Summary Dangerous and severe personality disorder (DSPD) services have a relatively short history, are currently under review and may be reconfigured in the next few years. Despite such uncertainties, implementation of therapeutic programmes for patients and prisoners in this category is likely to remain a high priority. We describe the background to the DSPD initiative in England and consider issues that arose in planning and delivering treatment services. Two bodies of evidence are particularly relevant: previous research into personality disorder and its treatment, which we suggest is, as yet, of limited value, and research into the outcomes of offender treatment programmes. The latter is clearly relevant but greater consideration of adapting programmes for the patient population and of breadth of treatment is required in the DSPD setting. The important task is to integrate components for the treatment of personality disorder and offending behaviour in a holistic manner. We describe further challenges in delivering treatment and suggest that ongoing evaluation of treatments is critical in this area of practice, given the impoverished knowledge base.
In the past, personality disorder has been the Cinderella of Cinderella health services. Many psychiatrists have considered personality disorder to be untreatable, some doubting the legitimacy of treating it within the health system. The issue of how to treat and manage (predominantly) men with severe personality or psychopathic disorder who also pose a risk to the public has been even more contentious. This latter group was traditionally managed within the criminal justice system, but the problem of defining which agencies should be responsible for them was brought into sharp focus during the acrimonious public debate following the conviction of Michael Stone for the murder of a mother and child in 1998. Although Stone was considered to have a personality disorder, psychiatrists dealing with him did not consider the disorder treatable and hence he could not be detained under the Mental Health Act 1983. In February 1999, the UK Government announced proposals to introduce the Dangerous and Severe Personality Disorder (DSPD) pilot programme, the legal provision for which would be embedded within a new legislative framework.
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