This is what I have done so far.

It needs rewording a bit from the -------------

as some is text straight from a paper. The referencing has only been jotted down and
not checked .

I have the papers and can send them

I just need in writing a price, how to pay, that you can make this dissertation up to
8000 words, guarantee it will go through a plagiarism program, it will pass and can be
done asap.

If not do I get my money back and can this be in writing.

Sorry for this but I have never relied on anyone before. I have had extenuating
circumstances for the past 2 years and if I do not submit this time am off the course. I

I will ring you at some point today from work

Kim

Next email shows my proposal. The feedback was that there may not be enough words
to cover all points so it needs to be straight to the point. I only want a pass

Individuals diagnosed with a Personality Disorder have always been regarded as

particularly difficult to treat (Maden 2007). Under the Mental Health Act 1998
personality disorder was deemed untreatable until only recently, the treatability clause
that an individual could only be detained within a hospital setting if they would benefit
from the treatment. So regularly individuals with a Personality Disorder were not given
access to treatment and remained in the community unless they had a custodial
sentence, regardless of the risk they posed (Vollm and Konappa 2012).

There are then the tragic incidents like the Michel Stone case which was believed by
many to be the final straw in governmental frustration with the psychiatric community
perceived to be avoiding a difficult patient group (Maden 2007). Michael Stone a known
psychopath attacked and killed Lin Russell and her 6 year old daughter as they walked
home. The eldest daughter who was 9 was also battered and left for dead but she
survived, the family's pet dog was also killed.

The Michael Stone case contributed to the development of the Dangerous and Severe
Personality Disorder (DSPD) program combined with the amendment of the Mental
Health Act and the development of four specialist units. Two of the units were
developed within the existing frameworks of the prison system at Frankland and
Whitemoor. The other two were developed within the National Health Service at
Rampton and Broadmoor (Tyrer et al 2010).

The dangerous and severe personality disorder (DSPD) pilot scheme was a government
initiative introduced in 1999 by the Home Office and Department of Health. It was
designed to provide a solution to the dilemma presented by those individuals diagnosed
as having a personality disorder (PD) that were deemed a high risk yet under the
Mental Health Act (2007) and were nearing the end of or had no custodial tariff.
Because under the Mental Health Act (1983) these individuals were classed as
'untreatable' despite presenting as high risk they would be released back into the
community. The Mental Health Act (1983) treatability clause stated that detention

within a hospital setting could only be achieved if the individual wastreatable (Tyrer et
al 2010) (Vollm and Konappa 2012).

Initially, the government planned to introduce an order allowing judges to detain

individuals on their predicted risk alone irrespective of whether or not they had actually
committed a crime (Vollm and Konappa 2012). This was also to be supported with a
new diagnosis but due to poor evidence (Gunn 2000) (Duggan and Howard 2009) and
the potential misuse of preventative detention (Tyrer et al 2010) (Estman 1999) (Mullen
1999), the government decided to instead amend the mental health act treatability
clause instead. Their plans were integrated into the existing prison and mental health
hospital frameworks and resulted in four units being developed to house individuals now
deemed as DSPD. Funding since the beginning of the pilot has exceeded 200 million
and a further 10 million spent on evaluation now that the pilot has come to an end
(Vollm and Konappa 2012) and (Tyrer et al 2010).

There is no clinical diagnosis of DSPD in the DSM IV or ICD 10. The Home office and
Department of Health stated that for a referral to DSPD an individual would need to
satisfy all three of the following criteria (Tyrer et al 2010) :-

1. They are more likely than not to commit an offence within five years that might be
expected to lead to serious physical or psychological harm from which the victim would
find it difficult or impossible to recover from.

2. They have to have a significant disorder of the personality (a PCL-R score of 30 or 25

and two or more personality disorder diagnosis).

3. The risk they present appears to be fundamentally linked to the significant

personality disorder

Each of the four DSPD units were allowed autonomy in the design and implementation
of their treatment pathways allowing for the development of a range of diverse
approaches. The majority of the treatments are based on cognitive or psychotherapy
similar to those utilised within normal personality disorder settings (Alwin 2006) (Tyrer
et al 2010). A number of specific programs have been developed, such as Wong and
Gordon's violence risk program (Wong and Gordon 2007).

The DSPD program spanned ten years and the focus has been on evaluating whether it
was a successful project or not, however, information is limited. Tyrer et al (2010)
presented a number of perceived strengths and weaknesses on particular areas of the
programme. It was noted that the DSPD program had a number of positive effects such
as the development of a nationwide Personality Disorder Service. There was a positive
shift in staff attitudes, increase in available treatments and a general interest and
investment in a somewhat neglected patient group. Without the development of the
DSPD program none of these changes would have happened.

The DSPD program however was not all positive. Tyrer et al (2010) document an
extensive list of failings and negative aspects. Many criticisms were raised including a
lack of professional input into the terminology of admission criteria, the use of the
DSPD label as a diagnosis, and no clear definitions of dangerousness. It was alleged
that the DSPD units were used only for 'warehousing' with little treatment to offer.

In response to this paper Howells, Jones, Harris, Wong, Daffern et al (2011) discuss
inaccuracies and misconceptions discovered in the paper. An example is where it is
claimed the DSPD label was used as a diagnosis; no evidence of this was found.

Individuals admitted to the DSPD Program did pose a higher risk and displayed more
severe Personality Disorder traits when compared to the non-DSPD groups.
(Kirkpatrick, Draycott, Freestone et al 2010). The issue regarding lack of
treatment is that none of the four DSPD units reached full capacity until 2009, so due to
the lack of trained staff and full quota of patients being admitted, treatment pathways
did not run as planned in the beginning (Howells, Jones, Harris, Wong, Daffern et al
(2011).

--------------------------------------------------------------------

The treatment pathways required a high level of therapeutic input. In this case at least
25 hours of therapeutic activities and interventions was necessary from all of the multidisciplinary team. Interventions and treatment pathways were different in all four units
as autonomy was given allowing each unit to select their own therapies and treatment
pathways. This resulted in a diverse range of therapies available when comparing the
four units (Vollm and Konappa 2012). At Rampton hospital the Peaks Unit uses a
complex individualised treatment pathway to target specific factors relevant to each
patient that requires treatment in a high secure environment (Hogue, Jones, Talkes and
Tennant 2007). This approach using a 'what works'principle can be made tailored
through the combination of functional analysis and formal risk assessment (Howells,
Day et al 2007).

This approach enables individual factors to be identified that have contributed to the
resulting offending behaviour allowing an individual treatment pathway to be tailored to
address the factors identified. This supports the principles on the Peaks Unit promoting a safe environment, maintaining a therapeutic mileu to support engagement,
focussing on interpersonal factors and personality, addressing criminogenic needs using
specific therapies. Multi-disciplinary teams create a therapeutic mileu by close working
relationships, motivational work and promoting continuity of care. If a patient is
reluctant to engage in therapies then the therapeutic mileu is promoted for example by
using a different approach i.e. named nurse sessions (Hogue, Jones, Talkes and Tennant
2007).

The DSPD program at the Peaks offered 12 therapies; Dialectical Behavioural Therapy
(Linehan 1993) aimed to reduce violent behaviour and self-harm. Cognitive Analytical
Therapy (Ryle 1997) for the development of problem-solving skills and insight. To
target criminogenic needs other therapies were available for example sex offender
program and substance misuse program (Hogue, Jones, Talkes Tennant 2007). By each
unit having the ability to function autonomously therapies have been designed and
developed to treat Personality Disorder. Duggan et al (2007) identified over ten
different therapies and interventions from the analysis of 27 random controlled trials.
Most commonly utilised therapies were Cognitive Analytical Therapy, Dialectical
Behavioural Therapy and psychoanalytical based therapies. These were often used
alongside pharmacological interventions.

Individuals diagnosed with Borderline Personality Disorder responded better to

Dialectical Behaviour Therapy. Individuals diagnosed with Antisocial Personality Disorder
responded better to Cognitive Behavioural Therapy. Individuals diagnosed with Avoidant
Personality Disorder or Mixed Personality Disorders responded better to psychodynamic
based therapies (Vollm and Konappa 2012)

However the differences between the diagnoses and responses to therapeutic

interventions were minimal (Weinberg, Gunderson, Hennen and Cutter 2006),
(Davidson, Norrie, Tyrer, Gumley, Tata, et al 2006). So no clear answer was to be found
in recommending certain therapies to certain diagnoses. This may be explained by
Personality Disorder symptoms not remaining stable as originally thought before. The

pathological features of Personality Disorder are less stable and more developmentally
heterogeneous than previously believed (Ready and Robinson
2008) (Roberts, Caspi and Moffit 2003) (Hopwood, Donnellan, Blonigen,
Krueger, McGue et al 2011). This does support the age-related decline of pathological
traits in Personality Disorders. Over a ten-year period the Personality Disorder traits
were quite stable, however the Personality Disorder symptoms fluctuated according to
the environment which further highlighted the level of heterogeneity in the population.
Unfortunately this hinders the evaluation of treatment efficacy.

Randomised Controlled Trials are considered to be the gold standard in the evaluation of
treatment efficacy. They evaluate the impact of treatment but having an untreated
control group could in be considered unethical as a group meeting the criteria for a
DSPD program being left untreated could pose serious risk problems to self and others
(Draycott, Kirkpatrick and Askari 2012).

The HCR- 20 (Webster, Douglas, Eaves and Hart 1997) risk measure has been used in
studies to demonstrate change over time in patients meeting criteria for Personality
Disorder and Dangerous and Severe Personality Disorder (Morrissey, Beeley and Milton
2014). The study demonstrated changes as a result of the treatment so this could be
used to demonstrate treatment efficacy.

Vollm and Konappa (2012) conducted a literature review of papers relating to the DSPD
Program regarding treatment efficacy. Results showed a dearth of evaluative studies,
29 empirical research papers and three extensive research papers. There were no high
quality studies found evaluating treatment pathways or environmental impact. There
remains little evidence for the evaluation of the treatment efficacy of the DSPD
programme.

The DSPD pilot is being phased out and it is a question of assessing whether the DSPD
units have been a cost effective investment. Unfortunately there is a lack of evaluative
research making drawing a definitive conclusion difficult. This is perhaps due to the
relatively young age of the pilot and the lengthy process of publishing work; however
the distinct lack of information raises concerns (Vollm and Konappa 2012).t

Positive outcomes have been identified. Traditionally a difficult and stigmatized

population the DSPD program has enabled the exploration of different treatments for
personality disorders (Tyrer et al 2010). The National Institute for Health and Clinical
Excellence has made recommendations for personality disorder services to be available
throughout the UK.

A number of new treatments have been developed with a strong evidence foundation,
leading to a positive effect on staff morale with in this difficult client group (Bowers et al
2005). The admission criteria for DSPD was not based on strong evidence, however in
the upcoming ICD 11 personality disorder classifications the DSPD is similar now to
those used in the ICD 11 to assess severity and avoid excessive co morbid traits (Tyrer
2013).

The DSPD population statistically presents as a higher risk than other populations
however the severity of their personality disorder is no greater than other individuals
with personality disorder. Initially the majority of referrals to DSPD units were prisoners
nearing the end of their sentences, which supports claims that the unitswere simply a
place to house individuals still classed as a high risk and nearing release back into the
community (Howells et al 2011).

A number of new treatments have been developed with a strong evidence foundation,
leading to a positive effect on staff morale with in this difficult client group (Bowers et al

2005). The admission criteria for DSPD was not based on strong evidence, however in
the upcoming ICD 11 personality disorder classifications the DSPD is similar now to
those used in the ICD 11 to assess severity and avoid excessive co morbid traits (Tyrer
2013).

The observed reductions in risk and improvements in mental health have been minimal.
Aggressive behaviour and self harming was observed to increase in detainees although
this may be due to problems with the management of the detention system i.e. one
study highlighted inefficiencies during admission and assessments leading to substantial
delays, no clear pathways to progress and limited time spent in therapy considering the
number of staff available (Draycott et al).

The reasons for the phasing out the DSPD pilot schemes remain unclear but the
relevant facts are the large financial investments and apparent fallings of the pilot
schemes, however consideration must be given to the future of the detained population
(Kirkpatrick et al 2010).

One study suggests focussing on the initial roots of the pilot would be more beneficial
to the detained population and also would also reduce the financial investment
required. Originally the pilot scheme was supposed to be based on the
Dutch ter beschikking stelling (TBS) system. However during its development and

implementation it deviated significantly. The TBS system treated a similar population for
approximately half of the cost of the DSPD pilots and for a longer period of time.

DSPD units often struggle with clear goals for progression through the system whereas
the TBS developed a clear integrated pathway at all levels, from high secure through to
community support Noticeably maintaining a strong rehabilitation ethos, focussing on
paid work, regular leave and responsibilities involved in independent living enabled this
progression (Volm and Konappa 2012). If after six years there is no improvement the
focus shifts to improving the quality of life rather than on treatment. This is facilitated
by moving to long stay thus keeping costs down and maintaining the clear goals.

The TBS program still does has the problem of identifying what works best but it does
manage to avoid the higher expenditure incurred by the DSPD pilot which perhaps
qualify this system as a future alternative.

The DSPD Programme has been subjected to controversy and contradiction since it was
introduced and this continues even now it has been decommissioned. The service was
deemed a failure by many but this was because it was classed as a costly program with
limited evidence demonstrating success. This review of papers available has questioned
what achievements have been acknowledged and if failure is a fair description.

Some benefits have emerged, firstly DSPD individuals have gained

recognition and specialist services have been developed. The treatability clause which
caused controversy is no longer in the Mental Health and criteria has been established
toidentify individuals with DSPD.

Contradiction and debate continues regarding the initial aims for the DSPD
Program. The expected detention time, the suitability of the assessment process, public
protection, which treatments were effective and was risk reduced. In relation to
research, there is no argument as to whether the available studies have been beneficial
to the DSPD Programme, but initial proposals highlighted the need for knowledge as to
why people develop DSPD and how it can be prevented, and information in this area is
limited.

In relation to concerns raised regarding the initial development of the DSPD

Programme, the controversy of predicting future risk has not been addressed, and nor
has the potential of warehousing, although concerns continue. There is no indication as
to what individuals past their tariff can hope for, the most suitable environment is now
seemingly not a consideration, and it is unknown whether allindividuals with DSPD who
require treatment are able to access appropriate services.

Despite controversy, disagreement and debate over a variety of issues, the DSPD
Programme has achieved more of its initial aims than it has failed. Although its
downfalls and deficits are acknowledged, the number of achievementsI fulfilled can only
be described as successful. Many issues remain under question or are unknown, as it is
likely to be in other healthcare services. However, as healthcare services are always in
need of development, change and progression, it would be unjust to use this as a
reason for failure. Despite not meeting all of its targets, the DSPD Programme has not
entirely failed, and this needs to be acknowledged.

This systematic literature review is beneficial to healthcare for the following reasons.
Most significantly it has drawn together reports, papers and research into one document
to provide an in-depth, non-biased and comprehensive review of a specialist service
which has been subjected to much controversy. This is something which until now was
unavailable. Although downfalls and deficits exist, they have been acknowledged, and
the achievements that the DSPD Programme has made have been explored and
highlighted. The design of this systematic literature review is able to be replicated for
use in further studies in other areas of healthcare.

Finally, this comprehensive evaluation and appraisal has highlighted areas in which
further research is necessary in order to answer questions and address controversy and
dispute.

Accusations have been made regarding the failure of the DSPD Programme, which have
no doubt left staff and those who have the disorder with feelings of negativity or even
resentment. The findings of this systematic literature review provide evidence of the
achievements the service has accomplished, facilitating recognition of its success.
Furthermore, it raises the question of what will happen to DSPD patients who cannot
return to prison, something seemingly not addressed so far. These individuals deserve
to know what the future holds for them, and what services will be provided for them.

Throughout the discussion within this systematic literature review, questions have been
asked, and not all have been addressed. As such, further research is required to
address these issues. Most importantly, further information on reoffending rates needs
to be gained to ascertain the extent that treatment within the DSPD Programme has
been effective. Not only numbers of DSPD individuals who reoffend after release,
however. Other information is required,

mortality rates, for instance. No one lives forever, and statistical information is not
representative or accurate if assumptions are made that treatment has been effective,
if the individual is unable to reoffend due to death, and is in effect documented as being
low or no risk.

What DSPD patients detained within hospital, past their tariff, and therefore unable to
return to prison in line with the latest agenda, can hope for is unknown. Information is
needed on what options they have if DSPD services no longer exist within the NHS. For

those individuals who are returned to prison, research needs to be completed, in time,
to establish whether this has indeed resulted in more efficient and effective treatment.
The research recommended here would go some way to achieving the aim of
completing research within the field of DSPD that has not fully been met, but further
work on why DSPD develops and the most effective ways to treat the disorder remain
unaddressed and would be beneficial.

Lastly, studies using staff working in DSPD units as participants experienced a high
dropout rate. It would be interesting to explore whether this would still occur now that
the service is no longer under scrutiny as the fear of repercussion may be reduced.

2390

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