...comparable frequency aggressive behaviour across environments. Although limited number of patients available to study and methodological issues prevent definitive conclusions, reactions to admission and exposure to the therapeutic context appeared inconsistent, some patients demonstrating stability or improvement, others appearing to worsen or react negatively to admission. Neither psychopathy nor seventy of personality disorder interacted with admission and exposure to the new environment to impact on the course of aggressive behaviour. Results emphasise the need for staff to prepare for the inevitability of aggression in this group of patients during the lengthy, demanding and complex treatment process, and to consider the potential for a various reactions to admission, including deterioration, which may mean an increase in dangerousness or an aggravation of the personality disorder.

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Results from an assortment of well-designed studies including randomised controlled trials (Bateman & Fonagy, 1999; Verheul et al., 2002), and meta-analyses (Leichsenring & Leibing, 2003; Perry, Banon,& Ianni, 1999) indicate amenability and positive outcome to psychotherapy for some patients with some personality disorders, challenging the view that these disorders are intractable to psychotherapy (Bateman & Tyrer, 2004). Presently, no specific form of psychotherapy has demonstrated consistent superiority (Leichsenring & Leibing, 2003). Nonspecific contextual features--such as the integrity, structure, consistency and cohesion of the intervention; the focus on a collaborative relationship between therapist and patient; the tailoring of the treatment to the patient and the targeting of therapy interfering behaviours--contribute considerably to treatment effectiveness (Bateman & Fonagy, 1999; Bateman & Tyrer, 2004; Blennerhassett & Wilson O'Raghallaigh, 2005; Livesley, 2003).

Although this psychotherapy outcome literature is expanding, its focus fails almost exclusively on self-referred (help-seeking), community-based, chronically self-injurious women diagnosed with borderline personality disorder (BPD). The empirical literature describing treatment outcomes for forensic patients with personality disorder, patients with antisocial personality disorder (APD) and/or a high level of psychopathy is at present small. There is one randomised controlled trial with dually diagnosed patients (opioid dependence and APD) (Brooner, Didorf, King, & Stoller, 1998), although in this trial treatment was brief, the number of participants was small and outcome measurement focused on changes in drug use rather than personality traits. Single-case methodology demonstrating the potential of brief treatment using cognitive therapy (Davidson & Tyrer, 1996), and an extensive literature focusing on treatment of criminogenic needs in incarcerated and in-community offenders (see Andrews & Bonta, 2003; Howells, Hogue, & Langton, in press) indicates potential treatability. Though generalisation of efficacy cannot be assumed (Livesley, in press; Scheel, 2000), Evershead et al. (2003) argued that Dialectical Behaviour Therapy (DBT), the predominant psychotherapy for female patients with BPD, is applicable to the United Kingdom forensic context on the basis that this disorder is the most commonly diagnosed personality disorder amongst violent psychiatric patients.

Although it is possibly the least indicated form of treatment (Livesley, in press), contrary evidence from therapeutic communities operating within prison settings indicates caution when suggesting generalisability of psychotherapy treatment outcomes to non-help-seeking personality disordered patients or prisoners, especially those who score high on measures of psychopathy (see Ogloff, Wong, & Greenwood 1990; Harris, Rice, & Cormier, 1994). Currently though, there is insufficient empirical evidence to suggest exposure to treatment has an inevitable negative effect on psychopaths (D'Silva, Duggan, & McCarthy, 2004) or that they will necessarily behave poorly during treatment (Hobson, Shine, & Roberts, 2000; Shine & Hobson, 2000). In spite of this caution, the last 15 years of psychotherapy outcome research has resulted in some forensic mental health practitioners cautiously (at times optimistically) embracing psychotherapy, although some have argued that treatment should, at this stage, be considered evaluative research (Duggan et al., 2006). A range of outcomes, including adverse or iatrogenic (Jones, in press), should nevertheless be expected.

Study Aim

Against this background, we examined the course of patients' aggressive behaviour across two settings by assessing the frequency of incidents before (during their immediate period of incarceration in prison) and during admission to a unit designed to treat patients identified as dangerous and as having a severe personality disorder (DSPD; for further details see method). Comparison of behaviour across settings allows for identification and exploration of contextual factors potentiating and inhibiting aggression in personality disordered patients. Further, a reduction in aggressive behaviour may provide some indication of engagement and therapeutic context effectiveness. Previous studies evaluating the impact on prisoners of transfer to a 'therapeutic' environment within prison settings have measured changes in the course of aggression as a proxy for context and regime effectiveness (Cooke, 1989; Taylor, 2003). Hobson et at. (2000) recommend monitoring problem behaviours as a method for monitoring change and evaluating treatment effectiveness:

Given that the behaviour and personality traits of psychopaths are considered to be relatively stable over time, the...

NOTE: All illustrations and photos have been removed from this article.



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