Examination of witnesses (Questions 58
- 79)
TUESDAY 23 NOVEMBER 1999
MR PAUL
FARMER, MR
MIKE TOOK
and MS MARGARET
PEDLER
Mr Corbett: Good morning and thank you for coming
to help us with our inquiry.
Mr Malins
58. Dealing with people with dangerous severe
personality disorder, our papers tell us that the total number
of people involved is about 2,000, of which 98 per cent are men,
with 1,400 roughly in prison, 400 in secure hospitals and, say,
300 to 600 in the community. Can anybody comment on the accuracy
or the probable accuracy of those sort of figures?
(Mr Farmer) I will start perhaps by suggesting that
it is probably as reasonable a set of figures as you can get with
this situation. As we will come on to later, there are some real
difficulties around the nature of diagnosis of severe personality
disorder, but I think insofar as you can put figures on this,
that would be the case. Perhaps a supplementary point to this
would be that whatever the correct figure, if one of the proposals
were put in place, the numbers would almost certainly grow to
meet the size of the institution that may be established to fill
it, if you like, because I think it could very easily become a
convenient label to place some people into, so to some extent
the numbers debate is helpful, but it will not necessarily be
turned into reality.
(Ms Pedler) Can I just add two quick things on the
numbers. I think, if anything, the numbers are probably an underestimate
and in the Ashworth Inquiry report which looked in detail at the
numbers, they came up with a figure of 2,500 just for those in
prison and secure hospitals, leaving out the people in the community
which is higher than the figure in the Government's paper. I think
the reliability of the figures relating to people in the community
is very uncertain. The Government themselves say that there is
no existing research. The other important point, I think, is that
2 per cent of these figures are said to be women and I am very
concerned at the lack of reference in this paper to what will
happen to that 2 per cent of women. Is there to be a separate
system to deal with women? They are almost ignored in the paper
and I assume that the legislation will not just apply to men on
the face of it as that would clearly not be possible, so I think
that is an issue that does need addressing.
59. Again dealing specifically with these people
with dangerous severe personality disorder, the group I am interested
in for the moment are those who are out in the community who have
not committed a criminal offence or perhaps something frightfully
trivial. Do you think there are very many of those who are not
known to the authorities?
(Mr Farmer) It is a small number. It would be very
difficult, I think, to say how many and maybe no more than a couple
per health authority.
(Ms Pedler) I would be surprised myself if the people
who came within the definition that the Government are proposing
had not committed criminal offences and that is why I find it
difficult really to understand the Government's insistence on
keeping within these proposals, people who have not committed
criminal offences, because actually I think if you look at all
the other criteria, then the group that the Government are going
to want to target will have committed a criminal offence.
60. You refer to a couple per health authority
and my problem is for the moment I have forgotten how many health
authorities there are.
(Mr Farmer) That would add up to about 150.[1]
61. So 150 such people. I have taken the philosophical
point of view that if you have not committed a crime in this country,
you should be left alone, that is it. Now, that is my view. What
do you say to that? Do you take a different view, that people
who are potentially or who are very dangerous should have something
done to them if they have not committed a crime?
(Ms Pedler) No, I think this is an area where Mind
certainly has difficulty with the Government's proposals. The
Government say that there is no departure of principle here and
under the Mental Health Act people are detained on the basis of
mental disorder and a risk and that treatability does not apply
to people with a mental illness. I actually think that that is
not the correct statement of the position because the Mental Health
Act does say that if people are detained under the mental illness
diagnosis, it has to be appropriate for them to be detained in
hospital for medical treatment and I think that is the alternative.
Either you detain somebody under a mental disorder label, and
then there is the reciprocity principle and there has to be some
treatment available to the group concerned and that is the sort
of deal, if you like, between society and that group, or you detain
people through the criminal justice system because they have committed
criminal offences and you cannot sort of mix and match the two
in the way these proposals do.
62. If someone has not committed an offence,
would you see any sensible grounds for detaining them?
(Ms Pedler) I do not think there are unless it is
under the Mental Health Act because there is some reason to think
that they need treatment which they are not for some reason prepared
to accept.
63. When you are going to those who are released
from prison, do you think, as a general proposition, that the
quality of aftercare and supervision in this country is currently
strong enough?
(Mr Farmer) People released from prison who have a
personality disorder?
64. Yes.
(Mr Farmer) Almost certainly no. So far as the aftercare
is concerned for most people with a personality disorder discharged
from the criminal justice system or indeed people discharged under
the terms of section 117 of the Mental Health Act, it is often
found to be unsatisfactory.
Mr Malins: Yes, that is my experience too.
Mr Corbett: I was told the other day of somebody
coming out of Ashworth, I think it was, who was simply given a
railway warrant.
Mr Howarth
65. Can I just explore a little bit further
the question of numbers. You have accepted the Government's figure
of approximately 2,000, a ballpark figure. Have you any reason
to believe that that figure has increased in recent years and,
if so, why? Has it remained constant?
(Mr Farmer) I have not got any evidence to suggest
that the figure has increased. However, I think it perhaps is
worth mentioning at this point the very real difficulties around
identifying a diagnosis of severe personality disorder to individuals
and indeed the confusion that that might take place with a diagnosis
of a severe mental illness. If I may, I might give you an example
of that. Somebody who is a user of one of NSF's services was told
he had a severe mental illness and was then shunned by his local
psychiatric hospital having been diagnosed with an "untreatable"
severe personality disorder. His psychiatrist told us as an organisation
to have nothing to do with him because he would eventually be
sent to prison for a long time. Our outreach project took a slightly
different approach to this and offered him quite intensive, but
practical support around accommodation, benefits and meaningful
employment, and this eventually led to him re-establishing relationships
with his family, living in more stable accommodation and actually
talking to the media about his own experiences perhaps to reflect
a more positive image of this issue. I think our view is that
in terms of actually looking at absolute numbers, it is not possible
to do that simply because the diagnoses do vary and people within
the broad spectrum of mental illness and personality disorders
will go through a variety of different diagnoses over a period
of years, so the numbers may go up or down, but whether that actually
identifies the group that this particular inquiry is interested
in I think is another matter.
66. Are there any grounds for believing that
drug abuse can lead to this kind of disorder?
(Mr Farmer) Not on its own. I think there is considerable
discussion around the problems of those people who have what is
called a dual-diagnosis or in this case perhaps multiple needs
where substance abuse is a part of it and there is clearly evidence
around about dangerousness. There is some compelling research
in the United States which suggests that young men who are under
the influence of drugs and alcohol are much more likely to commit
serious offences than those people with a label of mental illness
or personality disorder.
67. I ask for rather a personal reason because
a young man who has now twice thrown a brick through my windows
at home I was told was suffering from schizophrenia induced by
drug abuse and that is why I posed the question.
(Mr Took) If I can just respond to that, I think if
someone has a predisposition to schizophrenia, it can be triggered
off by drug abuse. Drug abuse does not necessarily lead to schizophrenia,
so there needs to be a predisposition and a trigger.
(Ms Pedler) I think there is a much more tenuous link
between personality disorder and drug abuse. I think personality
disorder is a developmental condition which starts in childhood
and adolescence. I know that very young children can abuse drugs,
but I do not think there is the same link. They are separate things,
I think.
68. Could you perhaps give us some indication
about the difficulty of diagnosing personality disorder? I understand
that there are apparently nine categories. Can you perhaps run
through that without going into great detail and give us some
idea of the key differences?
(Ms Pedler) Between the different diagnoses of personality
disorder?
69. Yes.
(Ms Pedler) There are about ten diagnoses. There is
anti-social personality disorder which is the one which is referred
to in the Mental Health Act as psychopathic personality disorder
which is the one which is to do with disregarding the rights of
others, aggressiveness, disregard to safety, irresponsibility
and lack of remorse, and I think that is what most people think
of when they think of personality disorder. There are then these
other disorders, such as histrionic personality disorder where
somebody gets very sort of over-excited and over-dramatic about
things, or obsessive compulsive personality disorder where someone
has particular obsessions, say, about washing hands or all those
sorts of issues, and then there are paranoid personality disorders.
There is a whole range of personality disorders and some border-line
personality disorders where somebody is on the border between
personality disorder and neurotic disorder and people in that
group, if they are a risk to anyone, they are a risk to themselves,
not to other people, and the vast majority of people in all these
categories are not a risk to others at all and I think a lot of
them have been very worried by the Government's proposals.
(Mr Farmer) Perhaps it is worth adding to that that
because people who do have the label of personality disorder,
which I think estimates suggest are around 13 per cent of the
population, I think the stigma that this creates around people
who have got a personality disorder who are already very stigmatised
by society as a whole is unhelpful and I think it is instructive
perhaps on all of us to use the appropriate terminology of "severe
personality disorder" rather than the broader term of "personality
disorder" because I do not think it helps people's understanding
of the issue.
70. How many of these forms of disorder would
you say are dangerous? Psychopathic is obviously, but are any
of the other categories or are we dealing with that category only?
(Ms Pedler) I think there may be some people in the
other categories, say, in the category of paranoid personality
disorder and even in other categories the odd person who would
be a risk, but I do not think everybody in the psychopathic category
or the anti-social personality disorder category would also be
dangerous and fall within the Government's proposals, so I do
not think you can just pick out anti-social personality disorder,
although I think the bulk of people would be in that category.
71. What about anti-social personality disorder—is
that the same?
(Ms Pedler) That is the same as psychopathic.
72. That is the same?
(Ms Pedler) Yes, more or less.
73. So this new phrase, and I gather it is a
new phrase, "dangerous severe personality disorder",
do you think that that is a sensible shorthand description of
what we are talking about which is people who are potentially
at risk of committing the most serious offences in society, but
who perhaps have not yet committed those offences?
(Mr Farmer) My understanding of the term is that it
also includes those people who have committed offences as well
and it is not simply restricted to those people who are potential
offenders, but also those people who have already committed offences
and are in either the criminal justice system or in the health
system. It is a new term and I think to some extent it has clouded
the issue because there is not very much research on this term.
My understanding from it is that it is the "severe personality
disorder" which is the term and the "dangerous"
is, if you like, the adjective that is ascribed to individuals
with severe personality disorder. That is certainly the interpretation
we have placed on it.
(Ms Pedler) I think it is unfortunate, the whole term,
because it links severe personality disorder so closely with dangerousness
and I think there will be people who may have a personality disorder
to a severe degree who are not dangerous and I do not think it
makes quite clear that you can separate the term in that way.
It is almost assumed that everybody with a severe personality
disorder is dangerous and it equates in the public's mind the
term "personality disorder" alone with dangerousness
and I think it is unfortunate for that reason.
74. In the evidence which has been given to
us, it is perfectly clear that there is a great deal of disagreement
amongst the professionals as to both what constitutes personality
disorder and indeed how to treat it. Insofar as you do perhaps
represent those people who suffer and indeed their families, do
you think that there is enough research going on in this country
to try to deal with the problem? Do you believe that psychiatrists
and psychologists are making progress? Is there any indication
that there might perhaps be coming some kind of consensus or is
that complete moonshine?
(Ms Pedler) I think there has been some progress.
I think we welcome the Government's commitment to more research
and more resources in this area. The biggest issue that comes
up for us from people with a personality disorder label is their
inability to get access to the system or resources at an early
stage in the process and I think that is well illustrated by the
two examples that are given at the back of the Home Office evidence
to this Committee because actually if you read those, you think,
"Well, why did somebody not do something for these people
earlier who were clearly at great risk and were being let down
from the very beginning?" and those resources are not available.
Within the community, people find that once they get the label
of personality disorder, it is used to exclude them from services.
They go and try and get help from their GP or from specialist
psychiatric services and they are told, "Oh well, you have
not got a mental illness. You've only got a personality disorder
and we don't have any services for people with personality disorders",
so people are just sort of left without support that would enable
them to get off the slippery slope, if you like, and that, I think,
is a very important issue which does need addressing.
(Mr Farmer) In the context of mental health services
in general which are widely recognised to be under-funded, this
is perceived to be a tiny part of those already under-funded services.
75. I was not actually dealing with facilities
because we are going to come on to that, but I am dealing with
the question of research and whether this confusion amongst the
professionals in the field is any nearer being resolved.
(Mr Farmer) I think that the research at the moment
is quite theoretically based and would benefit from more practically-based
research with perhaps full evaluation processes of particular
treatment regimes. I think we will perhaps talk later about the
work that has been done in Grendon which perhaps illustrates what
might be done, but is not being fully evaluated and fully researched
at present. I think there is also need for far greater research
on the issue of risk assessment and also the overlap in the links
between severe mental illnesses and personality disorders. I think,
as far as we are concerned, research to date is not involving
the people who are most affected, namely the users and the carers,
and it seems to be undertaken at a fairly academic level and I
think our experience certainly would be that it would benefit
from more user and carer input.
Mr Fabricant
76. A constant thread running through the evidence
received from both yourselves and previous witnesses is that the
assessment of risk is not a science at all and that there is considerable
variability between the ability actually to diagnose a psychopathic
disorder, let alone actually make the prediction as to somebody's
behaviour arising from that possible psychopathic disorder. Nevertheless,
the Government also recognises that and they have set up three
working groups. In a note the Home Office have sent to us about
their three working groups, they say, "There is every reason
to believe that the processes will be at least as good",
this is diagnosis, "as those which operate at the moment",
and then they go on to say, very upbeat, that there is much reason
for "optimism that they will be better". Do you share
that optimism?
(Mr Farmer) It is a bit hard to say when we have not
seen the research on which it is based.
77. The Home Office has not seen it yet; they
have only just started the working groups.
(Mr Farmer) I think if one is looking at paragraph
34 of the Home Office's submission to this Committee, it appears
to identify a number of criteria and one of the points made by
your earlier witnesses around the notion of being unmarried as
one of those criteria, I think, struck all of us as being strange.
78. May I declare a personal interest in that
criterion!
(Mr Farmer) Certainly from NSF's perspective, our
assessment of the criteria that are being put forward is that
if somebody has scored a six or more out of the factors which
are highlighted, they would almost certainly already be in contact
with the criminal justice system and probably be within a criminal
justice system institution already, so I think we are slightly
concerned about it, what the criteria are that are being used
for assessing the risk of these individuals.
(Ms Pedler) I think it is a shame that the Government
have not been able to share their research on risk assessment
and develop the risk assessment tools before they issue these
proposals because they say that these are the crucial element
of the proposals and I do not think we have seen the evidence
to be satisfied. However, if they are saying, "Well, this
will be as good as existing risk assessment tools", existing
risk assessment tools are still going to give you a lot of false
positives. I notice that in the Home Office's evidence, they talked
about the confidential inquiry into suicide and homicide and said
that 9 per cent of the homicides were people who had a diagnosis
of personality disorder and that, therefore, people should be
able to be detained before committing offences when the threat
was clear and obvious, but if you look at the section of the confidential
inquiry which deals with risk assessment, what they say is that
if you look at those homicides, at the last contact in those homicides
none of the people was estimated to be of high risk and 94 per
cent of them were estimated to be of low risk or no risk and 6
per cent of moderate risk, so if that is the sort of ability they
are going to have to match up the risk assessment with the people
who are really going to go on and commit further offences, then
it seems to me that is not adequate.
79. Although one could argue then that Liberty's
and Justice's concerns would, therefore, be met, that nobody has
actually been diagnosed as high risk and then not committed a
crime. However, let me go on to something else with regard to
the analysis of risk. Generally it is perceived that the past
behaviour is the best way to determine what future behaviour may
be like. Do you anticipate that evidence may be made available
that someone is of high risk when previously they have not committed
a crime or attempted to commit a crime where there is no past
behaviour?
(Mr Farmer) Again referring back to what the Home
Office are suggesting, it would appear not. It would appear that
those people who are being identified are people who have already
had some sort of interface with the criminal justice system, maybe
not necessarily on a high level, but on a lower level, and I think
Margaret makes a very important point about their contact with
services whilst under the age of 18, perhaps contact with child
and adolescent services, plus contact almost certainly with social
services, so I think it is unlikely that under these proposals
people would be, if you like, plucked from nowhere and placed
in the sort of units that are being suggested. My understanding
of the attempt by the Home Office to address this problem, which
is a real problem, is that there are known to be people within
the community who are considered to be a risk and I think some
professionals particularly feel helpless about how they can actually
ensure that that person has some form of treatment or some sort
of support or care.
(Ms Pedler) There will also be people within the community
who are assessed as a high risk on the basis of past behaviour,
but who do not happen to have a diagnosis of severe personality
disorder and who will be left within the community until they
commit offences. I was thinking, for example, of Robert Oliver
and Sidney Cooke and I am not at all clear that they would be
caught by these proposals because the Mental Health Act is very
clear that just having a difference about our sexual preferences
does not count as a mental disorder, so they would be outside
this, and there would be people like that who presented as high,
if not higher, a risk than the people within these proposals who
were left untouched by them because of the concentration on diagnosis
rather than risk alone.
1 1Note by witness: There are 99 Health Authorities
in England and 5 in Wales, so the total figure is around 200. Back
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