1 Definitions [Questions (a) and (b)] The issue of definition is central to NSF(Scotland)'s concerns . Although it may seem surprising that the Government finds it necessary to ask which kind of offenders it should be concerned with, the question indicates that the government has particular concerns about those offenders who 'hit the headlines' for a variety of reasons. However, it is doubtful that these individuals are identifiable as a group. There are real difficulties in attempting to attach psychiatric or clinical definitions onto such concerns. Indeed, it may well be impossible to succeed in such attempts. We therefore think it important that the Committee review and consider the situation with all serious violent and sexual offenders, and in that context consider the issue of risk assessment about whether such individuals present a continuing danger to the public. It is difficult for NSF(Scotland) to know how effectively this can be done. It certainly should be done in a much wider context than solely psychiatric diagnosis. Psychiatry's contribution to this task must be clearly defined and limited. On the matter of 'personality disorder' itself, we believe that the multiplicity of issues this term raises must be recognised and taken into account. For example, NSF(Scotland) knows of many service users who have been given a diagnosis of personality disorder before or after the diagnosis of schizophrenia. Those in the latter group are sometimes given neuroleptic medication to control their disorder. Sometimes people have both diagnoses at the same time. In addition, there are many different types of personality disorder and we would like to see the diagnosis of 'anti-social personality disorder' separated from others. The Committee needs to be explicit about this, and to be clear that its remit relates to people with severe anti-social personality disorder. Unless this is done, everyone with the diagnosis of personality disorder will be regarded in the same way as those who commit violent crimes. Those who are also mentally ill are particularly vulnerable in this situation. We think it important to draw to the Committee's attention a further difficulty, that of the tendency by some mental health professionals to use the term 'personality disorder' as a throw away label rather than a fully considered diagnosis. This label can mean that some people are denied access to much needed services if their problems are difficult to resolve or treat successfully, and/or their behaviour presents a challenge. When we recently consulted with our own members and service users as part of the Millan Committee consultation, we received a number of comments similar to those below. We believe that such views are expressed frequently enough to be worthy of serious attention. ' If you're middle class you're bi-polar. If you're working class you have a personality disorder' 'Personality disorder is the dustbin diagnosis' We therefore urge the Committee to take such concerns into careful account in their deliberations. 2 Prison Sentences [Questions (c) to (k)] These questions relate more to criminal justice, therefore our contribution is more limited here. However, we do believe that the sentencer has a requirement for good quality evidence before passing sentence. This is particularly important in order to make some kind of informed risk assessment of future offending. Such evidence must be of a very high standard, and open to scrutiny. 3 Community Disposals [Questions (l) and (m)] There is an inherent conflict between support in the community and monitoring/supervision in the community. It should be absolutely clear to all concerned, including the offender, if the primary concern is to police the individual. Unless the person has a clearly defined serious mental health problem for which they require other forms of support and supervision, mental health services have no role in the policing of offenders. 4 Mental Health Disposals [Questions (n) to (r)] (n) A range of options is already open to the courts. It would be useful if greater resources were available for their implementation. (o) The process seems fine, the problems are inadequate facilities. The introduction of Hospital Directions has given further options, and we welcome the flexibility it permits for transfers between hospital and prison (and vice versa). (pi) Multi-disciplinary risk assessment is essential. This does not come cost-free. (ii) Given the known difficulties of identifying accurate predictors for future offending, we have been interested by recent reports of the development of an 'actuarial' model of risk assessment and hope that the Committee would consider the value of these used in combination with the contributions of skilled professionals. (iii) A general psychiatrist may well be the Responsible Medical Officer for hospital order patients without restriction orders at the point of discharge. This is usually straightforward, but if the individual has a history of violent or sexual offending, a second opinion from a forensic psychiatrist at this stage would be a useful safeguard. (q) The short answer is 'Yes'. People must continue to satisfy civil law criteria for detention. Hospital treatment is for people who are ill. Continued detention under the terms of civil law is compatible with the principle that people require treatment, but they should not remain in hospital solely for the purposes of containment. As with the question above, this does require effective tools for risk assessment. This answer brings us back to one of the fundamental issues facing the Committee, and corresponds with our view that one should not separate the issues about violent offenders with severe anti-social personality disorder, from those regarding other violent offenders (r) Adequate resources are needed to implement current procedures. For example, if risk assessment indicates the need for urgent re-admission to hospital, it can be well nigh impossible to find an appropriate in-patient bed. Concerns continue as to the current length of leave of absence (we have indicated these concerns in the past), and whether it may be too short to provide adequate safeguards for mentally ill patients. 5 Questions (s) to (v) Our overall views are clear regarding the dangers of separating serious offenders with severe anti-social personality disorder from other serious offenders. Other than that, we have no specific comment on these questions as they apply either to criminal justice or to matters of evidence to which we have no access/knowledge. 6 Dealing with offenders with personality disorders within the broad framework of the Mental Health (Scotland) Act 1984 [Question (w)] We do not believe that offenders with severe anti-social personality disorders should be dealt with under this legislation. There is some uncertainty and debate within the field as to whether this type of personality disorder should be considered within an 'illness' model. This arises partly from the nature of the disorder, and partly from the 'treatability' debate.,P. It has to be said that while in Scotland personality disorder is generally deemed untreatable, this is not necessarily the perception in other countries, including England. If in Scotland it is decided that personality disorder is untreatable, then any evidence to the contrary will certainly not come from within Scotland - we will create our own self fulfilling prophecy. There is an urgent and compelling need for research which will address the dearth of evidence about the effectiveness of interventions for personality disorder, and in particular for anti-social personality disorder. ,P. Within such a definition of 'treatments' we would include psychotherapeutic interventions, not only medication. However, even if an effective means of changing people's anti-social behaviour was identified, this would not automatically mean that people had been 'ill' and were now 'well'. If the decision is reached by Government that anti-social personality disorder should be dealt with under mental health legislation, then it should apply to all people with anti-social personality disorder, not just offenders. Moreover, account would have to be taken of the estimated 30 - 40% of the existing prison population who are considered to have an anti-social personality disorder, who may have had no contact, or only limited contact, with mental health services. Should such offenders also fall within the terms of mental health legislation, mental health provision would be overwhelmed, and not in the best interests of any parties concerned, including mental health service users. It is important to emphasise that NSF(Scotland) is not suggesting (quite the reverse) that people with other forms of 'personality disorder' should be denied access to mental health services. Such people often do seek such forms of support and should not be denied them on the grounds of their label/diagnosis. 7 Indeterminate detention NSF(Scotland) believes that the public have a right to protection. However, we reiterate that singling out for attention those individuals classified as having severe anti-social personality disorder is not helpful to the wider debate. It also runs the risk of stigmatising further those people who do not have a personality disorder, but do have a serious mental illness (or identified co-morbidity). Having said that, the public debate therefore needs to be widened. If someone has committed a murder, are we seriously suggesting that they should never be released? The impact of such an assumption on criminal justice and legal principles (let alone the system) would be fundamental and dramatic, but it is in this arena that the debate has to take place. We refer the Committee back to our response to Question (p) for our views on the need for multi disciplinary risk assessment combined with some form of model which can be used to predict risk. 8 Questions (z) -(ff) We have nothing further to add in response to these questions, although some of the views we have expressed elsewhere in the text are relevant.