the nice aspd guidelines: a clinical perspective

Copyright © 2010 John Wiley & Sons, Ltd 4: 16–19 (2010)DOI: 10.1002/pmh

CommentaryThe NICE ASPD guidelines: A clinical perspective

Personality and Mental Health4: 16–19 (2010)Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/pmh.111

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 evi-dence did not justify any empirically supported recommendations for individuals with antisocial personality disorder (ASPD) in terms of risk man-agement, psychological interventions or pharma-cological 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 aca-demic utility in clarifying the current lack of infor-mation 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 can-didates 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 argu-ments 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 recom-mendations, although these areas had associated features that diminished the impact of the fi nd-ings. For example, there was evidence for group-based 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

Treatment guidelines for ASPD


17

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 legisla-tion 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 set-tings is still helpful for work within the correc-tional system.

Strengths

Of course, these matters are not necessarily criti-cisms of the GDG—their role was simply to present the evidence that was available—and in doing so they have provided a valuable foundation docu-ment. 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 assess-ment and management, an approach that lends itself to the demystifi cation of the risk manage-ment process.

Some of the fi ndings fell into the category of common sense, such as the need to involve expe-rienced 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, justify-ing 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, resent-ment and rage linked to intrusive memories; avoid-ance with dissociative symptoms and substance abuse designed to numb; and increased arousal with hypervigilance and irritability. The complex-ity of the manner in which these individuals can present can require signifi cant individual psycho-logical work to establish suffi cient stability to make group work realistic. The guidelines produced rec-ommendations for group-based CBT work but the subtleties of engagement with those with ASPD might have benefi tted from a more nuanced dis-cussion similar to that used by the GDG in the area of risk assessment.

As the guidelines point out, genuine therapeu-tic engagement is problematic because of a combi-nation 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 situa-tion 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 incarcera-tion. 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-

Evans


18

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 engage-ment 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 psycho-logical 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 prepara-tory 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 misin-terpretation, 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 assess-ment, it was stated that psychopathy was more or less synonymous with the DSM-IV diagnostic cri-teria 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 offend-ing 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 out-comes 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 sub-jectivity and vagueness into the task. Second, given the propensity towards deceit and manipula-tion, the outcome measure needs to be simple and objective. Attempting to measure complex or subtle changes in psychological constructs as opposed to unambiguous behavioural manifesta-tions 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 prag-matic approach but one that might have benefi tted from broader explanation. Major studies examin-ing 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 read-ability, 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

Treatment guidelines for ASPD


19

available as to how to approach treatment of ASPD, outside of the data available about sub-stance 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 notewor-thy. This will be especially so as services increas-ingly prioritize in a time of scarce resources.

For some countries or states that do not have mental health legislation that leads to the pro-longed detention of those with personality distur-bance 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 psy-chotic violence is the highest priority. Services are under different obligations with respect to non-

psychotic 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 guide-lines. The GDG might have to develop further consensus statements rather than being in a posi-tion 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 manage-ment 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: [email protected]

the nice aspd guidelines: a clinical perspective

Documents