Violence Risk among People with Severe Personality Disorders - Research Paper Example

?Violence risk among people with severe personality disorders Personality disorder is not a term that represents a monolithic psychological disease category. The behavioral patterns of individuals who have different kinds of personality disorders can be as diverse as among normal citizens. Of course some of these disorders, especially the ones, which have been considered as severe, have been found to have behavioral violence associated with them. Different studies have shown that around 4.4% of the members of a given population will be having some kind of personality disorder (McMurran and Howard, 2009, p.5). There have been violence risk assessment schemes devised to measure the risk based on common standards (Webster and Hucker, 2007, p.44). Before exploring such risk assessment tools, it is paramount to understand the causes and nature of personality disorder and also the existing psychological theories on the same. Biological aspects The earliest reported diagnostic tendency in history, linked with personality disorders was to find a connection of heredity and genetics with the said disorder. It was Patrick (qtd. in Forrest, 1994) who carried out the “first comprehensive genealogical investigations of psychopathy and heredity” (p.70). The findings of that study as well as other studies that followed have suggested “between 50 and 70 percent of psychopaths have ancestral disturbance” (Forrest, 1994, p.70). Studies that were conducted in 1980s and 1990s also have proved the same (Forrest, 1994, p.71). The studies which investigated the biological aspects of personality disorder included twin studies, family studies, adoption studies, and also “criminality, male homosexuality and alcoholism” studies (Russell and Hersov, 1983, p.25). But there also has existed a counter argument, which says that there is no connection between heredity and psychopathy (Cloninger, Reich and Guze, 1975). An aberration in the chromosomal pattern was identified in early research as one aspect of the biological side of a personality disorder (Forrest, 1994, p.72). A study conducted “among mentally subnormal male criminals” had found that their genetic structure has an “extra Y chromosome” (Forrest, 1994, p.72). This genetic pattern has been named as “XYY genotype” and the characteristics of the individual having this chromosomal pattern have been described as “extreme episodic violence or aggression, low intelligence, behavioral pathology, and gonadal abnormalities” (Forrest, 1994, p.72). But more recent research has refuted this assumed violence risk associated with XYY chromosome (Forrest, 1994, p.72). Another approach has been to link personality disorders to “brain damage and neurologic pathology” (Forrest, 1994, p.72). This is to suggest that a personality disorder is the result of a neurological disorder (Forrest, 1994, p.72). Further explorations in this direction have concluded that the major cause of a personality disorder is the damage to hypothalamus and this in turn might be the result of “hereditary or genetic factors as well as intrauterine or post-birth head trauma” (forrest, 1994, p.72). Hare (1970) has made another interesting observation in which it is argued that a psychopath often has lesions inside the brain, which impair the psychopath’s skill to control behavior which may invite social disapproval. Psychological perspectives & theories From a psychological point of view, personality disorders can be defined as personality “systems that are poorly functioning and/or inefficiently adapting to the requirements of contemporary society” (Magnavita, 2004, p.3). Diagnostic and Statistical Manual of Mental Disorders (DSM- IV) has defined a personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (American Psychiatric Association, 2000, p.685). Personality disorders have been broadly classified into 10 specific types like paranoid personality disorder, schizoid personality disorder, antisocial personality disorder, borderline personality disorder etc. (American Psychiatric Association, 2000, p.685). There can be many subcategories as well as distinct groupings involving these categories. For example, personality disorders prone to violence are separately categorized under the name, intermittent explosive disorder, where the individual shows “discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property” (American Psychiatric Association, 2000, p.663). To understand the potential risk of violence and also to evolve a method for handling individuals with personality disorder, the different psychological theories on personality disorder come handy. The important theories are cognitive, behavioral, interpersonal, psychodynamic, integrative and pharmacological theories of personality disorder (Livesley, 2003, p.156; Lenzenweger, 2005). Each theory listed above has a tendency to approach the problem from one particular angle and hence practitioners have been often using these theories in combination. a. Cognitive theory Cognitive theory of personality disorder focuses its attention on the “schemas and core beliefs as organizational structures and global mental representations that guide information processing and behavior” (Beck, Freeman and Davis, 2004). These “schemas and core beliefs” are what a psychotherapist looks for in the psychopathology of the individual being treated (Beck, Freeman and Davis, 2004). It is assumed that such information could be available from “patient’s developmental histories, current problems and symptoms, and interview behaviors” (Beck, Freeman and Davis, 2004). The personality belief questionnaire and schema questionnaire are the major tools used by the therapist to further his/her knowledge about the patient’s mental schemas and core beliefs (Beck, Freeman and Davis, 2004). In treatment of certain personality disorders like paranoid personality disorder, cognitive therapy has been found to be very effective (Lenzenweger, 2005, p.103). b. Behavioral theory The behavioral theory of personality disorder pays attention to the behavior of the individual and aims at “changing those habitual ways of behaving that help to maintain maladaptive schemata and introducing new ways of behaving that support more adaptive schemata” (Livesley, 2003, p.298). The methods employed are, “challenging behavior avoidance, using graded tasks, acting against schema-based rules to test the reality of fears and negative expectations, making environmental changes, and behavioral rehearsal and role playing” (Livesley, 2003, p.298). Through these, effort is made mainly to change expression of traits in a more adaptive manner (Livesley, 2003, p.310). c. Interpersonal theory The basic premise of interpersonal theory is that “the destructive, maladaptive patterns characteristic of personality disorder are directly related to behaviors learned in relationships with loved ones or attachment figures” (Livesley, 2003, p.5). This theory ventures to pinpoint a “particular interpersonal context for each of the symptoms defining the respective personality disorders” (Benjamin, 1996, p.9). As delineated by Harry Stack Sullivan (1953), it is assumed that “an infant has a basic need for emotional contact, including bodily contact with other human beings” (as cited in Benjamin, 1996, p.17). The individual and social learning processes that happen through such contacts with others are thought of as crucial in developing personality traits. Psycho-dynamic interpersonal therapy is one combination of methods that is commonly used by therapists (Clarkin, Fonagy and Gabbard, 2010, p.346). Here, the “therapeutic relationship” is made use of in such a way as for self-identification and modification of behavioral patterns (Clarkin, Fonagy and Gabbard, 2010, p.346). But one drawback of this method has been that it requires prolonged psychotherapy (Clarkin, Fonagy and Gabbard, 2010, p.346). d. Psychoanalytical theory Psychoanalytical theory has declared, “observable behaviors (personality traits) and subjective disturbances that characterize a particular personality disorder reflect specific pathological features of underlying psychological structures” (Lenzenweger, 2005, p.114). Hence the treatment based on this theory focuses on “treatments that alter psychological structures and mental organization” (Lenzenweger, 2005, p.114). Patients with severe personality disorders are treated effectively using treatment models designed based on this theory (Lenzenweger, 2005, p.115). Psychoanalytic approach focuses on the “here and now” of the patient rather than the past history (Clarkin, Fonagy and Gabbard, 2010, p.115). During its course of progress, psychoanalytic approach has also become flexible enough to give space to therapeutic influences along with analytical aspects to ensure the well-being of the patient. e. Social learning theory Social learning theory focuses more on the group, community and society rather than on an individual while dealing with personality disorders. It says, “the characteristic behavioral responses that make up personality traits are shaped by continuous reinforcement from the social environment, particularly the family” (Paris, 1994, p.91). It is also argued that “learning takes place through imitation and modeling” (Paris, 1994, p.91). In that way, social learning theory can be seen as a projection of interpersonal theory into group situations. Sociological aspects Sociological aspects of personality disorders have to be discussed in view of the knowledge that “environmental influences play a part in criminal or psychopathic behavior” (Russell and Hersov, 1983, p.26). But in this regard, one major inference has been that environmental influences are “much more important in juvenile than in adult delinquents” (Russell and Hersov, 1983, p.26). But though child hood trauma has been considered as one factor that could develop into a personality disorder, it is also revealed, “some individuals who experience significant childhood trauma appear to emerge with minimal personality disturbance” (Adshead and Jacob, 2009, p.13). Another sociological aspect of the given issue has been that “psychotherapy services typically have a low proportion of ethnic minority clients” as is revealed by Geraghty and Warren (2003) in The Psychiatrist website at http://pb.rcpsych.org/cgi/reprint/27/12/453.pdf. The Psychiatrist website, at http://pb.rcpsych.org/cgi/reprint/27/12/453.pdf has also pointed out that this is not because such groups claim low occurrence of mental illnesses and personality disorders but because of the existing social discrimination that these groups suffer from. There is also a cultural aspect to the issue of cultural minorities in relation to personality disorders. As is described in the beginning of this essay, the very definition of personality disorder is- “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture” (American Psychiatric Association, 2000, p.685). It naturally follows that when a member of a culture migrates geographically to a different culture, the perceivably normal behavioral patterns in the first culture could be unacceptable and abnormal in the new culture. From the above discussions, it becomes clear that different psychological perspectives and theories overlap when individual cases of personality disorders are examined. Four therapeutic strategies are broadly suggested by psychology research (Livesley, 2003) to treat personality disorders: 1. Building and maintaining a collaborative relationship. 2. Maintaining a consistent treatment process. 3. Establishing and maintaining a validating treatment process. 4. Building and maintaining motivation for change. (p.171). All these four strategies/intervention methods stand for a deep understanding of and tolerance to the mental status of the patient. When viewed from a forensic angle, these should be the primary concern while handling individuals with personality disorder. But all the same, it also has to be kept in mind that people with personality disorders can harm other individuals and the society in certain instances. Hence, a balancing of a law and order approach with a humanitarian one will be the best action to adopt. Personality disorder and violence There can be no disagreement on the fact that violence is a serious matter of worry for individuals as well as society as a whole. Even the World Health Organization has termed violence, “a significant public health issue” (as cited by McMurran and Howard, 2009, p.3). Violence can be “defined as a range of behaviors intended to harm a living being who is motivated to avoid harm” (McMurran and Howard, 2009, p.3). While discussing personality disorder in connection with violence, it has to be kept in mind that it is not only the mentally ill persons who undertake violent acts. Individuals considered as normal could also be potential sources of violence (situations like mass violence and organized social rebellion) in certain circumstances. Risk assessment, treatment While addressing the issue of violence in association with personality disorder, it is clear that a major portion of this category of people will be non-violent in their behavior depending on the type of disorder they have. A study (as cited by McMurran and Howard, 2009) has shown that about half of the people diagnosed as having antisocial personality disorder by this study were not involved with any kind of acts of violence for past five years (p.5). But the same study also noted that patients having personality disorders listed under cluster B compared to ‘normal’ people “were 10 times more likely to have had a criminal conviction and almost 8 times more likely to have spent time in prison” (McMurran and Howard, 2009, p.5). Here, the personality disorders listed under cluster B include antisocial, borderline, histrionic and narcissistic personality disorders (McMurran and Howard, 2009, p.272). One alarming aspect of this cluster B category has been that “compared with mentally ill offenders, personality disordered offenders are more likely to reoffend after discharge from hospital” (McMurran and Howard, 2009, p.6). One study involving personality disordered offenders found out that “38% were reconvicted, 26% of them for a serious offense” (McMurran and Howard, 2009, p.6). Daffern (2010) has also opined that persons with personality disorder are at greater risk of exhibiting aggressive and violent behavior (p.15). This phenomenon draws attention to the difficulties involved in handling personality disordered individuals (Farrar, 1996, p.470-474).The formal risk assessment procedures are carried out mainly based on either “actuarial models” which make use of “formal decision algorithms developed on the basis of empirical research findings” or based on “structured clinical appraisals” which involves “consideration of the behavior of interest, the individual’s predisposing characteristics, […] and assessment of the antecedent events” (Daffern, 2010, p.22). Ethical issues It is not only the mental health practitioners but also the criminal justice practitioners who are entrusted with treating individuals having personality disorder in our society (McMurran and Howard, 2009, p.4). One the one side hospitals and on the other, prisons are avenues where such treatment happens. A third stakeholder in this process could be the group institutions existing in a society like, family, community and society as a whole. In a fourth possible instance, there can be an individual, either the therapist or a loved one (relative or non-relative) who could play a role in the treatment of an individual having a personality disorder. But in reality, it is a combination of any of these that deal with a person with a personality disorder. Once a person has been diagnosed with a personality disorder, particularly in a forensic context, the “differential therapeutics” involved has to include several aspects like: (1) treatment format- long term, intermittent, intensive short-term, supportive; (2) type/model- cognitive, behavioral, interpersonal, psychodynamic, integrative, pharmacological; (3) modalities- group, individual, family, couples, mixed, sequential and; (4) setting- hospital, outpatient, partial, residential (Magnavita, 2004, p.4). While certain types of personality disorders are partially or fully curable some other types are also there which “are very difficult to modify or transform” (Magnavita, 2004, p.5). Hence, the handling of individuals having personality disorder is a complex issue indeed and has to be done with discretion. But the baseline could be that in order to develop an effective and ethical approach in this matter, where “we need to expand our perspective of personality from the individual system to the subsystems that operate within the total ecological system” (Magnavita, 2004, p.5-6). This is a felt need also when we look into the different types of violent behavior associated with different types of personality disorders. For example, anger is exhibited by a person having borderline personality disorder when he/she feels, “caregiver or lover is… neglectful and abandoning” (Benjamin, 1996, p.9). While dealing with such an individual, one indivdual with the support of professional help could make the situation better. On the other hand, a person having antisocial personality disorder will exhibit an anger that “is cold and functional, executed to maintain or demonstrate control or distance, without remorse or regard for damage inflicted” (Benjamin, 1996, p.9). Such an individual, if unresponsive to treatment, might have to be kept away from the normal society, at least for a period of time. Here, detention will be a possible option. But even then, detaining such a person in a hospital will be preferable to detaining him/her in a prison. All these decisions will also eventually depend on the gravity of potential violence, both physical and mental, that could be imparted by these persons in the future. This investigation so far has thrown light on the various aspects of violence exhibited by personality-disordered persons. Here, it has to be reminded that mentally ill people are excused for their violent acts while personality-disordered individuals are often held responsible for their violent acts just like normal persons and imprisoned as normal culprits (McMurran and Howard, 2009, p.9). This is because, apart from certain character traits, personality-disordered individuals look and behave almost like normal people. But the society and the ethical values that it profess, make it necessary that acts of violence carried out by personality disordered people more as an illness than as a law violation. And we need to develop enough support mechanisms to avert acts of violence being committed by personality disordered people rather than locking them up in prisons (Home Office, 1990). A constant support mechanism built into the fabric of the social structure only can deal with this issue in a humanitarian way. Legal issues The Mental Health Act of 1983 has been formulated to handle the detention of individuals having mental and personality disorders in hospitals as is described by This act also has implemented “other compulsory measures including guardianship and supervised community treatment” for such individuals as is pointed out by Department of Health website at http://www.dh.gov.uk/en/Healthcare/Mentalhealth/InformationontheMentalHealthAct/index.htm. But after viewing the democratic freedom violations made under this act, The Mental Health Act 2007 was introduced, which made “a number of amendments to the Mental Health Act 1983 […] [and] extended the rights of victims by amending the Domestic Violence, Crime and Victims Act 2004 and amended the Mental Capacity Act (MCA) 2005 to introduce new deprivation of liberty safeguards” (Department of Health website). Mental Health Review Tribunal (MHRT) for England and Wales has Mental Health has been yet another creative intervention that has resulted in positive outcome (Department of Health website). It is the “First–tier Tribunal (Mental Health) [that] hears applications and references for people detained under the Mental Health Act 1983 (as amended by the Mental Health Act 2007)” (Justice, May 16, 2011). The proclaimed role of this tribunal is “protecting and helping vulnerable people” (Justice, May 16, 2011). In the Mental Health Act of 1983, section 37 and 41 are related to the issue of guardianship and in 99% of the cases that were reported, the guardianship had been “rested with the local authority” (Justice, May 16, 2011). The Care Programme Approach, which has became the basis for interventions since 1990s, envisages to give “high-quality evidence based mental health services” to all without discrimination (Department of Health, March 2008). The services under Care Programme Approach are now available to mentally ill as well as personality-disordered individuals and to those who are accessing secondary mental health services as well (Department of Health, March 2008). The National Institute for Clinical Excellence (NICE) guidelines were yet another set of rules to help protect the rights of personality disordered individuals as is described in the National Institute for Clinical Excellence at http://guidance.nice.org.uk/CG77. For example, under NICE guidelines, individuals with antisocial personality disorder are to be given “person-centered care”, cognitive-behavioral treatment in the case of children, “assessment in forensic/specialist personality disorder services” in the case of adults, and “multi-agency care” (NICE website). It is also directed that the autonomy of the patient is respected, families and community have to be involved, only limited pharmacological interventions have to be made, and inpatient treatment has to be as brief as possible (NICE website). NICE is also “co-sponsoring a series of workshops” on personality disorder (NICE website). Conclusion From the above discussion, paradigm shift in the official perspective regarding personality disorder, based on the now generally accepted notion that individuals having personality disorders need to be given treatment in a humanitarian ambience rather than in prisons. It is also now almost accepted that only such individuals among this category, who could become a potential threat of violence to the society should be detained, and that too in hospitals rather than in prisons. But as the Mental Health Review Tribunal has found out, in 99% of cases, the guardianship has rested with the local authority, which in turn will transfer it to law and order agencies. Some hope is emerging in the horizon in this direction. Multi-therapy approach and multi-care systems have been the newly prescribed intervention strategies (NICE website). Efforts are also on “to identify such individuals at the earliest point of contact with the criminal justice system and to deal with them accordingly, or advise on future management” as is revealed by the RCPsych website at http://apt.rcpsych.org/cgi/content/full/6/1/22. The methods that can be applied include, “diversion at the point of arrest”, making “psychiatrists […] available directly or indirectly to the courts”, and also “screening for mental health-related problems may also take place on admission to prison” (Wix, 1994; Joseph and Potter, 1990; James et al., 1997; Hillis, 1993). It is through such a concerted effort based on ethics and humanitarian values that individuals with personality disorders and related violent behavior could be helped to adapt into the system and not dumped in a prison. References Adshead, G. and Jacob, C. 2009. ‘Personality disorder: the definitive reader’, Jessica Kingsley Publishers, London. American Psychiatric Association, American Psychiatric Association.Task Force on DSM-IV 2000. ‘Diagnostic and statistical manual of mental disorders: DSM-IV-TR’, American Psychiatric Pub, Arlington, VA. Beck, A.T., Freeman, A.M. and Davis, D.D. 2004. ‘Cognitive therapy of personality disorders’, Guilford Press, New York. Benjamin, L.S. 1996. ‘Interpersonal diagnosis and treatment of personality disorders (2nd edition)’, Guilford Press, New York. Clarkin, J.F., Fonagy, P. and Gabbard, G.O. 2010. ‘Psychodynamic psychotherapy for personality disorders: a clinical handbook’, American Psychiatric Pub, Arlington, VA. 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