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CERI EVANS, Canterbury Regional Forensic Psychiatry Service, Hillmorton Hospital, Christchurch,
New Zealand
Perspectives
From my perspective as the clinical director of a
moderately-sized adult regional forensic psychiatric
service in New Zealand providing a commentary
on ‘Antisocial Personality Disorder: Treatment,
Management and Prevention’ (NICE, 2009), the
cupboard was essentially bare in being able to
provide relevant evidence-based recommendations
for service development. In brief, the available evidence
did not justify any empirically supported
recommendations for individuals with antisocial
personality disorder (ASPD) in terms of risk management,
psychological interventions or pharmacological
treatments. There is a certain irony in
being asked to provide a commentary on a 400-
page document, which essentially, highlights the
absence of empirical evidence.
Of course, there is political, strategic and academic
utility in clarifying the current lack of information
about how to manage those with ASPD.
The Guideline Development Group (GDG)—and
an impressive group it was—made explicit the
point that the guidelines are there to be revised
and they certainly tried to point the way ahead by
identifying what, in their view, were the best candidates
for signifi cant research projects in this area.
The rehearsal of conceptual arguments about
why ASPD should be considered a health issue will
assist those involved in funding roles in general
terms; and the recommendations that could be
made on the available evidence will assist in arguments
for funding specifi c types of programmes,
such as group-based CBT methods for those with
ASPD and co-morbid substance abuse problems,
even though this is primarily within correctional
settings.
And there were some areas where the GDG felt
that there was suffi cient evidence to make recommendations,
although these areas had associated
features that diminished the impact of the fi ndings.
For example, there was evidence for groupbased
cognitive-behavioural interventions in
reducing re-offending in people with ASPD and
substance misuse problems but this evidence is
predominantly from the criminal justice system
as opposed to health settings. Moreover, forensic
practitioners should not need to be told about the
central importance of addressing substance abuse
in individual treatment plans.
Similarly, there was evidence that a few risk
assessment instruments are moderately effective at
predicting violence at the ‘group’ level. However,
the usefulness of these instruments is limited by
the absence of the critical detail necessary to
develop individual risk management plans and the
fact that the statistical accuracy at the group level
does not necessarily translate to predictions about
individual behaviours.
A further disappointment was the decision by
the GDG to exclude research conducted with
individuals who had ASPD and psychotic illnesses
such as schizophrenia (p. 193). This immediately
excludes the most relevant scenario in which
ASPD presents to forensic services in countries
like New Zealand, in which services and legislation
are not designed to provide assessment and
treatment of personality disorder in the absence of
mental illness. An appreciation of the assessment
and treatment guidelines for ASPD in prison settings
is still helpful for work within the correctional
system.
Strengths
Of course, these matters are not necessarily criticisms
of the GDG—their role was simply to present
the evidence that was available—and in doing so
they have provided a valuable foundation document.
Interestingly, some of the most practical
guidance was found in sections whereby the GDG
relied on a consensus statement because of the
absence of relevant empirical data. In particular,
the section on risk assessment developed the
common sense view that that risk management
should be based on detailed descriptive analysis of
violent behaviour to discern patterns of violence
arising from mental state and situational factors,
an approach based on identifying worrying
scenarios. With the potential for risk assessment
instruments to have statistical signifi cance but not
clinical relevance, it was refreshing to read a major
review that advocated for contextual risk assessment
and management, an approach that lends
itself to the demystifi cation of the risk management
process.
Some of the fi ndings fell into the category of
common sense, such as the need to involve experienced
therapists, to provide supervision, to avoid
disruption of programmes and to encourage good
communication between agencies, and so on.
However, these basic aspects of care are often
where treatment interventions fall down, justifying
their inclusion.
Some of the recommendations, while being
easily defensible, had an academic feel rather than
a pragmatic clinical fl avour, such advice to treat
co-morbid disorders including anxiety, depression
and PTSD. A more revealing description might
have illustrated the manner in which complex
trauma issues can be central to antisocial attitudes
and behaviours rather than PTSD being merely a
co-existing condition. An important subgroup of
those with antisocial behaviours are characterized
by early adverse experiences leading to a broad
range of post-traumatic phenomenology, including
emotional disturbances including shame, resentment
and rage linked to intrusive memories; avoidance
with dissociative symptoms and substance
abuse designed to numb; and increased arousal
with hypervigilance and irritability. The complexity
of the manner in which these individuals can
present can require signifi cant individual psychological
work to establish suffi cient stability to make
group work realistic. The guidelines produced recommendations
for group-based CBT work but the
subtleties of engagement with those with ASPD
might have benefi tted from a more nuanced discussion
similar to that used by the GDG in the
area of risk assessment.
As the guidelines point out, genuine therapeutic
engagement is problematic because of a combination
of the nature of ASPD with its propensity
for deceit and the element of coercion that is
usually involved in the way individuals present for
treatment. The diffi culties inherent in this situation
cannot be underestimated. Treatment goals
should be modest. Counter-transference issues
are inevitable. There are real questions about trust
and the authenticity of any apparent engagement.
The capacity for manipulation and false progress
is high. It is more realistic to aim for psychological
movement based on the individual appreciating
that a reduction in offending behaviour is in their
longer term interests, so that they avoid negative
consequences such as physical harm, lost contact
with family and friends, and long-term incarceration.
Most would agree that therapy designed to
develop insight and a sense of guilt or shame is
probably naïve. To compound matters, some with
ASPD will fi nd pecuniary motivations in develop
ing therapeutic contact, particularly within the
prison setting.
The bottom line is that individuals with PTSD
will need to be able to see a benefi t from engagement
with the therapeutic process. Their lifelong
coping mechanisms provide safety insofar as they
experience it and removing this set of responses
and attitudes exposes the individual in a psychological
sense. Therefore, motivational work often
precedes group work. While not underestimating
the importance of group work in supporting peer
challenge of denial and minimization, the GDG
might have underplayed the relevance of preparatory
individual psychological work for at least a
proportion of individuals with ASPD. The group
process may be a necessary one for this group but
it might not be suffi cient.
There were some minor concerns. There was
inconsistency, or at least the potential for misinterpretation,
with the use of the term psychopathy
in relation to ASPD. When defi ning the disorder,
the guidelines made clear that a minority (10%) of
those with ASPD had psychopathy (p. 20) and
psychopathy was stated to be a condition distinct
from ASPD. However, when discussing risk assessment,
it was stated that psychopathy was more or
less synonymous with the DSM-IV diagnostic criteria
for ASPD. For those clinicians unfamiliar
with these concepts, the implication is that these
terms can be used interchangeably. This would not
do justice to the body of empirical research on
psychopathy and given the profi le that the PCL-R
is afforded in terms of risk assessment, it would
confuse the area of risk assessment.
Although the GDG felt that the use of offending
behaviour was a potentially controversial proxy
measure for their evaluation of research evidence,
this is in keeping with clinical approaches that
tend to focus on more specifi c behavioural outcomes
like violence reduction. The GDG cited
three reasons in support of their stance: offending
is related to ASPD diagnostic criteria; the focus
on offending requires that attention is placed on
mediating factors which are likely to be relevant
for ASPD; there are high rates of ASPD in some
offender populations, particularly in those who are
imprisoned. There are two further reasons why the
focus on offending is not only a defensible approach
but a clinically sensible one. First, given that those
with ASPD presenting for treatment are a coerced
group, their motivation towards modifying or
‘changing’ aspects of their lifestyle is likely to be
ambivalent, if not oppositional. Working with the
individual to develop a genuine alignment to
reducing offending behaviour is a challenging, but
as indicated above, it is potentially realistic if they
can perceive the negative consequences of these
behaviours for themselves. Trying to engage an
individual with psychological work that is less
direct immediately introduces an element of subjectivity
and vagueness into the task. Second,
given the propensity towards deceit and manipulation,
the outcome measure needs to be simple
and objective. Attempting to measure complex
or subtle changes in psychological constructs as
opposed to unambiguous behavioural manifestations
is likely to lead to unclear outcomes and
unfortunate decisions.
The GDG also selected conviction as the most
robust measure of reoffending, which was a pragmatic
approach but one that might have benefi tted
from broader explanation. Major studies examining
the nature of the association between mental
disorder and violence have identifi ed the major
limitations involved in looking at convictions
alone as the measure of reoffending, and have
introduced self-report and third party information
as additional measures. Although the use of these
methods would likely have been uncommon in the
studies considered here, the value lies with an
appreciation of the limitations of the measure.
Although the objective was not ease of readability,
clinicians would have been engaged by
even brief accounts of the content of some of the
CBT approaches that were advocated.
Not all violence is equal
One of the things that the guidelines do is to show
starkly how little relevant empirical research is
available as to how to approach treatment of
ASPD, outside of the data available about substance
abuse. Put another way, if the studies about
substance abuse were removed from the guidelines
there would be very little that could be said in the
way of evidence-based recommendations at all.
The recommendation (p. 211), for example, that
group-based CBT work for individuals with ASPD
extends to mental health service settings is based
on little research within these settings. Forensic
psychiatry has signifi cant challenges in developing
an effective research agenda, which makes the
GDG guidance on next steps in this area noteworthy.
This will be especially so as services increasingly
prioritize in a time of scarce resources.
For some countries or states that do not have
mental health legislation that leads to the prolonged
detention of those with personality disturbance
but no mental illness, the issue of how to
provide better treatment for individuals with
ASPD is less topical than whether it should be
provided. As one of the GDG has made clear in
the excellent book ‘Treating Violence’ (Maden,
2007), not all violence is equal (p. 158), and psychotic
violence is the highest priority. Services are
under different obligations with respect to nonpsychotic
violence. For those eventually tasked
with revising the guidelines, the single step that
would be of greatest assistance would be to increase
the focus on the assessment and management of
ASPD in the context of psychotic illness, a task
that was deliberately avoided in the current guidelines.
The GDG might have to develop further
consensus statements rather than being in a position
to provide evidence-based recommendations,
but practical guidance of this nature—as found in
‘Treating Violence’—would capture the attention
of forensic clinicians.
References
Maden, T. (2007). Treating violence: A guide to risk management
in mental health. Oxford: Oxford University Press.
National Institute for Health and Clinical Excellence(NICE). (2009). Antisocial personality disorder: Treatment,
management and prevention. NICE Clinical Guideline 77.
London: NICE.
Address correspondence to: Dr Ceri Evans,
Clinical Director, Canterbury Regional Forensic
Psychiatry Service, Hillmorton Hospital,
Christchurch, Private Bag 4733, New Zealand.
Email: ceri.evans@cdhb.govt.nz
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