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http://www.newscientist.com/channel/opinion/mg19425993.900-violent-antisocial-beyond-redemption.html
Research has shown psychopaths don't respond to treatment, and that if anything, they use the treatment to better understand the normal human mind and learn to be more effective psychopaths.Violent, antisocial, beyond redemption?
Exclusive
11 April 2007
NewScientist.com news service
Peter Aldhous
Whether you think of them as mad or bad, they are certainly dangerous to know. All societies contain a few extremely violent individuals, who are either psychopaths or have a related severe personality disorder. With no concern about the harm they inflict, little can be done to change their behaviour, psychiatrists say.
Now the UK government is challenging this dogma in the hope of protecting the public from these highly risky people. It has already altered criminal law to allow certain violent offenders to be given indefinite jail sentences. Over the coming weeks, parliament will debate legislation that could broaden the definition of mental disorders and create powers to detain such people for treatment (see "Doctors or jailers...", below).
Meanwhile, the government is rolling out an unprecedented treatment and research programme aiming to show it is possible to reduce the risks posed by the most dangerous violent offenders. Just like the changes to the law, the "Dangerous People with Severe Personality Disorder" (DSPD) programme is highly controversial. However, even critics concede that it holds the best chance yet of showing whether violent psychopaths can be reformed - and so psychiatrists worldwide will be watching.
Every country faces the dilemma of how to manage violent people with personality disorders, who are resistant to conventional treatments. The UK government's determination to address the issue stems in part from a brutal double murder in 1996, in which Lin Russell and one of her young daughters, Megan, were bludgeoned to death with a hammer. Michael Stone, a violent man with a history of drug abuse, was later convicted. He had been in and out of prison, and also diagnosed with antisocial personality disorder (ASPD), a pervasive disregard for the rights of others. Considered untreatable in hospital, he was left at large.
The case threw a spotlight on personality disorders, one of the most contentious areas of psychiatric medicine. These are enduring patterns of thought and behaviour that deviate markedly from cultural norms. There are many forms, and while most people with a personality disorder are not dangerous, some who - like Stone - are diagnosed with ASPD show a propensity for violence.
ASPD is related to psychopathy, but psychopaths must also exceed a score of 30 in a checklist called the PCL-R. They are rare, making up perhaps 0.5 per cent of the UK population, and are manipulative, lack empathy and disregard social obligations. Yet psychopaths and people with ASPD are not necessarily violent. To muddy the waters still further, the diagnostic criteria for some personality disorders overlap, and people may suffer from several at once.
In deciding which violent offenders to treat under the DSPD programme, UK officials therefore had to devise a complex set of criteria to define exactly what dangerous and severe personality disorder is (see "Defining DSPD"). This definition has come under widespread attack. "It's an amalgam of clinical disorders that makes no sense as a diagnostic category," says Robert Hare of the University of British Columbia in Vancouver, Canada, who devised the PCL-R checklist. In particular, he queries its potential to include people who may neither be psychopaths nor fit a diagnosis of ASPD.
The DSPD criteria also require that an offender's dangerousness is linked to their personality disorder. While it is possible to assess someone's likelihood of committing further violence, attributing this risk to an underlying disorder is difficult, as people can be violent for many reasons. "There is no accepted way of establishing that link," says Jeremy Coid, a forensic psychiatrist at the Wolfson Institute of Preventive Medicine in London.
UK government officials acknowledge the criticisms, but say that treatments are individually tailored, and focus on reducing the risk of reoffending rather than trying to effect a cure. Government officials also say that the difficulty of treating severe personality disorders should not become an excuse for not tackling the problems that they cause.
About 130 people who have committed serious violent offences are enrolled in the DSPD programme, which is based in specialist units at two prisons and two secure hospitals. It should eventually include 300 subjects, and the programme's success will be evaluated by a team led by Tom Burns and Jenny Yiend of the University of Oxford. They will examine subjects' attitudes, emotional regulation, and other factors that can vary with treatment, to estimate the risk of further violent offences. Burns and Yiend expect to have initial results by 2009.
One DSPD treatment project in particular, which specifically focuses on psychopaths, is attracting interest from forensic psychiatrists. Psychopaths at a specialist unit within Frankland prison in Durham, UK, are being subjected to the most intensive treatment plan yet devised. Known as Chromis, it employs individual and group therapy to try to shift ingrained patterns of thought and behaviour. Rather than just relying on short sessions of therapy, it recruits the entire staff of the unit to turn prisoners' lives into a continuous exercise in cognitive-behavioural therapy.
Chromis pays particular attention to engaging psychopaths by identifying things they want from life that might be obtained by taking part. This focus on "what's in it for me" may be vital, because psychopaths typically see no problem with their behaviour. "Most of the time they just refuse treatment," explains Sheilagh Hodgins, head of forensic mental health science at the Institute of Psychiatry in London. "If they do take part, they tend to take over and disrupt it."
Although still in its pilot stages, psychiatrists familiar with Chromis say that no other project has a better chance of challenging the notion that violent psychopaths are beyond help. "If, with the resources they're throwing at it, they don't get a change, it will be very discouraging," says Hodgins.
Defining DSPD
Offenders are eligible for treatment under the UK's DSPD programme if they are deemed more likely than not to commit a future offence that could cause serious harm from which a victim would find it difficult or impossible to recover. They must have a severe personality disorder, and there must be a link between that disorder and the risk of violent offending. "Dangerous and severe personality disorder" is:
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A score of 30 or above on PCL-R, the checklist used to assess psychopathy.
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A PCL-R score of 25 to 29, plus diagnosis of at least one personality disorder other than antisocial personality disorder.
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Two or more personality disorders.
Doctors or jailers...
In 1999, the UK government released a consultation document that had civil liberties campaigners and psychiatrists up in arms. "Managing Dangerous People with Severe Personality Disorder" proposed using mental health law to detain such people on the grounds of public protection, whether or not they had actually committed a crime.
After years of acrimonious debate, the Mental Health Bill now before parliament has retreated from this goal. Instead it broadens the definition of mental disorder and removes the "treatability" test that would allow psychiatrists to detain someone only if they were likely to benefit from treatment. In its place is a looser requirement that "appropriate treatment" should be available.
The UK's Mental Health Alliance, which represents 79 organisations, opposes the bill, arguing it could be used to detain a wide variety of people - not just those posing a risk to the public or to themselves. "There is every reason to believe that these new broad powers will also be used on other groups of people for whom detention is not the best option," says Andy Bell, who chairs the alliance.
The House of Lords amended the bill in response to such complaints, but the government intends to push the original version through the House of Commons. "The accusation that... the 'appropriate treatment' test will turn doctors into jailers is nonsense," a Department of Health spokeswoman told New Scientist.
