APPENDIX 6
Memorandum by the Royal College of Nursing
of the United Kingdom
MANAGING DANGEROUS PEOPLE WITH SEVERE PERSONALITY
DISORDER
PROPOSALS FOR
POLICY DEVELOPMENT
The Royal College of Nursing (RCN) is the UK's
largest professional association and trade union for nurses, with
over 318,000 members, of whom 25,000 are active in our mental
health forums. Most RCN members work in the NHS, with around a
quarter working in the independent sector. The RCN works locally,
nationally and internationally to promote standards of care and
the interests of patients and nurses, and of nursing as a profession.
The RCN is a major contributor to the development of nursing practice,
standards of care and health policy.
The Royal College of Nursing welcomes the opportunity
to present evidence to the Home Affairs Select Committee Enquiry
into the proposals for Managing Dangerous People with Severe Personality
Disorder. Mental health nurses have been advocating the need for
improved therapeutic opportunities and environmental conditions
for people with severe personality disorders. The RCN is eager
to contribute to any developments in this area.
This paper is structured to follow the same
format as the proposals themselves. The RCN is currently carrying
out a consultation of its mental health nursing members to enable
a full response to the proposals by the end of the year. We have
endeavoured in this submission to communicate the views of our
members as fully as possible. However, our consultation process
has yet to be completed.
PART 1—SETTING
THE SCENE
The RCN welcomes the current debate and consultation
regarding Dangerous Severe Personality Disordered individuals.
Mental Health nurses are well aware of the often very high and
serious risks which this group can pose to themselves as individuals,
to other service users, to staff working with them and to the
general public. Part one of the government consultation document
sets out the values and principles which underline the proposals
and highlights weaknesses in the current system—moving away
from the dichotomy of punishment versus treatment towards detention
based on serious risk.
The RCN has concerns that the proposals' focus
on the need to "move on" (ie, the need for change) should
not be to the detriment of patients or prisoners and the staff
working with them. The RCN notes that Article 5 of the European
Convention of Human Rights has been considered. We suggest that
Article 3, which addresses humane conditions and suitable treatments,
should also be taken into account. For patients and prisoners,
regardless of the reasons why they are detained or in care, the
quality of conditions and the environment of care will have a
major impact on their recovery and is likely to have a role in
risk minimisation.
Article 3 therefore should be adhered to, particularly
in the light of the Ashworth Inquiry Report.
PART 2—THE
PROBLEM
1. The RCN has concerns over the use of
the phrase Dangerous Severe Personality Disorder. This phrase
is in danger of perpetuating an area of confusion within the forensic
mental health care system. Is the intention to describe the "criminality"
aspect of severe personality disordered peoples' behaviour, for
example that of sexual predators? If so, would it not be better
to be explicit about this? RCN members have expressed concern
that the forensic (and wider) mental health field is fraught with
muddled conceptualisation. Is not an additional unclear phrase
likely to add theoretical confusion, and therefore confusion about
assessment and intervention? No defintion of "dangerous severe
personality disorder" is actually given. On page 5, a defintion
is given of "severe personality disorder", but the relationship
between severe personality disorder and dangerousness is not identified.
It is also essential that no person is given
a label of DSPD without a formal investigation of any other underlying
psychiatric disorder. This is implicit but not explicit in the
document.
2. The RCN notes that the proposals acknowledge
the challenge posed by this group of people with Personality Disorders.
Security issues are highlighted along with the need for tight
rules of behaviour. The RCN is concerned that individuals rights
to as much freedom of movement as possible is not also mentioned
as an issue in managing this group of people. Nurses want to maximise
individual choice in working with patients and regard it as important
to work towards minimising regimes wherever possible. Obviously,
with this group of people with severe personality disorder, such
decisions about freedom of movement would rightly need to be made
on best possible assessment and evidence (these are addressed
in the document in respect to protection of the public) but nevertheless
this right still does apply.
The RCN makes further submissions on the framework
of compulsion in a separate section below.
6. The proposals report that the number
of women with personality disorders who would be assessed as dangerous
is very low and highlights the need for different service solutions
e.g., women therapists, private areas. The RCN is concerned that
the reality, that services in secure settings for women is sorely
inadequate, will be perpetuated under these prosposals unless
women's needs are made much more explicit. In current forensic
settings in some instances women have been provided with the same
sort of services (if not accommodation) as men who have actually
committed sexual crimes against women. Women's experiences of
secure settings will be different from men's and the manifestation
of their "psychopathic" or "personality" disorder
also differs, as do assessed causes and risks. There needs to
be much more clarity about causes, risks and therapeutic and environmental
needs of the women in secure settings than is envisaged by this
document (this view is also reflected by the MHAC Eight Biennial
Report).
Black and other ethnic minority groups will
also need to have their own assessment, environmental and therapeutic
needs adequatley addressed by any new system.
10-20
The RCN welcomes the acknowledgement that there
is lack of co-ordination and approach in caring for people with
severe personality disorder. There is a need to provide resources
to build evidence and a consistent approach, both in terms of
therapy and security needs. The RCN would want to point out the
extensive experience that mental health nurses have in providing
24 hour care to this group. The RCN is concerned that this experience
and the role of mental health nurses in future developments in
therapeutic models and research is rarely mentioned. It appears
implicit from the document that psychiatrists and psychologists
will have the lead in the assessment and treatments of this group—will
their role include carrying out control and discipline activities?
Nurses' roles need to be more explicitly discussed and their involvement
in developments relating to this group needs to be planned with
nurses to ensure optimum use of nursing skills and their involvement
in training. For example will there be a potential role for mental
health nurses in working with prison staff or probation staff
(in community settings) in the future?
Readers are referred to Annex C in respect of
the knowledge base and evidence relating to causes, assessments
and treatment of severe personality disorders. Annex D highlights
current and future research activity. These provide an up-to-date
summary of current knowledge, state and highlight the role of
risk assessments and security models, in addition to providing
examples of "good practice" and future planning. The
RCN wishes to highlight a number of points relating to annex C
and D.
Firstly, the RCN is keen that social and environmental
factors are attended to with as much vigour as attention to ICD
10 or DSM IV categories—both in terms of their role as casual
factors and in their basis for interaction with mental health
workers, most specifically those nurses who provide 24 hour care.
In the future, emergent and successful models of engagement will
be a combination of appropriate risk assessment and security arrangements
together with individual plans for therapeutic, social and occupational
activities. Getting the balance right for each individual on a
day to day basis, has been the core of mental health nurses role
in working with this client group and it is likely that mental
health nurses will continue this role in some setting in the future.
Nurses need to be central in the development and utilisation of
new assessment and treatment programmes and this includes research
activity.
Secondly, research and evaluation findings will
have likely implications for the care and treatment of the wider
group of people with personality disorder in mainstream settings
and the effectiveness of service models. The RCN prefers to view
personality disorder as a continuum, with a need for greater clarity
of definition of such terms as "dangerous" and "high
risk" as repeatedly alluded to in the document. Greater links
with mainstream services would also help avoid de-motivation in
other settings caring for severe personality disordered people.
PART 3—THE
WAY FORWARD
Framework
3. While the RCN acknowledges the paramount
need for public protection alongside effective services and quality
of experience, there is concern regarding the stigmatising effect
of focusing solely on the "dangerousness" of this group
of people, which could lead to decreasing rehabilitative opportunities.
4 + 5
While the RCN welcomes the new framework proposals
as a means of establishing a comprehensive and ongoing debate
on working with this group of people, it would like to recommend
the addition of a more explicit monitoring system. This would
facilitate objective assessments of the quality and effectiveness
of the framework and services. The RCN would want to raise the
question as to how patients and their carers perspective will
be included in review? Will there be a body with a role similar
to that of the MHAC?
Also, the RCN is concerned that the proposed
framework appears to be based on the view that provision for this
group of persons must inevitably and always be based on compulsion,
not choice. A system which offers help to persons who, as well
as dangerous, are commonly very distressed, need not always be
based on compulsion.
The proposed framework should include provision
of services which might be offered (without compulsion) to potentially
dangerous persons, both in prison and outside, and might be freely
accepted. Maintaining a trusting relationship with patients is
central to a Mental Health nurse's role. Also, the public might
be better protected if the service provided to potentially dangerous
people is one with which they might willingly co-operate.
It is accepted that compulsion will sometimes
be necessary. The RCN's view on the principles which should be
used to decide when compulsion may be used and when it should
not are indicated below.
Principles
8. The government proposals have implications
not only for the management of offenders, before the courts and
in prison, but also for the process of civil sectioning under
the Mental Health legislation. Nevertheless, the statement of
principles in this section of the government paper makes no reference
to fundamental nursing and medical ethics. Nurses have very strict
ethical standards which guide the circumstances in which they
might impose treatment on patients against their will. As a matter
of ethics, nurses will not impose treatment against the patient's
will unless the patient will benefit from the treatment. Also,
compulsory nursing care is only justified if the patient lacks
"insight" and is not capable of a valid consent. As
a matter of ethics, nurses do not seek to make decisions about
the care of patients who are mentally capable of making such decisions
themselves.
The RCN supports the involvement of nurses in
providing help to offenders in custody. The RCN believes that
there is an urgent need that suitable help should be offered,
and that nurses have an important role to play. Also, Mental Health
Nurses have skills in the management of difficult behaviour, and
their skills could be used to help provide a humane environment
to personality disordered people who need to be confined because
of the serious offences which they have committed.
However, the government proposals are not confined
to offenders. They appear to open the possibility of compulsory
medical confinement, irrespective of whether offences have been
committed or not, irrespective of the mental capacity of the patient,
and irrespective of whether the patient will benefit or not. The
RCN believes that this is an unprincipled proposal, and that it
ignores fundamental medical and nursing ethics.
The RCN would not necessarily object to an extension
of the circumstances in which personality disordered people can
be sectioned under civil procedures, provided that the criteria
for sectioning is in accordance with nursing ethics. The criteria
for sectioning are considered further below.
The RCN would also argue, as a matter of principle,
that any health service should attempt to incorporate patients
and their carers' views into service developments. The RCN would
wish this activity to be included as a principle in the management
of dangerous people with severe personality disorders. Will research
be funded and carried out to identify models for effectively enabling
user/carer feedback?
9 + 10
RCN members have expressed concerns over the
potential manipulation of assessment pathways. There may be a
danger that all those people with a history of violence will be
pushed in the direction of specialist assessment. It is possible
that "difficult to manage" patients and prisoners will
be referred by under-resourced and an "at-a-loss" mainstream
service. This view is linked to our concern over definitions and
boundaries relating to dangerousness and severe personality disorder.
Is there a danger that a new service will be swamped without having
developed sensitive assessment tools and adequate staffing mix
and skills? There is also concern that, regardless of which Option
is adopted, that clear management strategies and co-ordination
guidelines are developed to manage the potentially complex sources
of referral.
11. The RCN welcomes the acknowledgement that
there is a need to develop robust risk assessment procedures and
tools. The RCN is concerned however that there is a danger of
patients and prisoners having a label of dangerous bestowed upon
them from which they cannot be removed. The most effective assessments
in predicting future risk are actuarial based on historical factors
(eg sex, age, history of offending). Therefore once someone is
assessed and identified as meeting a certain score (eg PCLR) it
will be very difficult to reduce such a score. There is concern
that there also needs to be research which does not solely focus
on actuarial measures for predicting future risks but also allows
for dynamic factors within those actuarial measures which can
be manipulated to reduce risk factors. Otherwise, there is a risk
that people who are "dangerous" will be locked up without
any expectation of change.
12. The RCN welcomes the acknowledgement of
the need for a transitional phase, believing that the management
of this phase is crucial to the success of the improvement of
services for this group of patients and prisoners.
The Options
The RCN is currently co-ordinating a wide-ranging
consultation of its mental health nurses to provide a full response
to the government on the proposals for people with dangerous severe
personality disorder. The RCN represents a wide range of mental
health nurses' views, working in a diversity of clinical settings.
It is evident from the initial flow of views from members that
there is a diversity of views regarding acceptable options, with
an equally diverse range of rationales for the choices taken.
The RCN does not feel it is in a position currently
to fully represent is members' views on a preferred option but
can present the questions and issues already highlighted by its
members in a more general way.
Option A—criminal justice legislation
The RCN believes that full and rigorous information
is vital to the correct "disposal" of a dangerous offender
suffering from a mental disorder. This principle would also apply
whether or not a person was deemed as having a severe personality
disorder or not. In any case the skills and knowledge of person(s)
who carry out assessment and co-ordination and present information
to a court will be crucial to the necessary information reaching
the people who need it and in the correct and understandable format.
Advice to courts and the understanding of judges and magistrates
is crucial. It would be important to explore this in more detail.
Will the period of assessment be determined
by the courts?
The proposals suggest that improved quality
of evidence of risk of serious re-offending associated with severe
personality disorder may change sentencing practice. If mental
health nurses are involved in making assessments in this respect,
arrangements would need to be made to provide time and resources
to do this.
One concern with this option is that it may
amount to "tinkering" with existing services to get
a "fit" to what is deemed good practice, this could
be to the detriment of patients and staff.
Option A—proceedings in civil legislation
Under section 3 of the Mental Health Act, a
patient or prisoner may not be compulsorily admitted to hospital
for treatment of a "psychopathic disorder" unless compulsory
treatment "is likely to alleviate or prevent a deterioration
of his condition". This condition for sectioning is very
hard to satisfy and has caused problems. However, the RCN would
not support simply removing this requirement, without other clarification
to the critieria for sectioning.
In its recent consultations, the Mental Health
Act Scoping Review Team suggested that the basic criteria for
compulsory mental health treatment should be a test of mental
capacity. The RCN supports this proposal so long as the test is
robust. A test of capacity is in accordance with fundamental medical
and nursing ethics, as indicated above.
There are particular difficulties with the assessment
of the mental capacity of a person whose underlying problem is
a personality disorder. A personality disorder does not, in itself,
cause any disturbance of mental capacity. However, the capacity
of people with personality disorders often is impaired, eg by
chaotic substance misuse, by associated anxiety and depression,
or by other emotions (anger, sexual desire) which the person cannot
control. The RCN would support the development of a principled
and robust set of criteria for the assessment of the mental capacity
of personality disordered persons. We would wish to be consulted
further as to the development and detail of such criteria. We
are, however, extremely concerned that there should be adequate
safeguards, since any provision for the compulsory detention of
persons because of their personalities has terrible potential
for abuse.
Option B
Under this option there would be separate specialist
facilities for personality disordered persons who have been assessed
as dangerous.
The RCN is concerned that there may be a danger
of a "split" service with the risk of isolation and
stagnation.
The proposals acknowledge the complexity of
providing a separate service which could provide for the wide
range of patients and prisoners who might be described as having
a personality disorder and be assessed as dangerous. Ultimately
this type of separate service could be very difficult to manage
in terms of placing people appropriately or transferring people
to and from mainstream prison and health services following assessment
or review. The RCN would not want to see such a system rushed
through without clarity of approach and perhaps a trial period
with acompanying evaluations.
Would offenders be kept separate from other
people who are deemed to need this service?
Would only some people be offered therapy? Would
there be a mini prison and a mini hospital on the same site? Would
the staffing be different? What about security needs and enabling
service users to "take risks" as part of a therapeutic
approach?
What sorts of numbers of staff are likely to
want to move to work in new specialist facility?
Option B—proceedings in criminal legislation
These proposals broadly follow the proposals
of the Butler Committee Report of 1975 and the recent Fallon Inquiry
Report. We are not hostile to these proposals but would wish to
be consulted further about the details. We would emphasise the
need for adequate safeguards, as indicated in the Butler Committee
Report.
Option B—proceedings in civil legislation
The RCN's views on the criteria for sectioning
of non-offenders are set out above.
Preventative detention—general comments
The Government proposals, clearly and explicitly,
recommend a system of preventative detention, (ie, internment).
It is explicityly recommended that people might be compulsorily
detained, not on the grounds of offences they have committed,
but on the grounds that they might commit offences in the future.
The RCN is very uneasy about this proposal,
especially since it is suggested that the procedures of Mental
Health sectioning should be used to impose this preventative detention.
The procedures for mental health sectioning were designed as a
therapeutic tool and should be therapeutically led.
However, the RCN does support the view, expressed
in the Clunis Report and elsewhere, that people who commit serious
violent or sexual offences should come before the criminal courts,
even if they are already receiving treatment for a mental disorder,
so that the courts can decide the most suitable disposal. Mental
Health professionals have attempted to put this proposal into
effect, with the full support of the RCN.
ADDITIONAL COMMENTS
In relation to both the options RCN would like
to highlight a number of additional concerns:
— the need to adequately manage the
transition phase to ensure continued support for existing patients
and staff;
— that clear definitions regarding
dangerousness, high risk and severe personality disorder are agreed;
— that robust risk assessments are
developed with nurses involved in their development particularly
if nurses are to be involved in carrying out risk assessments;
— recruitment to new services or to
support service developments will have an impact on mainstream
services;
— mental health nurses have caring
and therapeutic principles at the centre of their role. There
is serious concern that nurses will be asked to work in a way
which is contrary to these principles;
— nurses are involved in the 24 hour
care of people with dangerous severe personality disorder. The
RCN would want to see mental health nurses involved in any research
or evaluation activity taking their expertise into account;
— training staff to carry out assessments
and provide appropriate interventions for this group will require
forward planning and a role for education establishments/training
departments. The RCN is concerned about the readiness for this.
Royal College of Nursing, 1999
October 1999
References
Mental Health Act Commission, Eighth Biennial
Report.
The Clunis Report.
Committee on Mentally Abnormal Offenders (1975)—Report,
Home Office.
Department of Health and Social Security. Cmnd
6244. HMSO London (Chairman: Lord Butler of Saffron Waldon KG).
EXECUTIVE SUMMARY
Definitions
The RCN has concerns over the use of the phrase
Dangerous Severe Personality Disorder. Is the intention to describe
the "criminality" aspects of severe personality disordered
peoples' behaviour, for example that of sexual predators? If so,
would it not be better to be explicit about this? The mental health
field is fraught with muddled conceptualisation, and is not an
additional unclear phrase likely to add theoretical confusion,
and therefore confusion about assessment and intervention? The
relationship between severe personality disorder and dangerousness
is not identified in the document. In addition, the RCN is concerned
that there is a danger of patients and prisoners having a label
of dangerous bestowed upon them from which they cannot be removed.
Individual choice and compulsion
Nurses want to maximise individual choice in
working with patients and regard it as important to work towards
minimising regimes wherever possible. The RCN accepts that compulsion
will sometimes be necessary, but would emphasise that the proposed
framework should include provision of services which might be
offered to potentially dangerous persons, both in prison and outside,
on the basis that they might be accepted freely.
Services for women
The RCN is concerned that inadequate services
for women be perpetuated under the proposals unless women's needs
are made much more explicit. Women's experiences are different
from men's and the manifestation of their "psychopathic"
or "personality" disorder also differs, as are assessed
causes and risks. There needs to be much more clarity about the
needs of women in secure settings than is envisaged by this document
(this view is also reflected by the MHAC Eighth Biennial Report).
The role of nurses
The RCN is concerned that nurses' experiences
and their future role in therapeutic models and research are rarely
mentioned. It appears implicit from the document that psychiatrists
and psychologists will have the lead in the assessment and treatments
of this group—will their role include carrying out control
and discipline activities? Nurses' roles need to be more explicitly
discussed.
Nursing ethics
The Government document includes a statement
of principles, but this statement makes no reference to nursing
and medical ethics. The proposals relate to a group of people
with serious mental health problems and propose to make use of
procedures under the Mental Health Act. Nurses will be expected
to work within the framework provided by these proposals. It is
essential that the Ethics of our profession are respected. As
a matter of ethics, nurses will not impose treatment against the
patient's will unless the patient will benefit from the treatment.
Also, compulsory nursing care is only jusified if the patient
lacks "insight" and is not capable of a valid consent.
As a matter of ethics, nurses do not seek to make decisions about
the care of patients who are mentally capable of making such decisions
themselves. We would expect the proposed framework to take account
of this.
Mental Capacity
For these reasons we would emphasise that the
main criterion for civil sectioning should be a Capacity Test.
This is already proposed by the Mental Health Act Scoping Review.
We acknowledge that there are particular difficulties with the
assessment of capacity for personality disordered patients, because
mental capacity is not usually impaired by the underlying disorder,
but by associated chaotic substance misuse, by associated anxiety
and depression, or by other emotions (anger, sexual desire) which
the person cannot control. The RCN would support the development
of a principled and robust set of criteria for the assessment
of the mental capacity of personality disordered persons.
Preventative detention
Finally, the RCN is very concerned at the proposal
that procedures under the Mental Health Act, which was designed
as a therapeutic tool, should be used for a process of preventative
detention (ie, internment).
However, the RCN does support the view, expressed
in the Clunis Report and elsewhere, that people who commit serious
violent or sexual offences should come before the criminal courts,
even if they are already receiving treatment for a mental disorder,
so that the courts can decide the most suitable course of action.
Mental Health professionals have attempted to put this proposal
into effect, with the full support of the RCN.
Royal College of Nursing
October 1999
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