtaining the sources and
applicable studies in accordance to the research question. Moreover, the abstract of selected
studies were explored to formulate the search strategy.
Qualitative and quantitative studies have been examined illustrating the information
about personality disorders. Peer reviewed articles were explored in the context of personality
disorders from Elsevier (January 2013 to December 2016), PubMed (January 2012 to
December 2016) and ScienceDirect (January 2014 to December 2016). Searched studies were
restricted for only selection of English language. The individual database was constructed on
20
the basis of search strategies. Personality disorders, pathology, dysfunction, aggression,

dangerous, offend, criminology and anti-social were the key terms used in the study. 10
articles were included in the qualitative approach after passing the inclusion criteria of
systematic review. Furthermore, those articles were excluded from systematic review, which
contain irrelevant information and poor outcomes. Studies before 2012 were not included in
the systematic review.
3.5 Data Extraction System
In this methodology, the core focus of data extraction system was based on to extract
articles in respect to dangerous severe personality disorder programme. In order to hunt this
approach, data extraction system mainly focused on methodology and findings of the
included studies. Moreover, data extracted studies on the basis of aim and research question
of the study. The selected studies entirely focused on the identification and description of
research questions.
3.6 Quality Appraisal System
Quality appraisal is considered to be the most important component of systematic
review approach. The main focus of quality appraisal system is to evaluate the quality of
studies included in the systematic review approach. In current study, 10 studies have been
selected in the inclusion criteria of systematic review. The quality of these selected studies
were assessed from PEDro scoring scale (poor quality= <3, fair quality= 4-5, high quality6=10) (Elkins, Moseley, Sherrington, et al., 2013, 188-189). The quality of selected studies
was assessed on above mentioned scoring scale. Among selected studies, numbers of studies
were rated on PEDro scoring scale 6-10 due to their high relevancy of findings, quality of the
study and updated references. Moreover, few studies were rated on PEDro scoring scale 4-5
due to their average quality of methodology and findings.
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CHAPTER 4: RESULTS & DISCUSSION

4.1 Systematic Review Results
A systematic review approach has been implemented to critically review the effects of
dangerous severe personality disorder programme on mentally disordered individuals and
offenders. Bennett (2015) has applied psychopathy checklist-revised (PCL-R) to identify the
occurrence of personality disorders in the association of treatment dropout. The findings of
the study did not show any incidence of treatment dropout with the PCL-R scores among the
patients. This might be caused from the higher fluctuations of treatment in the treatment
interventions to utilize personality disordered prisoners throughout the personality disorder
diagnosis. In addition, the narcissistic personality disorder has been anticipated to be revealed
when the extent of such symptoms are considered within the individual traits. It has been
examined that offenders with narcissistic traits did not feel that treatment is effective to
acquire their unique abilities (Bruce et al., 2014). Thereby, strategies have been devised to
capture the abilities or qualities of offenders with a sense of difficulties, a sense of
entitlement and a sense of self-importance. The challenges of narcissistic personality disorder
might be viewed on the abilities of clinicians in order to manage complex presentations and
behaviours (Bennett, 2015).
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Table 1: Systematic Literature Review

Authors
Barrett and Byford
(2012)
Title
Costs and outcomes of an
intervention programme for
offenders with personality
disorders.
Method
The incremental cost of
the DSPD programme has
been determined by using
a Markov decision model.
The purpose was to
determine cost
effectiveness on the basis
of monetary incentives.
Bateman et al (2016)
A randomised controlled trial

of metallization-based
treatment versus structured
clinical management for
patients with comorbid
borderline personality disorder
and antisocial personality
disorder.
To investigate the
mentalization-based
treatment for alleviating
symptoms of anti-social
personality disorder, a
systematic review has
been used to recruit
offenders for the
treatment.
Results
The results have
revealed that costs were
highly consistent with
the intervention
programme. It was
anticipated that cost per
serious offence was
approximately over 2
million. Costeffectiveness
interventions have been
developed from the
prior evidences that
lead to the adjustments
of the programme.
The incentives have
been reported from
mentalization-based
treatment to recognize
the behaviours of
patients along with
ASPD and comorbid
BPD. These incentives
encompasses
enhancement of
psychiatric symptoms,
social adjustment,
Conclusion
Personality disorders
programme was supported
from the effectiveness in
terms of the cost throughout
the intervention programme.
It is deemed that the
monetary values of the
programme are higher as
compared to the incentives
for personality disorder
offenders.
It has been concluded that

the mentalization-based
treatment assumed to be
likelihood treatment to
consider the ASPDassociated behaviours as
compared to treatment
effects and high level
acceptability.
Bennett (2015)
Personality factors related to

treatment discontinuation in a
high secure personality
disorder treatment service.
Psychopathy checklistrevised has been assessed

from the information
acquired from 92 male
offenders. These
offenders were recruited
from the high secure
prison DSPD unit.
Increased treatment
dropout was associated
with the diagnoses of
personality disorder and
PCL-R.
Bruce et al (2014)
Community DSPD pilot

services in South London:
Rates of reconviction and
impact of supported housing
on reducing recidivism.
A cross-sectional cohort
study design has been
utilized to examine the
consequences of 107 high
risk offenders associated
with personality disorder.
interpersonal issues,
negative mood, extent
of suicide attempts,
self-harm, hostility,
minimization of anger
and paranoia.
It has been reported
that treatment dropout
has been comparatively
related with the
diagnosis of narcissistic
personality disorder.
However, PCL-R
scores were not
comparatively
associated with
treatment dropout. The
patterns have been
indicated that observes
the diagnosis of
antisocial personality
disorder as related to
augmented treatment
dropout.
The total sample was
relatively lower as
compared to mean
offender group
reconviction scores
identified (51%). The

treatment disorder is highly
associated with narcissistic
personality disorder to
further explore the
responsivity issues.
The results have concluded

that information of
community supervision and
role of supported housing
must be evaluated in future
studies.
23
Participants were
recruited from the
outpatient department of
housing groups. The
samples were described
through criminal justice,
self-reported and
collateral data.
Howard et al (2012)
Are patients deemed

dangerous and severely
personality
disordereddifferent from other
personality disordered patients
detained in forensic settings?
The psychopathy
checklist-revised (PCLR) was used to detain 38
male prisoners in DSPD
units and 62 male
offenders from
conventional medium
hospital units.
Kouyoumdjian et al
(2015)
A systematic review of
randomized controlled trials of
interventions to improve the
health of persons during
imprisonment and in the year
Systematic review design

has been approached to
recognise the effects of
psychological
interventions for
results of multivariate
analysis have stated
that offenders with
increased support with
housing groups were
potential to reoffend
than the other groups.
Five male offenders
reoffended violently
even though there was
no difference among
groups.
High scores have been
reported on PCL-R
among the DSPD
group. Furthermore,
greater severity and
more convictions have
been indicated in the
DSPD groups.
Interpersonal and
affective features of
psychopathy have been
reflected from the
regression analysis.
There was direct
association of
dialectical behaviour
therapy with clientcentred therapy and
Higher psychopathy scores

have been emerged among
the DSPD group; however,
there was no information
acquired regarding the
personality aspects of
psychopathy.
BPD core pathology has

been associated with the
comparisons of
psychotherapies for the
control groups. Core and
24
after release.
Patel (2015)
Violent thoughts and fantasies

in a high secure mentally
disordered offender group: an
exploratory study.
Rampling et al (2016)
Non-pharmacological
interventions for reducing
aggression and violence in
serious mental illness: A
systematic review and
narrative synthesis.
borderline personality
disorder. MEDLINE,
EMBASE, BIOSIS and
PsycINFO have been
used to extract the data.
transference-focused
therapy with schemafocused therapy. A
moderate statistical
significance has been
found from the effects
of non-comprehensive
intervention
programmes.
A qualitative
The results of the
methodology has been
thematic analysis have
included in the study to
shown that violent
explore violent thoughts
thoughts and fantasies
and fantasies among
were fundamental
mentally disordered
constituent in the
offenders. These
concepts and function
participants were
to sustain the needs of
recruited from the units of individuals. Functional
high secure hospital.
analysis has showed
assorted functions of
VTF including dealing
with provocation and
emotional regulation.
A systematic review for
23 practical
non-pharmacological
interventions and
diverse psychological
intended to diagnosis
intervention studies
were selected including
Seven relevant journals
randomized controlled
along with five online
design. High risk of
associated pathology was

investigated from the results
of non-comprehensive
psychotherapeutic
interventions.
The findings have shown

the need to sustain and
evaluate the experiences
found between violence and
acting to approach violent
activities. A thorough
evaluation has been
emerged for VTF showing
certain illustrations on the
underlying function of VTF.
The findings have revealed

that there was
comprehensive evidence
regarding the nonpharmacological
interventions in order to
reduce the violence
25
databases were used to
extract the data.
Sampson et al (2013)
Cost implications of treatment

noncompletion in a forensic
personality disorder service.
Stoffers et al (2012)
Psychological therapies for
experimental biasness
has been found from
the dialectical
behaviour therapy.
Cognitive behavioural
therapy and modified
reasoning and
rehabilitation have
been found among the
mentally disordered
offenders.
A medium secure hospital 78% costs have been
personality disorder has
highly incurred among
been selected to acquire
non-completers as
the data. A Markov cohort compared to
simulation was used
completers.
along with a probabilistic Furthermore, the results
decision-analytic model.
have indicated that
The anticipated costs
non-completers incur
were examined from the
52000 to the NHS and
potentiality of cost
criminal justice system
differential over the time as compared to
horizon.
treatment completers.
Treatment completion
rates in personality
disorder units might
provide cost savings for
NHS services and
criminal justice system.
A systematic review
The studies extracted
activities. A stronger
evidence base is required to
develop quality RCTs and
long-term consequences.

enhanced strategies for
retention and engagement is
required to accomplish
better cost-effective
outcomes. Routine
monitoring of treatment
must be ensured by
hospitals to better improve
quality of treatments.
The adaptation and
26
people with borderline
randomized controlled
trials have been used to
enhance the health of
prisoners in captivity.
Social science and
biomedical databases
have been searched for
the extraction of 95
studies.
from the databases

have shown the health
risks and interventions
for male offenders in
captivity. Health
service utilization and
enhanced mental health
were examined among
offenders after release
in 59 studies.
implementation of effective
recognized from the studies
in order to enhance the
health of offenders.
27
28
4.2 Discussion
Numerous studies have explored the informed treatment dropouts by observing the
attitudes and tolerance towards the personality disorder diagnosis. These studies have been
fairly supported to comprehend the significance of personality disorders and maintained
involvement of clinicians and offenders towards treatment (Howard et al., 2012;
Kouyoumdjian et al., 2015). The exclusion of treatment dropout from the psychotherapy
treatment programme emphasizes the personality disorders of antisocial personality and
narcissistic personality disorders. It has been explored that attributes of personality disorders
are not associated to the PCL-R scores in order to acquire assorted range of confronting
personality disorder traits. Antisocial personality disorders have been deemed essential for the
personality disorders to be found associated with treatment dropouts. Therefore, the
personality concept of psychopathy is challenged from the particular set of traits (Patel,
2015).
Barrett and Byford, (2012) have examined the cost-effectiveness of the DSPD
programme by approaching decision modelling to consider its effectiveness on the practicable
treatment of personally disordered individuals. The findings have evaluated that there was no
positive and direct link from the cost-effectiveness of the DSPD programme on the
personality disorders offenders. The major cause behind the failure of cost-effectiveness
programme might be linked to the interest that reveals to reduce the serious offence. On the
contrary, anticipated costs have illustrated greater for the costs of the programme as
compared to the monetary value of anticipated incentives (Rampling et al., 2016). It has been
observed that the DSPD programme was effectively executed in the high secure prisons and
hospitals to identify the costs of the programme. Furthermore, greater incentives from the
cost-effective model might be yielded by executing the programme within lower prison areas
(Barrett and Byford, 2012). The seriousness of committed offences by offenders has been
29
revealed from the cost-offset model. Prior researches have argued that incentives can be
greater than costs when low-cost prison is preferred to execute the DSPD programme. The
past evidences have supported the argument, recording the phases of offences with the
association of personality disorders committed on discharge (Stoffers et al., 2012; Sampson et
al., 2013).
The evidence has indicated that the cost-benefit of specialist treatment for personality
disorder offenders have been associated with the findings showing effective implementation
of economic models in several different criminal justice systems. However, eradications in
the costs of intervention groups did not assumed from the intensive and lengthy and
interventions. Thereby, there is a need of establishing cost-effective intervention programme
to investigate the personality disorders in the mainstream prison areas. Bateman et al (2016)
have implemented a randomized control design to evaluate the clinical management of the
patients with Borderline Personality Disorder (BPD) and Antisocial Personality Disorder
(ASPD). The study has evaluated the effects of eradicated symptoms associated to patients
social behaviour along with ASPD and BPD. These symptoms have been compared with the
outpatient structured protocol of equivalent magnitude excluding mentalizing constituents.
The information extracted from the randomized control design has indicated that
mentalization-based treatment provides effective treatment for the individuals with ASPD and
comorbid BPD. Results have indicated that symptoms of hostility, anger and paranoia are
significantly observed among patients with structured clinical management cluster.
Furthermore, impulse control-related issues and extent of suicide occurrences have been
adhered at the end of intervention programme. However, significantly lower occurrences
have been observed among patients with personality disorders from symptoms of self-harm
episodes. The aggressive activities of offenders have been identified from the measures of
30
depressing mood as showing vulnerability to the hallmark of ASPD and BPD (Bateman,
Bolton and Fonagy, 2013).
Significant enhancement and better adjustment have been showed from the
occurrence of personality disorders among mentalization-based treatment. At the end of
treatment, social adjustment, interpersonal issues, and poor general functioning have been
included in the enhanced MBT intervention programme. Sampson et al (2013) have explored
the cost-effective program for non-completion treatment in forensic personality disorder
service. The results of the study have provided in-depth significance regarding the clinical
information extracted from the forensic personality disorder service. It has been observed that
there was slight decrease in the treatment completion extent as compared to the completion
time found in prior studies. 23% personality disorder offenders have been attributed in the
severe or very severe personality disorder cluster. Furthermore, the average cost for
completing the treatment was found to be 499,759 whereas 551,473 was found among noncompleters. Thus, it has been examined that there is potential chances to incur low costs
among completers than the non-completers over 10 years (Cloninger and Svrakic, 2016).
It has been observed in the deterministic results that there is augmentation in the
cumulative costs for both groups; however, this augmentation is revealed at an eradicating
extent. The anticipated difference in costs of DSPD treatment among completers and noncompleters were identified by approaching the decision-analytic modelling methods. The
study has also revealed the outcomes of treatment completion from the modelling techniques
used for personality disorder offenders (Draycott, Kirkpatrick and Askari, 2012). The
probability of the anticipated cost difference is found to be higher among costs of initial
treatment for completers. Therefore, it is assumed that the offenders spent more time with
community and less in hospitals and prisons that complete their treatment as compared to
non-completers. Furthermore, the frequency of non-completers has been augmented since
31
following years in one of the three hospital states. However, there was no causal relationship
found between post-discharge costs and treatment completion. The complete treatment of the
individuals has been revealed from the incentives offered from the services of forensic
personality disorder (Gask, Evans and Kessler, 2013).
Despite having cost-effectiveness and incentives of DSPD programme, there are
several challenges posed in the complex situation in prisons and hospitals. Furthermore,
significantly enhanced treatment is found from the arousal and behavioural dimensions of
anger and paranoia within the treatment group as compared to control groups (Hopwood,
Baker & Morey, 2008). The contemporary issues of anger and behavioural dimensions have
been revealed among personality disorder individuals along with severe mental illness.
Thereby, Stoffers et al (2012) have implemented ADHD intervention programme to address
the problems associated with the personality disorder behaviours of offenders. The findings
have suggested that ADHD is effective in exploring the drop-out treatment of the intervention
program. It is deemed that short-term cognitive skills are more accepted among patients with
personality disorders.
32
CHAPTER 5: CONCLUSIONS
The homicidal occurrence on Mrs Russell and her daughters and public outcry over
the attack have become the cause to construct the DSPD programme. A cynical misuse has
been examined from the services of mental health to improvise public safety agenda from the
initial phases of the development of the DSPD programme. The commitment was supported
from the establishment of the DSPD programme to provide effective and appropriate
facilities to enhance mental health consequences and to ensure optimistic development for
this specific cluster. The DSPD programme is essential in representing the mental health
services for the dangerous and harmful individuals.
The core focus of the dangerous severe personality disorder initiative has been
specifically approached to the concepts of those experiencing mental health services and
criminal justice. Furthermore, the approaches are sustained to conflict the demands of
satisfying public safety and services of mental distress. It has been concluded that the
initiative of DSPD lies in the achievement of both services and public safety. Violent
behaviour is the major concern examined to influence on the outcomes of the DSPD
programme. Thereby, the DSPD initiatives are diverted from the required health needs of
deprived and marginalized cluster.
The complex issues of dangerousness are associated to the mental health in the form
of personality disorders. The instigation of DSPD programme is recognized to be the
effective implementation to focus and resolve these issues. The opportunities have been
developed by the effective treatment services of the DSPD programme for those individuals
who formerly acquired very less attention towards mental health care personality disorder
issues. In the United Kingdom, several different health care units have been constructed
specifically for the treatment of personality disorders individuals. The intervention
33
programmes have been efficient in determining the behavioural patterns of individuals by

utilizing myriad treatment therapies.
The major concern being raised for the DSPD programme is the high-level costs,
which positively restricts the offenders/individuals to approach towards the program. Thus,
individuals satisfaction towards the programme is obstructed through this dilemma. It has
been examined that the DSPD programme will be considered as failure due to its high-level
costs. However, there are several incentives provided by the DSPD initiative, which
consequently encourage the individuals to focus on the suggested therapies. The flexibility of
the DSPD programme has been approached to provide management and assessment
approaches to physicians and individuals. Specific disordered features have been
accomplished by eradicating the personality features in the DSPD programme.
The application of therapeutic services within the DSPD programme might be
effective throughout the mainstream prisons and strategies for individuals having personality
disorders acquiring their needs. The negative consequences might be emerged on the
behavioural outcome in case the concentration of intervention disrupted by approaching the
behaviour and the treatment throughout the individuals. A sense of identity and belonging and
empowerment has been provided by encouraging the DSPD initiative throughout the
treatment services. Thereby, practical implications of the DSPD initiative have reported that
personality disorder offenders might receive appropriate services within the community
model.
34
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Personality Disorder

Dangerous and Severe Personality Disorder Program

[Name of the Class]

The biological, psychological and social factors creation is fundamental in the

To comprehend the literature review in regards to the DSPD programme

1.3.2 Research Questions

1.4 Significance of the Study

CHAPTER 2: LITERATURE REVIEW

Figure 1: Structure of the DSPD Programme

2.3 Cognitive-Behavioural Programmes for Offenders

treatment involved in the DSPD programme. Studies approaching cost-effectiveness

the basis of search strategies. Personality disorders, pathology, dysfunction, aggression,

CHAPTER 4: RESULTS & DISCUSSION

Table 1: Systematic Literature Review

A randomised controlled trial

It has been concluded that

Personality factors related to

Psychopathy checklistrevised has been assessed

Community DSPD pilot

It has been concluded that

The results have concluded

Are patients deemed

Systematic review design

Higher psychopathy scores

BPD core pathology has

Violent thoughts and fantasies

associated pathology was

The findings have shown

The findings have revealed

Cost implications of treatment

Psychological therapies for

It has been concluded that

The adaptation and

from the databases

programmes have been efficient in determining the behavioural patterns of individuals by

systematic review of randomized controlled trials of interventions to improve the

Scott, S. (2014). 13 Contesting Dangerousness, Risk, and Treatability: A Sociological View

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