Paul John Griffiths
What are the implications for psychological therapy work with offenders of the recent trend to regard personality disorders as trauma/neglect-derived disorders of self-regulation?
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This essay was originally submitted to the University of Birmingham for the Master of Science in Criminological Psychology. It provides examples of inappropriate referencing and poor use of English grammar. The term Personality Disorder (PD) has served as an ‘umbrella term’, for any number of psychological disorders. The primary difficulty in determining just what belongs under the umbrella and just how it is being used, derives from the fact that several official definitions have been traded in for newer models over several decades (Reber 1988). This essay discusses implications for psychological therapy with clients who have PD and investigates the trauma/neglect hypothesis.
There is likely to be association between disorders of personality and criminality, since the legal definition of psychopathic disorder under the Mental Health Act 1983, includes an element that the disorder has resulted in ‘abnormality aggressive or seriously irresponsible conduct’ (Prins 1995). In essence, it is a legal category defined by persistently violent behavior. The criminal behavior attracts attention to the offender who may subsequently be diverted into care (Peay 1997). This essay firstly defines what is meant by PD and how this concept has developed.
But what about trauma? Trauma is defined as physical injury caused by some direct external force or as psychological injury caused by some extreme emotional assault (Reber 1988). Neglect, defined by Geddie (1971), is to treat carelessly, to pass by without notice, to omit by carelessness or to fail to bestow due care upon. The second section ‘Etiology’ establishes the place Trauma and Neglect have within the area of PD from a developmental social perspective.
PD research has shown exceptional and exciting expansion over the past 15 years from noted authorities, increasing the body of knowledge (Clarkin & Lenzenweger 1996) and so the third section, ‘Diagnosis’ considers at some of the assessment tools available today that derive from such research.
Psychopathy is defined by Reber (1988), as any abnormal mental condition of which etiology is unknown and a diagnosis has not or cannot be made. In this sense, he suggests, the term is an open admission of ignorance, and indeed, Wright (1971) states that Psychopaths are among the most difficult of all criminal groups to cure. So in Section Four, it’s necessary to consider ‘treatment’ in terms of psychological intervention in current use in both prison and health sectors. And to summarize what progress if any has been made in treating a client group difficult both to define and to assess.
HISTORICAL PERSPECTIVE Back to Contents
From a health perspective, the Nineteenth Century French Psychiatrist Pinel, is usually given the credit for the description of the characteristics we currently regard as psychopathic (Prins 1995). The term ‘Psychopathy’ itself was first introduced by a Viennese physician Ernst Von Feuchtersleben in 1845 (Hunter & Macalpine 1963), meaning mental disease as distinguished from neurosis or functional disease of nerves.
Much later Scneider (1923) identified ten forms of psychopathic personality defining them as "those abnormal personalities who suffer from their abnormality or whose abnormality causes society to suffer". However, it was perhaps Henderson (1939) who influenced the British concept of Psychopathy, by introducing the idea of individual progress within a group setting, thus rejecting the concept of total mental unsoundness, defect or delinquency. Cleckley (1964) outlined sixteen criteria for the diagnosis of Psychopathy, originating an understanding of the condition in terms of personality traits.
The Mental Health Act 1959 first defined psychopathic disorder within a legal framework. It was an attempt to correct and bring up to date older legislation that hampered efforts to treat patients early in their illness (Crowcroft 1967). This became The Mental Health Act 1983, Section 1 (2); ‘psychopathic disorder’ means a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned (Prins 1995).
Jones (1996) interprets Section 1. "Any other disorder or disability of mind" could include "PD". A person who suffers from a disorder, which comes within this category, is eligible for detention under sections 2, 4, 5, 135 & 136 of the Act, that is sections authorizing short term detention. Significant impairment of intelligence in this definition of psychopathic disorder means mental impairment. The definition of psychopathic disorder does not refer to treatability. The effect of sections 3, 37 & 47 is that psychopathic and mentally impaired persons cannot be compulsorily admitted to hospital for treatment unless it can be shown that the medical treatment is likely to alleviate or prevent deterioration of their condition (Fallon et. al. 1999).
Evidence of abuse/neglect in the histories of individuals with borderline PD is now overwhelming. Up to 80% of borderline PD patients’ report abuse/neglect in surveys (Tyson 1999). Taylor (1987) offers a compelling argument for childhood neglect and failure of parental "empathic attunement" as the basis for later dependent PD. Early research of Glueck and Glueck (1950), compared delinquents with non-delinquents; and found that discipline received by the delinquents was on the whole "lax and erratic on the part of the mother, and either over strict or lax and erratic on the part of the father"; both parents used physical punishment and little reasoning and praise. Whereas the non-delinquents parents were firm, kind and consistent, reasoned more and used little physical punishment.
Taylor’s (1987) "psychobiological dysregulation" model is based on the premise that adequate parenting provides the basis for learning of self-regulation, physiological and psychological. Dependent Personality and/or proneness to certain psychosomatic illnesses may result from early failure of the parent to fulfil their regulatory functions for the infant. Severe rejection in childhood, and the absence of conditions which foster attachment to others, are common features of the histories of psychopaths (Wright 1971). This model has been extended by Linehan (1995) who proposes a biosocial model of Borderline PD (BPD), in which "biological vulnerability" and "invalidating environment" are found to be contributing factors.
It is the general cohesiveness of the family unit that counts and important that they are seen to be fair. Delinquent individuals see their parents and especially their fathers as generally unjust and inconsistent (Wright 1971). The hallmarks of an individual with a ‘PD’ may include: ambivalent parental feelings provoking in turn a cold, wayward response, resulting in long-standing behavior difficulties, lovelessness, cunning, evasion, and deceit, coupled with superficial charm (Prins 1995).
The research of Van Der Kolk & Fisler (1994) into ‘child abuse and neglect’ observed chronic inability to modulate emotional and behavioral responses. In reaction to this, traumatized children learned to secure a range of age-appropriate behaviors that are attempted to help them control intense affective states. These include self-destructive behaviors, eating disorders and substance abuse. Often these behaviors will co-exist. One of the great mysteries of the process of traumatic experience is that as long as the trauma is experienced as speechless terror, the body continues to keep score and reacts to conditional stimuli as a return of the trauma.
The World Health Organisation (WHO 1982) has formulated The International classification of disease – 10 (ICD-10). There are ten categories of PD. The category of ‘Disocial PD’ appears to equate with the limited description of a ‘Psychopathic Disorder’ in the 1983 Act. The American Psychiatric Association has developed The Diagnostic Statistical Manual, now in its fourth revision (DSM-IV) and also describes 10 specific PD grouped into three clusters. The Anti-social PD correlates most closely with ‘Psychopathy’ (see figure one).
A pervasive pattern of disregard for the violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
A: The individual is at least 18 years.
B: There is evidence of conduct disorder with onset before the age of 15 years.
C: The occurrence of anti-social behavior is not exclusively during the course of a schizophrenic or manic episode.
Figure One: Anti-social Personality Disorder (DSM-IV)
Cleckley (1964) reminds us that the individual who continually display psychopathic traits as callous indifference to others and aggressive, antisocial behavior through " a deep seated sense of injustice and frustration", is not necessarily psychopath. In fact this trait of emotional indifference has been observed in many men regarded as social successes, men such as scientists and directors of industry! Psychopaths have been found to suffer from neurological abnormalities, and their evidence that genetic factors play an important role in predisposing individuals to this condition (McCord, W & McCord, J. 1964). This illustrates the need for comprehensive assessment that utilizes a battery of measures and incorporates testing ‘physiological’, ‘sociological’ and ‘psychological’ skills.
Several specific measures are available for identifying psychopaths in deviant populations: Cleckley’s Criteria (Cleckley 1964), Psychopathy Checklist (Hare et. al. 1990), Scale 4 of the MMPI ‘Psychopathic Deviate’ (Hollin 1996), ’Socialization Scale’ of the CPI (Gough 1969) and the Behavior Classification Dimensions (Quay 1977). Benjamin (1996) raises the subject of the overlap among diagnostic categories. These various measures have been found to correlate with one another, but correlations are not sufficiently high for them to be regarded as interchangeable. The psychopaths of one investigator do not, then, necessarily correspond to those of another (Blackburn 1993).
Hare (1980) conducted a factor analysis of data derived from the Cleckley criteria and found five factors, which offer a succinct description of the psychopath: an inability to develop warm, empathic relationships; an unstable life-style; an inability to accept responsibility for his antisocial behavior; an absence of intellectual and psychiatric problems; weak behavioral control. The Psychopathy Checklist-Revised (Hare 1996) consistently predicts both general and violent recidivism among offenders and is considered to be "unparalleled" for risk assessment purposes (Blackburn 1999).
Following the Second World War in the rehabilitation units for ex-prisoners of war, the basic emotional problems were demoralization and desocialization, and neurotic rather than psychotic illness was involved. Maxwell Jones (1952) set up a treatment center for psychopathic, abnormally aggressive or seriously irresponsible men, as distinct from psychotic. His findings appeared to justify the conclusion that it is possible to change social attitudes in relatively desocialized patients with severe character disorders, provided that they were treated together in a therapeutic community. Maxwell Jones went onto run Dingleton Hospital on the same lines with psychotic as well as neurotic and psychopathic patients (Crowcroft 1967).
Those classified in legal terms as ‘psychopathically disordered’ and in clinical terms as ‘PD’ have an unenviable reputation for being difficult and resistant to treatment. PD is poorly understood and there is little consensus as to definition, assessment intervention and possible treatability. The report of the committee of the inquiry into Ashworth Special Hospital’s ‘Personality Disorder Unit (Fallen 1999) states that the patients are at the severest end of spectrum and have extremely disordered personalities, many having previous convictions for sexual and serious violent offences.
British therapeutic communities developed methods aimed at people originally labeled as psychopathic and later as PD. This, coupled with the relative failure of mental hospital therapeutic community concept, has led to the treatment of PD being seen as the main area of efficacy of social therapy (Roberts 1997). The report of East & Hubert (1939) ‘The psychological treatment of Crime’ took twenty-five years to manifest into the jewel of the prison system "H.M.P. Grendon". It is now a therapeutic center for the treatment of prisoners, many of whom have PD (Fallon et. al. 1999). The Grendon template (Cullen 1997) includes comprehensive assessment utilizing a battery of psychometric measures, Democratization, Permissiveness, Communalism and Reality Confrontation, the objectives being: to help each man to improve his self-esteem and sense of self worth; to improve his behavior towards others and to reduce the number and severity of future crimes. Similar structure was found in the Scottish Prison system at The Barlinnie Special Unit, that operated from 1973 to 1995 (Cooke 1997). The Max Glatt Center at HMP Wormwood Scrubs has successfully been operating as a therapeutic community for the past twenty-four years (Jones 1997).
In Germany, at present there are fifteen Social-therapeutic Institutions (Lösel & Egg 1997). They have four categories: recidivists with serious PD; dangerous sexual offenders; young adult criminals who have been assessed as especially crime-prone and finally, criminally non-responsible offenders. The treatment program operates over a two-year period. Therapists working with PD must cope with the growing reluctance of purchasers to pay the costs of extended treatment. Magnavita (1997) suggests a flexible, short-term dynamic model with working with adults with PD. She continues the work of pioneers in the field of short-term therapy and incorporates other allied approaches e.g., ‘active defense analysis and empathic affirmation of the core self. She reiterates the important use of ‘anxiety’, ‘personality restructuring’ and for maximizing the therapeutic alliance. The Connecticut Center for short-term Dynamic Psychotherapy (Magnavita 1997) specializes in rapid and enduring changes in personality-disordered clients.
Fallen, Bluglass, Edwards & Daniels (1999) reiterates that individuals at the severest end of PD, tend to test boundaries between staff and patients to destruction and undermine and sometimes even corrupt their therapists and carers. At present "very few services within the NHS have any kind of specialist expertise in the care and management of PD patients, let alone severely PD patients". The admission figures for 1996 of offenders suffering from psychopathic disorder given a restriction order indicate the infrequency with which the provisions are used (21 orders or 10% of admissions). Yet the numbers recalled in 1995 after receiving a conditional discharge (17% of all recalls) suggest the relative vulnerability of this group (Kershaw & Renshaw 1996).
Innovative clinical work is presently emerging from America, especially from practitioners such as Brown & Fromm (1999). A brief summary of their methodology follows: The natural process of stress, distress, critical incident stress and posttraumatic stress form a continuum on which an understanding of their function can be based. This continuum is controlled by biological process. Posttraumatic stress can be a trigger for development of ‘PD on a behavioral and biological level. The neurological nature of traumatic memories being fragmented sensory material related to a traumatic critical incident experience. The intrusive symptoms of post traumatic stress disorder are the reoccurring efforts of the brain to form a memory that can be stored in a normal manner. Failure to modulate hyperarousal in recovering trauma victim will trigger the traumatic symptom cycle of hyperarousal-numbing. Stress response management skill development, aids the ability to regain balance on the neurochemical level from the trauma cycle. Therefore, treatment must be paced, timed and strategic in its administration. Using the knowledge of the symptoms of the condition to dictate the appropriate type of intervention is a very productive approach. During periods of hyperarousal, interventions that promote relaxation, comfort and safety are most productive. During periods of numbing, interventions that promote affective generation and cognitive processing of traumatic material are productive (Brown 1999,1999a).
With regards to Organizational issues; Professor Donald West, said at the Inquiry into the Personality Disorder Unit (Fallon et. al. 1999) that Psychopaths have particular needs and that in order for ‘behavior modification’ and ‘attitudinal change’ to emerge the following provisions are needed:
Blackburn (1993) suggests that due to the small number of methodologically adequate reports into treatment of psychopaths only two conclusions can be drawn: one, while classical psychopaths have been shown to respond poorly to some traditional therapeutic interventions, it has yet to be established that ‘nothing works’ with this group. Second, some offenders with PD do appear to change with psychological treatment, although no particular approach has consistently been found to be beneficial, but procedures which structure the therapeutic environment, such as the token economy and the therapeutic community, and eclectic psychotherapy, group therapy, social skills training and cognitive restructuring can all claim examples of positive effects. Prisoners identified as psychopaths by the PCL have more extensive criminal records are more involved in rule violations in prison, and are more likely than non-psychopaths to reoffend following release (Blackburn 1996). The research from Bailey & MacCulloch (1992), reveals that psychopathic patients re-offend at higher rates than the mentally ill, and that conditionally released patients fare better than those given absolute discharge.
However, when the mind is able to create symbolic representations of these past experiences, there often seem to be taming of terror: a de-somatisation of experience. This includes the development of a capacity to endure pain in order to attend to recuperation. Much of the treatment of these patients consist of clarifying how current stress are experienced as a return of past traumas and small disruptions in present relationships as a repetition of prior abandonment. The availability of words will help them start making the necessary connections between their current affective dysregulation and their past histories of abuse and neglect. This may allow them to make a distinction between past helplessness and current access to ways of coping that were not available when their lives were controlled by people who were unable to respond to their needs (Van Der Kolk & Fisler 1994).
Rice, Harris & Cormier (1992), in evaluating a general therapeutic community program, found that offenders with high Psychopathy scores had higher rates of violent offending after discharge, whereas those with low Psychopathy score showed lower rates of violent recidivism. Therefore, suggesting that psychopathic offenders may not be appropriate for some styles of group work and reiterating the need for appropriate selection for group programs. PD Clients represent a tremendous challenge to those charged with the task of management. Such a challenge Prins (1995) suggests presupposes the capacity to step outside narrow boundaries of learning and experience and to take on board findings from a wide range of disciplines.
Indeed, developments in understanding the neurological basis for PD and the way in which Post Traumatic Stress disorders are acquired may change the emphasis back to the medical as distinct from the psychological/multi-disciplinary approaches. However, medical understanding would require much more research and insight with a defensive profession than is likely to be forthcoming.
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