APPENDIX 5
Memorandum by the National Schizophrenia
Fellowship
THE ISSUES
AS NSF SEES
THEM
A. THE CURRENT
SITUATION
1. Individuals who commit a serious offence
and have been imprisoned, can be discharged upon the completion
of their sentence even though their underlying social/psychological/psychiatric
problems are still present and they say that they will repeat
their original offence.
2. Individuals who have an anti-social personality
disorder, who have not committed a crime which would result in
a prison sentence, cannot be held against their will. No support
is currently available for such individuals or their informal
carers in the community.
3. People with a severe mental illness and
an anti-social personality disorder usually end up either in prison,
where there is no effective healthcare, or hospital where there
is no effective security. In both places the individual's behaviour
often has a negative effect on the other prisoners/in-patients.
4. NSF is concerned that there have been
wide-spread failings in the High Secure Units within Special Hospitals
which have been set up specifically to meet the needs of people
with severe anti-social personality disorder.
5. NSF is of the opinion that a risk assessment
is far too inaccurate at present to use as the basis for long-term
decisions regarding care and detention.
B. DSPD & TREATMENT
The label of "Dangerous Severe Personality
Disorder" is new and unresearched. It is not a medical definition
and is therefore within a healthcare framework is inappropriate
as a starting point for research and service development.
6. English prisons currently hold around
1,000 people with an anti-social personality disorder who are
deemed by the Government to be dangerous. Prisons are overcrowded
and often these individuals do not receive "treatment".
7. The early stages of a severe mental illness
(and/or an untreated severe mental illness) can be misunderstood
by clincians and "diagnosed" as an anti-social personality
disorder or DSPD.
NSF has worked with the family of one woman
who was held in a strip cell and then in prison for 11 months
before she was correctly diagnosed as having schizophrenia. She
was prescribed medication, which controlled her symptoms. She
had been thought to have an untreatable severe anti-social personality
disorder.
8. NSF is also aware that psychiatrists
have wrongly "diagnosed" people with a mental illness
as having an untreatable anti-personality disorder. This decision
is sometimes based on a lack of hospital beds and staffing problems
in mental health teams.
C. PRINCIPLES
9. NSF is concerned that in European law
an individual has insufficient protection of their civil liberties
if they are assessed as being of unsound mind.
10. NSF believes society has a duty to care
for its damaged members.
D. STIGMA, MENTAL
ILLNESS AND
DSPD
11. There are many different types of personality
disorder of which anti-social personality disorder is one. It
is the only one clearly associated with dangerous behaviour towards
others although not all people with this diagnosis are dangerous.
However, the use of the term by Government spokespeople and the
media is leading to the impression in the public mind that all
people with a personality disorder are dangerous.
12. If legislation regarding the management
of people with DSPD is joined to legislation regarding the management
of people with a mental illness (ie The Mental Health Act) this
will further cement the link between the two groups of people
in the public mind and have a negative effect on both in terms
of their quality of life and the care that they receive.
E. A WAY FORWARD?
13. There are many health "conditions"
for which there is no "cure" at present and where palliative
care provides some relief from pain or prolongs life for short
periods of time. DSPD, as it has been defined, is such an "illness"
and although there is no cure there are models of support which
provides some relief to the individual and reduce their anti-social
behaviour.
14. To understand these approaches and legislate
accordingly a wider definition of "Treatment" is required
which includes a medical approach, such as medicine and symptom
recognition, but also assesses social, emotional, psychological
and spiritual needs.
15. NSF is conscious of the fact that the
Government's paper and much of the discussion around the issue
so far has omitted reference to women, young people and people
from black and ethnic minorities, who have DSPD. These groups
all present additional needs which would have to be taken into
account for any new service to be successful.
16. NSF believes that the isolation of individuals
with any mental health problem or personality disorder in an institution
miles away from family, friends and their care and support network
has a very negative effect on all concerned. Any set up with just
a few centres would involve individuals being separated from their
local support network.
NSF'S FIVE
POINT PLAN
1. More Research and Development
Focusing especially on psychotherapeutic interventions;
the factors which predice or cause anti-social personality disorder;
risk assessment; and the links with severe mental illness. Evidence
of international experience would be particularly useful.
2. Pilot Separate Service as outlined in
Option B
To test the effectiveness of Option B, a pilot
service should be set up in one of the present special hospitals
or a comparable establishment, and in one of the prisons. Pilots
will allow research to be conducted into the best management approaches
to use including looking at the involvement of all relevant stakeholders.
3. Pilot Community Management Approaches
There is evidence that assertive outreach style
support, with staff who have experience of working with this group
can provide support and minimise risk to a level where detention
is frequently less necessary. It can also provide more security
than is currently available.
4. Changing the Law and/or Practice to allow
renewable detention
For highly dangerous individuals who refuse
offers of treatment and support and have already committed a serious
offence which has resulted in a prison sentence NSF believes that
renewable detention is appropriate. The human rights issues embedded
within renewable detention would, however, need to be comprehensively
examined.
5. Increased provision of, and therefore
access to , an expert second opinion services
Diagnosis and risk assessment are not precise
sciences. A second opinion from an experienced psychiatrist with
appropriate expertise would be likely to result in the most appropriate
service being provided to both minimise risk and maximise an individual's
quality of life. NSF is particularly concerned about people who
are wrongly diagnosed with a personality disorder when they have
a severe mental illness and people who have both diagnoses but
are only receiving support for one. All people considered for
the proposed DSPD system should be assessed by an expert second
opinion service to establish whether they have a treatable condition.
11 October 1999
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